Every finding on record at The Estates at Fridley LLC

Based on observation, interview, and document review, the facility failed to identify alternatives prior to installing or using grab bars (bars installed at the head of the bed for a resident to hold onto for bed mobility or transfers), ensure grab bars were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of grab bars for 1 of 3 residents (R1) who was observed to have grab bars on their bed.R1's diagnoses list dated 3/27/26 included spastic hemiplegia (stiff, weak muscles and involuntary movements on one side of the body) affecting left side and muscle weakness.R1's admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairmentDuring an observation and interview on 3/27/2026 at 12:25 p.m., R1 was observed in her room sitting in a power chair. R1's bed was observed with bilateral grab bars. R1 stated she utilized the grab bars to roll in bed and for transfers.R1's care plan dated 1/23/26 indicated R1 required assistance with bed mobility to sit up, boost up and get feet in and out of bed, and was independent with transfers. R1's care plan did not mention or address the use of grab bars/side rails.R1's electronic medical record (EMR) did not include a grab bars/side rail assessment that had been completed to determine necessity, and whether R1 could safely use side rails. Additionally, it was not evident did not R1 or R1's representatives were educated on the risk of having a grab bar on the bed, and/or a consent form was completed.During an interview on 3/27/2026 at 2:25 p.m., licensed practical nurse (LPN)-A stated a bed mobility devise form needed to be completed prior to having grab bars installed on a resident's bed. LPN-A confirmed R1's electronic medical record (EMR) did not contain a completed bed mobility devise assessment.During an interview on 3/27/2026 at 3:26 p.m., assistant director of nursing (ADON) stated a bed mobility devise assessment determined a resident's need and safety prior to having grab bars installed on a resident's bed. ADON confirmed R1's electronic medical record (EMR) did not contain a completed bed mobility devise assessment.

Based on observation, interview and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 49 residents who resided in the facility. Findings include:During interview on 1/28/26 at 5:00 p.m., R2 stated she stays in her bed and can lay and sit up in her bed. R2 stated she has noticed mice in her room all of the time, and last week she noticed a mouse running in her room and then it ran out into the hallway. R2 stated her room is right crossed from where the residents go in and out to smoke on the patio area and thought that was how they were getting in the building. R2 said she had told the maintenance director about the mice in her room, and he had put some sticky mouse traps down but felt the facility could more to control them. In addition, R2 stated the facility should make sure there was not food in resident rooms that were not in containers or being left out. During interview on 1/28/26 at 7:40 p.m., R1 stated she overheard a nurse stating a mouse was seen coming out of a power outlet in the building in her room, there were ten different occasions where she had seen a mouse in her room. In addition, R1 stated she had pressure ulcers on her coccyx and was concerned with a mouse infestation. During observation and interview on 1/29/26 at 8:44 a.m., with R4, food was in containers and bags on the nightstand. R4 stated he had noticed mice running on the floor and had seen one last week. Then R4 opened his seater on his walker and showed a bag of Rat/Mice X (Mouse Ready Trays are a new approach to effectively kill unwanted rats and mice from industrial buildings, livestock premises, homes, barnyards and any area where the unwanted pests inhabit) and stated he treats the problem himself and places the Rat/Mice X in the corners of his room. Also, during observation there was a Guardian pest control cardboard sticky trap noted to be under his closet door.During interview on 1/29/26 at 9:12 a.m., registered nurse (RN)-A stated he had seen mice in the breakroom approximately two weeks ago and had also heard residents complain of mice in their rooms. During observation and interview on 1/29/26 at 9:36 a.m., R5 stated she would see mice and just found a dead one between her stacked plastic totes against her back walls and removed it herself. R5 further stated she had one stuck in one of the sticky traps and could not stand the sound of the screaming mouse, so she took it in the hallway and put it in a garbage can and wrote a note there is a mouse in here. R5 also stated, one night recently she watched two baby mice playing on her floor by her bed all night long and could not believe they could actually climb the wall; so after that she used one of those coffee glass constrainers from the vending machines and tried to make her own trap with that and using doughnuts in it. R5 stated she never did catch a mouse with that but still hears them in the walls at night. Observation of R5 rooms showed stacks of plastic totes, bags of clothing and miscellaneous clothing on her bed. During interview 1/29/26 at 12:55 p.m., the maintenance Director (MD) stated he had been working at the building for almost a year know and he was aware of the mice problem in the building. MD stated it was getting worse during the cold wintertime, and they use Guardian Pest control in addition to anytime there is a citing the nurses were to document that in a book, so when Guardian comes out, they know where to treat. MD stated they come out once a month, and last week he had requested them to come for more bait around the building. MD stated Guardian did reach out to him and informed they were out of bait and will come out this week. MD stated R2 has complained to him about the mice in her room. In addition, the MD stated they are in wooded area with apartments around them, along with the residents going in and out of the door to smoke which causes the mice to come into the older building. During interview on 1/29/26 at 2:08 p.m., facility administrator stated Guardian Pest Control was supposed to come in yesterday to provide pest control products for the mice and was informed they ran out of products and was hoping to arrive later in the week. In addition, the administrator stated the MD does a good job with patching the windows, adding extra traps. The administrator said he is new to the facility and does not know the complete contract but believes they come out monthly and as needed. During interview on 1/29/26 at 4:13 p.m., Dietary Manager (DM) stated the facility does have a mouse problem and feels they need to be more proactive with treating them and doing more. The DM stated she has not seen them in the kitchen but had been informed they have trapped them in the live trap in the kitchen under the three-compartment sink. The DM stated all of the food in the kitchen and storage area was contained in containers and they had not seen any mouse droppings.During observation and interview on 1/29/26 at 4:27 p.m., leaving the therapy room in the back hallway noticed a bed against the wall with stacks of old wheelchair petals, wheelchair cushions, bags of unknown items stacked above the bed. When interviewed Physical Therapy Assistant (PTA)-A stated the bed is broken and all of the equipment is broken or non-useable. PTA-A stated she had observed a resident who liked to store food in the bed and she had seen mouse droppings in the bed. On 1/30/26 at 1:00 p.m., received a return phone call from service technician (ST) from Guardian Pest control which was originally placed prior to exit on 1/29/26 at 3:45 p.m. he stated the plan was to but did not due to lack of supplies. The ST stated he was on his way to the facility and had concerns with the clutter in the facility rooms and hallways and planned to discuss this with the facility. In addition, the ST stated he comes out once a month and as needed to treat pest control and directed me to call the central office for his service logs and treatment. Visit dated 1/30/26 from Guardian indicated, during the visit the administrator asked for recommendations to help with mice activity and he listed the following: fixing any door sweeps that have gaps in them, making sure rooms are decluttered as best as possible and make sure trash is picked up in common areas and rooms and taken care of daily, making sure food debris/crumbs are cleaned up and if food is left in rooms it needs to be in a sealed containers and same goes for kitchen, Physical therapy common area has a lot of old parts in a corner which has been reported of having residents hiding food in it, fix any open holes in walls, usually around pipe fittings in wall are places to look for, and make sure any mouse droppings are cleaned up as soon as possible. The facility Pest Control policy dated 5/08 directed the facility was to maintain on-going pest control program to ensure the building was kept free of insects and rodents. All insecticides and rodenticides are permitted in the facility are to be stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily.

Based on interview and document review, the facility failed to ensure the comprehensive care plan was updated to ensure elopement risk and civil commitment were identified, and appropriate interventions were developed for 1 of 3 residents (R1) reviewed. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment and diagnoses that included Wernicke's encephalopathy (an acute neurological disorder with symptoms that include difficulty moving and confusion), alcoholic cirrhosis (liver damage) of the liver, and alcoholism not in remission. R1's Elopement Risk assessment dated [DATE], indicated a score of 4. The assessment indicated an elopement risk based on the nurse's assessment. The assessment further indicated with a risk score of 4 or greater, the facility should develop a care plan related to elopement risk. R1's progress note dated 9/19/25 at 9:03 a.m., indicated R1 was on a civil commitment. R1's care plan reviewed on 10/3/25 lacked information or staff direction related to R1's elopement risk and civil commitment. During an interview on 10/1/25 at 10:52 a.m., social services designee (SSD)-A acknowledged R1 was on a civil commitment and indicated she uploaded court documents on 9/25/25 when she received them by e-fax. The SSD-A stated R1's commitment was through May 21, 2026, and the recommendations in the commitment were for R1 to continue psychiatric treatment because R1 was a significant danger to himself, was chemically dependent, and not safe to live at home alone. The SSD-A acknowledged R1 did not have a care plan related to the commitment but should have. During an interview on 10/1/25 at 11:42 a.m., registered nurse (RN)-A stated R1 did not have care plan interventions related to elopement or civil commitment, but should have, and further stated it was not her job to develop the care plan. During an interview on 10/1/25 at 2:30 p.m., the director of nursing (DON) acknowledged R1's care plan lacked focus areas for elopement and civil commitment, but both should have been included in R1's care plan. The DON stated the care plan was used to direct staff on how to care for the resident, and staff would not have known their responsibilities for either focus area. The Elopement Policy dated 6/23, indicated upon admission, each resident was assessed to establish elopement risk. Documentation should include a care plan that addressed potential to wander or exit the facility and measures taken to prevent elopement. A policy for civil commitment was requested and not provided.

Based on interview and document review, the facility failed to accurately document risk factors on an elopement assessment for 2 of 3 residents (R1, R3). Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment and diagnoses that included Wernicke's encephalopathy (an acute neurological disorder with symptoms that include difficulty moving and confusion), alcoholic cirrhosis (liver damage) of the liver, and alcoholism not in remission. R1's orders dated 9/17/25, indicated quetiapine fumarate (antipsychotic medication used to treat mental health conditions) oral tablet and 25 milligrams (mg) at bedtime. R1's Elopement Risk assessment dated [DATE], indicated two risk areas: 1. Ambulatory or ability to self-propel a wheelchair and 2. Resident was asking to go home. Based on Assessment scale, that would have indicated a score of two, but was documented as a score of four. The assessment also included point for risk factors for prescribed antipsychotic medications and cognitive deficits, which were not indicated but should have been. Those indications would have increased the score to four, accurately assessing R1 to be at risk for elopement. R1's care plan reviewed on 10/3/25 lacked information or staff direction related to R1's elopement risk. R1's progress note dated 9/27/25 at 2:05 p.m., written by registered nurse (RN)-A indicated R1 was on LOA, and further indicated vital signs from a previous day, resident was alert and oriented, was free of signs and symptoms of SOB [shortness of breath], no swallowing difficulties, mood indicators, or behaviors observed. R1's progress note dated 9/27/25 at 11:13 p.m., indicated R1 was still on LOA. During an interview on 10/1/25 at 11:42 a.m., RN-A acknowledge she completed R1's Elopement Risk Assessment on 9/17/25. RN-A reviewed the assessment and stated if the assessment indicated a score of 4, the resident was at risk for elopement, and she had not accurately completed the assessment. R3's admission MDS dated [DATE], indicated R3 admitted on [DATE], with intact cognition and diagnoses that included hepatic (liver) encephalopathy, cachexia (great muscle and weight loss), alcoholic cirrhosis of liver with ascites (abdominal swelling caused by accumulation of fluid), chronic hepatic failure, adult failure to thrive, depression, and alcohol abuse in remission. R3's orders dated 9/16/25, indicated quetiapine fumarate oral tablet, 25 milligrams (mg) at bedtime. R3's Elopement Risk assessment dated [DATE], indicated a score of one because the resident was ambulatory. The Elopement Risk assessment failed to indicated the resident had confusion due to hepatic encephalopathy and was taking a psychotropic medication (drugs that affect the mind, emotions, and behavior). This would have indicated a score of three, instead of one, on the assessment for R3. No care plan intervention needed. During a subsequent interview on 10/2/25 at 10:21 a.m., RN-A acknowledged she completed R3's Elopement Risk Assessment on 9/16/25, RN-A further acknowledge R3 did have confusion due to hepatic encephalopathy and was prescribed an antipsychotic medication and should have checked those risk factors on the assessment. RN-A stated she does not usually look at the diagnosis list and medication list when completing the Elopement Risk Assessment but should. RN-A further acknowledged she did not complete R3's Elopement Risk Assessment accurately. During an interview on 10/1/25 at 2:30 p.m., the director of nursing acknowledged both R1 and R3's Elopement Risk Assessments were completed inaccurately and should have included elopement risk points for cognitive deficits and antipsychotics medications. The DON stated it was the expectation the nurses would review diagnoses and medication list when completing the assessment. Additionally, the DON stated R1 should not have documented progress notes when R1 was on LOA, and the assessment completed by RN-A was not accurate. The Elopement Policy dated 6/23 indicated upon admission, each resident is assessed to establish elopement risk, and is reassessed quarterly, annually, and as needed due to significant changes. For residents at risk of elopement documentation should include a care plan that addresses potential to wander or exit the facility and the measures taken to prevent wandering/elopement. A policy for skilled charting was requested and not provided.

Based on interview, observation and document review, the facility failed to develop a baseline care plan for 1 of 4 (R2) residents reviewed for care plans. R2 had a cervical fracture and cervical collar but did not have relevant interventions in the care plan for the management of the collar. Findings include:A cervical collar is a medical device used to support and protect the neck and spinal cord.R2's face sheet dated 11/19/25 indicated R2 was admitted on [DATE] and had diagnoses of other displaced dens fracture (cervical spine fracture), subsequent encounter for fracture with routine healing, type II diabetes with diabetic nephropathy, depression, chronic pain, anxiety, need for assistance with personal care, and dorsopathy (back pain).R2's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated R2 was cognitively intact, had no behaviors and required moderate assistance with activities of daily living. The care area assessment was signed 11/12/25.R2's hospital Discharge summary dated [DATE] included the following directions for cervical collar care:-Strictly follow all recommended collar use guidelines and activity restrictions provided from the hospital. In general, the Aspen collar (C-collar) will need to remain on at all times unless otherwise indicated.-Care of the skin under a cervical collar should be performed and documented every 8 hours. Conduct a neurological assessment and document after initial collar application, then every 8 hours (and as needed), or per provider orders.-Providing skin care to a patient in a cervical collar:1. Place the head of the bed flat.2. A second caregiver will secure the head and neck to maintain alignment.3. A third caregiver will stand by to assist with log rolling turns.4. Note neurological assessment of extremities. Remove the front portion of the collar and assess the visible skin condition carefully. Assess for areas of redness, rashes or skin breakdown.5. Cleanse face and neck with soap and water. Gently dry skin thoroughly.6. The pads on an Aspen collar should be changed daily and as needed.R2's care plan dated 11/19/25 included a section for skin integrity. Interventions included monitor skin integrity daily during cares, weekly skin inspection by nurse, monitor for skin breakdown. The self-care deficit section had interventions including assist with bathing (specify), assist with dressing (specify), assist with personal hygiene (specify). The care plan did not address C-collar or any specific interventions related to the care of the C-collar.R2's November treatment administration record (TAR) did not include treatment orders or related care interventions for the C-collar, changing or removing the C-collar, assessing the skin or neck under the C collar or when to notify a physician for concerns.R2's Weekly Skin Inspection dated 11/15/25 indicated R2 had no new skin issues but did not specify if her C-collar was removed to assess the skin.R2's Weekly Skin Inspection dated 11/8/25 indicated R2 declined a bed bath, shower and skin inspection.R2's hospital discharge paperwork dated 11/6/25 included the following directions for cervical collar care:-Strictly follow all recommended collar use guidelines and activity restrictions provided from the hospital. In general, the Aspen collar (C-collar) will need to remain on at all times unless otherwise indicated.-Care of the skin under a cervical collar should be performed and documented every 8 hours. Conduct a neurological assessment and document after initial collar application, then every 8 hours (and as needed), or per provider orders.-Providing skin care to a patient in a cervical collar:1. Place the head of the bed flat.2. A second caregiver will secure the head and neck to maintain alignment.3. A third caregiver will stand by to assist with log rolling turns.4. Note neurological assessment of extremities. Remove the front portion of the collar and assess the visible skin condition carefully. Assess for areas of redness, rashes or skin breakdown.5. Cleanse face and neck with soap and water. Gently dry skin thoroughly.6. The pads on an Aspen collar should be changed daily and as needed. During an interview on 11/19/25 at 12:14 p.m., R2 stated staff have not washed the skin underneath her C-collar. Her C-collar was supposed to be on 24/7, she had been there for almost two weeks and staff have not removed the collar to assess the site or change the padding. It had been itchy all the time. Tearfully, she stated I understand this is scary and it's scary for me too, but I need help with it.During an interview on 11/19/25 at 12:39 p.m., registered nurse (RN)-A stated she was R2's nurse for the day. When a new resident is admitted with a brace, the admissions staff will enter the documentation into the electronic health record (EHR). Information about brace should be in the order set. Anytime the brace comes off and when residents have showers it should be documented. The opportunity to check their skin underneath would be during showers and if the brace is taken off at night or if they complain of discomfort. RN-A had worked with R2 several times and had never removed her C-collar. RN-A documented the skin assessment from 11/15/25 but didn't assess the skin underneath the collar and stated the nursing assistant who gave the bed bath also wouldn't have removed the collar.During on observation on 11/19/25 at 2:21 p.m., RN-A entered R2's room at the request of the surveyor to remove the C-collar and assess the skin. R2 reminded RN-A that removing the C-collar r required two staff. RN-A called in a nursing assistant (NA)-A to assist, NA-A held R2's head and neck straight while RN-A removed the C-collar. The skin underneath was red but had no open areas. After RN-A and NA-A left the room, R2 reported staff had just come in before the surveyor to remove the C-collar and change the pads.During an interview on 11/19/25 at 2:52 p.m., R2's nurse manager RN-B stated admission staff would put in the C-collar orders when a resident comes from the hospital and nurses on the floor would double check the orders.During an interview on 11/19/25 at 2:52 p.m., the director of nursing (DON) stated C-collar are managed by doing an assessment and changing it on shower day. When asked if interventions for managing the C-collar should be in the care plan, the DON did not answer but stated the nurse manager is responsible for the care plan. She stated there should be orders in the order set for managing the C-collar. When asked what areas for improvement there were for managing R2's C collar, the DON only mentioned that there should have been orders in the EHR.The neurosurgery clinic that was managing R2's cervical fracture did not respond to the interview request.A facility policy or procedure pertaining to braces or collars was requested but not received.

Based on interview, observation and document review, the facility failed to properly assess and monitor skin conditions for 1 of 4 (R2) residents reviewed for medical braces and quality of care. R2 had a cervical collar (C-collar) for a cervical fracture and the facility failed to document orders, complete skin assessments, assess the site and change the brace padding.Findings includeA cervical collar is a medical device used to support and protect the neck and spinal cord.R2's face sheet dated 11/19/25 indicated R2 was admitted on [DATE] and had diagnoses of other displaced dens fracture (cervical spine fracture), subsequent encounter for fracture with routine healing, type II diabetes with diabetic nephropathy, depression, chronic pain, anxiety, need for assistance with personal care, and dorsopathy (back pain).R2's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated R2 was cognitively intact, had no behaviors and required moderate assistance with activities of daily living.R2's hospital Discharge summary dated [DATE] included the following directions for cervical collar care:-Strictly follow all recommended collar use guidelines and activity restrictions provided from the hospital. In general, the Aspen collar (C-collar) will need to remain on at all times unless otherwise indicated.-Care of the skin under a cervical collar should be performed and documented every 8 hours. Conduct a neurological assessment and document after initial collar application, then every 8 hours (and as needed), or per provider orders.-Providing skin care to a patient in a cervical collar:1. Place the head of the bed flat.2. A second caregiver will secure the head and neck to maintain alignment.3. A third caregiver will stand by to assist with log rolling turns.4. Note neurological assessment of extremities. Remove the front portion of the collar and assess the visible skin condition carefully. Assess for areas of redness, rashes or skin breakdown.5. Cleanse face and neck with soap and water. Gently dry skin thoroughly.6. The pads on an Aspen collar should be changed daily and as needed. Review of R2's baseline care plan did not include the aforementioned hospital instructions according to the hospital discharge summary. R2's November treatment administration record (TAR) did not include treatment/care for the C- collar, changing or removing the C-collar, assessing the skin or neck under the C collar or when to notify a physician for concerns. R2's Weekly Skin Inspection dated 11/15/25 indicated R2 had no new skin issues but did not specify if her C-collar was removed to assess the skin.R2's Weekly Skin Inspection dated 11/8/25 indicated R2 declined a bed bath, shower and skin inspection.During an interview on 11/19/25 at 12:14 p.m., R2 stated staff have not washed the skin underneath her C-collar. Her C-collar is supposed to be on 24/7, she had been there for almost two weeks and staff have not removed the collar to assess the site or change the padding. It had been itchy all the time. Tearfully, she stated I understand this is scary and it's scary for me too, but I need help with it.During an interview on 11/19/25 at 12:39 p.m., registered nurse (RN)-A stated she was R2's nurse for the day. When a new resident was admitted with a brace, the admissions staff would enter the documentation into the electronic health record (EHR). Information about brace should be in the order set that would come across to the treatment administration record to alert nursing the treatment needed to be completed. Anytime the brace comes off and when residents have showers it should be documented. The opportunity to check their skin underneath would be during showers and if the brace was taken off at night or if a resident complained of discomfort. RN-A had worked with R2 several times and had never removed her C-collar. RN-A documented the skin assessment from 11/15/25 but didn't assess the skin underneath the collar and stated the nursing assistant who gave the bed bath also wouldn't have removed the collar.During an interview on 11/19/25 at 1:36 p.m., R2's physical therapist (PT)-A stated PT would only be responsible for adjusting the fit of the C-collar and nurses should be managing the collar. Everyday the skin should be washed as there could be a lot of sweating underneath the C collar. Pads should be changed at least every shower day. All care for the C-collar should be documented. PT-A was not aware of any concerns with managing the care of R2's C-collar.During on observation on 11/19/25 at 2:21 p.m., RN-A entered R2's room at the request of the surveyor to remove the C-collar and assess the skin. R2 reminded RN-A that removing the C-collar required two staff. RN-A called in a nursing assistant (NA)-A to assist, NA-A held R2's head and neck straight while RN-A removed the C-collar. The skin underneath was red but had no open areas. After RN-A and NA-A left the room, R2 reported staff had just come in before the surveyor to remove the C-collar and change the pads.During an interview on 11/19/25 at 2:52 p.m., R2's nurse manager RN-B stated residents who have a C-collar should have daily skin assessments and should be documented in a progress note. The pads should be changed weekly and as needed. admission staff would put in the C-collar orders when a resident comes from the hospital and nurses on the floor would double check the orders. RN-B stated R2 refused the weekly skin check at least twice but was unable to provide supporting documentation for both refusals.During an interview on 11/19/25 at 2:52 p.m., the director of nursing (DON) stated C-collar are managed by doing an assessment and changing it on shower day. The DON went on to explain that R2 had been refusing a lot of cares such as getting out of bed, eating and seeing the physician. When documenting in the skin assessment form, nurses should remove the C-collar to assess and document the findings. When asked what areas for improvement there were for managing R2's C-collar, the DON only mentioned that there should have been orders in the EHR.The neurosurgery clinic that was managing R2's cervical fracture did not respond to the interview request.A facility policy or procedure pertaining to braces or collars was requested but not received.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed when the facility did not evaluate the effectiveness of R1's interventions for mental health needs. R1 entered R2's room and physically pushed him over backwards in his wheelchair, then attempted to throw the wheelchair at R2 before staff intervened. R1 displayed an outward change in condition on 10/13/25, went to the hospital on [DATE], and R1 called the police on 10/21/25 prior to the incident with R2. R1 had exhibited drug induced psychosis from recreational methamphetamine use in days leading up to the abuse. R2 was fearful of living with R1 in the facility. Findings include: R1's care plan dated 3/24/25 indicated R1 had a history and diagnosis of substance abuse: alcohol use. R1's interventions on 3/24/25 were education on the substance abuse policy and staff was to monitor and check vitals of resident if he was found under the influence. On 10/16/25 the following interventions were added: Monitor resident for intoxication or impairment. Provider notified of substance use while at the facility. When R1 was noted to have been smoking illegal substances like Marijuana, using cocaine or methamphetamine, etc. or was intoxicated (unsteady gait, slurred speech, pinpoint pupils etc. do not administer any medications - update the provider for more directions. R2's care plan dated 7/25/25 indicated R2 had altercations in mood and behavior due to new placement in a skilled facility. R2 had a diagnosis of traumatic subdural hemorrhage with loss of consciousness (bleeding in the brain). R2's interventions were to monitor and document mood state/behaviors upon occurrence. Redirect R2 as needed. Provide emotional support, validation and comfort measures as needed. R2's significant change Minimum Data Set (MDS) dated [DATE] indicated R2 had a Brief Inventory of Mental Status (BIMS) score of 10 indicating R2 was cognitively impaired. R2 required supervision with toileting, dressing, and personal hygiene. R2's pertinent diagnoses were encephalopathy (disruption in the function of the brain), hemothorax (blood accumulation between the lung and chest wall that is most likely caused by trauma), muscle wasting and symbolic dysfunction (a social impairment disorder that refers to language deficits). R1's quarterly MDS dated [DATE] indicated R1 had a (BIMS) score of 15 indicating he was cognitively intact. R1 required moderate assistance with toileting and showering. He required set-up assistance with personal hygiene. R1's pertinent diagnoses were displaced fracture of the neck and hand, alcohol abuse and adjustment disorder with mixed anxiety and depressed mood (a mental health condition characterized by a combination of symptoms typically associated with anxiety and depression, arising in response to a significant stressor or life change). R1's progress note dated 10/13/25 at 10:39 a.m. during morning meeting, the DON and intradisciplinary team (IDT) were notified by a housekeeping staff that R1 was out in the facility parking lot letting air out of the DON's vehicle tires. The DON went out and found resident at the far end of the parking lot near a grey truck, in the act of letting air out of the tires. When she asked R1 why he was doing this he mumbled something and went around to the other side of the truck and started letting air out of the front tire. The DON asked him to stop and when he was asked why she informed him she was calling 911. While she was on the phone with 911, R1 went to her vehicle and started letting air out of writer's rear passenger tire, she told R1 to stop touching her vehicle and R1 turned and went towards the front of the parking lot to a black truck owned by another resident and began letting the air out of the rear driver's side vehicle, at that time the police arrived and started speaking with R1. Housekeeping staff called the DON over and pointed out a scratch on the passenger side of her vehicle. The scratch was approximately 12 in length and looked to be superficial. The officer asked R1 why he was doing that, and he said something about the TV and his mental health, it was unclear what he was saying (English is not his first language). The officer asked the DON if she wanted to press charges for the scratch and was told she did not, as it was superficial. The police officer suggested that R1 go back into the facility. R1's information was provided, and the DON's contact information was provided. The IDT would review R1's chart for any medication changes, behavioral notes, and review his substance use disorder (SUD) checklist to ensure resident's care plan was appropriate and up to date. When the DON returned to office, there was a voicemail from the police stating they had observed R1 rolling down the frontage road as they were leaving. R1 signed the leave of absence (LOA) binder but did not supply information as to where he was going or when he would return. R1's progress note dated 10/13/25 indicated at 1:38 p.m. indicated R1 was on an LOA. There were no further progress notes until 10/15/25. R1's progress note date 10/15/25 at 1:29 p.m. indicated at around 12:35 p.m. during this shift registered nurse (RN)-A noted R1 moving around with his wheelchair in the hallway speaking in Spanish. A few minutes later R1 came to the nursing station and reported his roommate's TV was loud. RN-A went to the room and found the TV was off and the roommate was asleep. RN-A encouraged R1 to go and sleep with no effect. R1 continued speaking in Spanish and exhibited an anger outburst, using vulgar language to staff. R1 came to the nursing station and stated, call 911 I am having pain on my lower abdomen. R1 refused to allow RN-A to take his vital signs, 911 call was initiated. R1 continued speaking in Spanish and became aggressive toward RN-A. R1 knocked the nursing station computer with his cane twice and the computer fell to the floor. He also tried to hit RN-A with his cane while on the phone with the 911 dispatcher for the second time. He then started taking photos of RN-A with his iPad and took a wireless phone and threw it toward RN-A. Soon the paramedics and police arrived and took R1 to the emergency department, the DON was notified. R1's emergency department note dated 10/15/25 at 5:11 p.m. indicated R1's clinical impressions were psychiatric illness and methamphetamine-induced mood disorder and altered mental status. R1's assessment indicated due to chronic suicide ideation, severe chronic chemical dependency/alcohol, chronic intoxication, history of multiple violence episodes, he had a chronic risk of suicide, accidental overdose/death, chronic risks for violence towards self and others, unable to care for self, had chronic risks of being a danger to self/society. R1 denied current suicidal or homicidal contracts for safety. R1 was willing to go to chemical dependency treatment and remain sober. He made many future oriented comments. R1 did not meet the criterial for a 72-hour psychological hold therefore he would be discharged back to the facility. R1 admitted to using methamphetamines 5 days ago and then again 3 days ago. R1 had auditory hallucinations to throw things, but denied auditory hallucinations to kill self, hurt self, or others. R1's progress note dated 10/21/25 at 9:31 a.m. indicated R1 called 911 on himself. The assistant director of nursing (ADON) spoke with the police afterwards and they stated R1 had reported that he knows the facility was tapping into his devices and posting videos of him and broadcasting it to the world and people are looking at him and laughing. In addition, R1 stated to the officers that staff were putting things in his eyes to make him see what they want him to see. R1 was provided with his case worker and the police department's business cards. The officers stated they would give the case worker the information so they could follow up with the R1. R1 also requested the name and badge numbers of the police officers that responded. R1's nursing progress note dated 10/21/25 at 8:21 p.m. indicated licensed practical nurse (LPN)-A heard someone calling for help in R2's room. LPN-A rushed to the room and witnessed R2 on the floor with his wheelchair tipped over. R1 was standing over the other client threatening to cause more harm. It was reported that R1 had approached R2 throwing him on the floor. R1 was sent to the hospital for evaluation and a 72-hour hold. R1 was agitated and appeared not himself, R1 was threatening to cause harm to staff and taking staff's video stating that he was to call someone to come harm staff. He agreed to go to hospital. R2's nursing progress note dated 10/21/25 at 8:21 p.m. indicated LPN-A heard someone call for call for resident to stop, on arrival LPN-A witnessed R2 seated on the floor with his wheelchair tipped over next to him. R1 was standing over R2 and continued to make threats toward R2 that he was going to finish this. LPN-A separated both residents. R2 stated R1 was a very disturbed young man. R1's Emergency Hold Order Application dated 10/21/25 at 8:43 p.m. ordered by R1's Primary Care Physician indicated R1 had a psychiatric history and current methamphetamine usage. R1 was behaving in a violent and erratic way putting the facility staff and other residents at risk. Not transporting him to an elevated level of care is a risk for morbidity and mortality to self and others. R2's nursing progress note dated 10/21/25 at 10:20 p.m. indicated R2 was sent to the emergency department for evaluation. R2's hospital after visit summary dated 10/21/25 indicated R2's reason for the visit was due to a fall. R2's instructions were to return to the emergency department if he developed any pain such as severe headache, trouble breathing, vomiting. It did not appear R2 had any injuries related to his fall. R2's care plan on 10/21/25 indicated R2 was the victim in a resident-to-resident altercation. R2's interventions were 15-minute checks initially for safety. Monitoring R2 for signs and symptoms of emotional distress. R1's incident report dated 10/22/25 at 10:31 a.m. indicated on 10/21/25 at 8:20 p.m. there was a resident-to-resident altercation. The incident was reviewed with the resident, direct care staff, the medical provider, and the IDT. The incident analysis indicated R1 was exhibiting paranoid behaviors earlier in the day. R1 was in the hallway and had flipped R1 out of his wheelchair. He stated I got you'll pictures, watch, see what happens holding a camera and making threats toward staff, R1 appeared upset that staff called law enforcement to intervene. The contributing factors were R1's diagnoses of double below the knee amputation, muscle weakness, other signs involving cognitive function and awareness were fatigue, major depression disorder and adjustment disorder. R1's prescriptions were cyclobenzaprine (muscle relaxant) which R1 had not taken recently, duloxetine (anti-depressant), melatonin (natural sleep agent), metoprolol (blood pressure medication), gabapentin (for seizure and nerve pain), and Seroquel (anti-psychotic). R1 had been having refusing his mediations and having erratic behaviors in the past week. R1 had a history of substance abuse. R1's interventions indicated to see his care plan. Other interventions included R1 was taken by paramedics/police department. If he returned to the facility, he would be on 15-minute checks for safety. R1 was already on substance use monitoring. R2's incident report dated 10/22/25 at 11:09 a.m. indicated on 10/21/25 at 8:20 p.m. there was a resident-to-resident altercation. The incident was reviewed with the responsible party, the resident, direct care staff, the medical provider and IDT. The incident analysis indicated a nurse heard someone call for R2 to stop on arrival the nurse witnessed R2 seated on the floor with his wheelchair tipped over next to him. R1 was standing over R2 and continued to make threats toward R2 that he was going to finish this. The nurse separated the residents. The contributing factors was documented as not applicable (NA). The follow-up interventions indicated to see the care plan. Other interventions included the resident was placed on 15-minute checks for safety and monitoring for emotional distress after returning from the emergency department. The facility was unable to provide documentation of the 15-minute checks completed on R2. Additional notes indicated IDT reviewed the resident-to-resident altercation R2 was the victim. The IDT team would continue to monitor. R1's medical record lacked a reassessment or if care planned interventions for support treatment or services for mental health concerns were provided to R1 as it related to his mood or behavior to attain the highest practicable mental and psychosocial wellbeing of R1. Interventions and position responsible included: MDS section D/PHQ 9 will be conducted per regulation and PRN. Date Initiated: 3/24/2025 Social Service Designee (SSD) Monitor and document mood state/behaviors upon occurrence. Date Initiated: 03/24/2025 Nursing (NSG) Redirect prn. Date Initiated: 03/24/2025 NSG Social Services to assist resident and family prn. Date Initiated: 04/18/2025 SSD Encourage utilization of social supports. Date Initiated: 04/18/2025 SSD Staff to visit with resident one on one during cares and prn. Date Initiated: 04/18/2025All Provide emotional support, validation, and comfort measures prn. Date Initiated: 3/24/2025 All Introduce resident to other residents with similar interests. Date Initiated: 04/18/2025All Monitor Target Behaviors per protocol. Date Initiated: 04/18/2025 NSG R2's social service progress note dated 10/22/25 indicated R2 had a trauma questionnaire completed due to the resident-to-resident altercation. R2 stated he had no trauma, but stated he was very confused. That was his baseline. R2's trauma assessment dated [DATE] at 1:33 p.m. indicated R2 was asked; have you ever had any traumatic experiences in the past that you feel we should be aware of that may affect your preferences or care needs. R2 answered no. Additional notes indicated R2 stated he had no trauma at that time; however, he was very confused. R2's nursing progress note dated 10/23/25 at 1:11 p.m. indicated R2 expressed he was scared because of the incident that happened with R1. It was explained to him that the facility would do everything in their power to keep him safe if R1 were to return. R2 was offered social services to assist him to move to a sister facility if he no longer felt safe at this facility. R2 stated that prospect was also scary because he would have to get to know new staff and his way around a new facility. He was asked if he would like to speak with a therapist to discuss his feelings. R2 stated that talking would not do anything he just needed to cool down and think. He was again offered social services if he needed to talk. R2's social service progress note dated 10/23/25 at 1:51 p.m. indicated social services met with R2 again and offered therapy, which he declined. The facility would request the therapist introduce themselves to R2 when they were onsite. R2 was also offered alternate placement; to which R2 stated the facility was his home and his grandmother even lived there at one point. Other facility options were discussed and R2 stated that two things could be true at the same time, he could feel uncomfortable at the facility yet have the feelings it was his home. Upon observation and interview on 10/23/25 R2 was seated in his room in his wheelchair looking at his phone trying to call a non-emergency police line to get a restraining order on R1. R2 stated a young tough crazy man became aggressive and pushed him, tipping him backwards in his wheelchair, then he lifted the wheelchair and was going to throw it on top of him. R2 stated he was scared and still was. R1 had a street personality and assaulted R2. R2 felt he was an easy target because he was a smaller man in a wheelchair and did not have the appearance of a fighter. During the interview R2 wheeled himself to the door four times to look out the door to see if R2 had returned from the hospital. R2 stated he had been told if he was fearful there was a sister facility R2 could be moved to when R1 returned. R2 stated the facility was his home, he had friends and why would an aggressive 20-something year old criminal be to stay? Upon observation on 10/23/25 at 12:58 p.m. R2 was in the hallway of the facility speaking to the director of nursing (DON). The DON was telling R2 the facility would do their best to keep him safe if R1 were to return and if they could not and he was still scared he could be a moved to a sister facility. R2 was upset stating why should he move? Why should he feel unsafe in his own home? What gave the criminal the right to live there? Upon interview on 10/23/25 at 2:35 p.m. RN-A stated he was the nurse who worked 10/15/25 when R1 was complaining about hearing his roommate's television when it was off. R1 was pacing the hallways speaking in Spanish trying to tie rubber therapy bands around residents' doors. He states speaking loudly and wanted 911 called for abdominal pain. R1 called 911 himself and following his call RN-A spoke with the dispatches who told RN-A to call the police. R1 then got upset, threw his phone, and started hitting the computers and attempted to attack RN-A. R1 was taken to the emergency department. RN-A stated he did not feel safe with R1 around and he was scared for the residents. RN-A stated R2 was really scared, especially if R1 would be returning to the facility. R2 told RN-A he could not stop thinking of when R2 assaulted him. R2 remembered the situation well, even though he was forgetful. Upon interview on 10/23/25 at 2:55 p.m. licensed practical nurse, LPN-B stated on the evening of 10/21/25 she heard yelling and part of the yelling was LPN-A yelling for help. She went to R2's room and saw him on the floor and R1 yelling and trying to hit LPN-A. LPN-A told LPN-B to call the police so she called the police. R1 was still trying to fight staff when the police arrived. The police calmed R1 down and the paramedics arrived the paramedics did not want to take R2. The facility had called the DON, and the DON was in the process of having the Medical Director place a 72-hour on R1 for the safety of the residents and staff. R1 had assaulted staff a few days prior, and the hospital returned R1 the same day. LPN-B denied any interventions for R1 following his physical altercations with staff on 10/15/25. LPN-B stated when R2 returned from the hospital following the assault he told her that was the worst situation he had ever been in and how painful it was. LPN-A stated she was personally fearful because R1 would try to fight any staff, he would fight anyone. Upon interview on 10/23/25 at 3:45 p.m. Nurse Practitioner, NP stated it sounded to her like the hospital was trying to send R1 back to the facility. She stated he needed inpatient care for safety. She was not certain how R1 ended up at the facility in the first place. She stated she was concerned for R1 going out and using drugs and there was a not skilled need for him to be at the facility anymore. She stated R2 suffered mental abuse as he did tell her he was upset about the incident, but did not give her specific details. R2 had cognitive issues at his baseline. Upon interview on 10/27/25 at 8:21 a.m. R3 stated he was aware that R1 had used methamphetamines and assaulted R2. He stated he was fearful at the facility and concerned R1 could have a weapon. Upon interview on 10/27/25 at 9:40 a.m. LPN-C stated she heard about R1's assaulting of staff and R2. She stated she was scared and R2 was going to kill people. Upon interview via a Spanish interpreter on 10/27/25 at 10:20 a.m. R1 stated he recalled scratching the employee cars in the parking lot on 10/13/25, getting upset and attempting to hit staff with is his cane on 10/15/25 and then on 10/21/25 pushing R2 over in his wheelchair. He stated he was hearing voices. He stated he had received psychiatric care back in his country (Ecuador) for alcohol and mental health. He nodded his head yes to methamphetamine use in the past few weeks. He stated the lights and noises at the facility made him not be himself. He felt like the staff were all liars and joking about him. This was not the first time he had used illegal drugs. He did not answer the question of if he heard voices in the past. Upon interview on 10/27/25 at 1:01 p.m. the director of social services (SW)-A stated R1 started having behaviors after an unplanned leave of absence from 10/10/25 - 10/11/25. On 10/13/25 R1 was letting air out of the tires of staff cars in the parking lot. On 10/15/25 R1 physically assaulted registered nurse (RN)-A. On 10/15/25 R1 was discharged from the emergency department with a lab result showing R1 tested positive for methamphetamines. On 10/21/25 R1 pushed over R2 unprovoked in his room and was assaultive to staff. The paramedics took R2 to the hospital and he was there until 10/24/25. Upon interview on 10/27/25 at 1:26 p.m. the ADON stated R1's behaviors started on 10/13/25 when a housekeeper noticed R1 in the employee parking lot scratching cars and letting the air out of times. The ADON stated R1 was off his baseline. R1 told the police officers the television voices were telling him to scratch the cars. The officers told the ADON if he started behavior like that again to reach out to them. R1 left the facility for a couple of hours and the ADON had gone home before R1 returned. 10/14/25 a staff member reported to the ADON R1 was out in the parking lot again. The ADON went out to speak with R1. R1 admitted to hearing voices, but did not have a diagnosis for hearing voices. R1 stated he had heard voices before. The ADON told R1 if the voices felt real to let the staff know. R1's next situation was a few days later when he started going after RN-A with his cane. The ADON did not speak with R1 following R1's actions of trying to hit staff.The ADON stated she reported R1 hearing voices to the DON and she thought SW-A had reached out to the in-house psychiatrist to complete a diagnostic assessment. The ADON the believed the facility added interventions for R1 following the car scratching of 10/13/25 and the attempt to hit staff with his cane on 10/15/25 were to just be more alert to his behaviors. Upon interview on 10/27/25 at 2:14 p.m. the DON stated 10/13/25 was the date she felt R1 started a psychotic episode and at that point the staff was not aware R1 had used methamphetamine. R1 was scratching the cars and letting air out of the times in the staff parking lot. R1 told the DON as he scratched her car that the television told him to do it. She stated staff was to monitor him more often. On 10/15/25 R1 assaulted a staff member with his cane behind the nurse's station. R1 was taken to the emergency department and sent back hours later. On 10/21/25 the DON received a call from the facility stating R1 had pushed R2 over in his wheelchair. The police and paramedics had been called. The DON had the paramedics wait as she was obtaining a 72-hour hold on R1 since two days prior he had gone to the hospital with methamphetamine psychosis and was sent right back. R1 required acute psychiatric care due to the vandalism, assaulting of staff and the resident assault. The staff and residents were not safe. Upon interview on 10/27/25 at 3:10 p.m. LPN-A stated he had a week off prior to his shift on 10/21/25. He was unaware there were any concerns with R1. R1 was going in and out of the building from his room to the smoking area on 10/21/25, which was common for him. He was laughing and smiling, which was not out of the ordinary either, however he was speaking to himself in Spanish. LPN-A did not think anything of him speaking to himself. The facility was not completing 15-minute checks on him. A little after 8:00 p.m. on 10/21/he heard R2's roommates wife yelling for help. He ran to the room, R2 was on the floor, R1 was screaming at him ready to throw his wheelchair on him. LPN-A stood between them, and R1 was pushing him. LPN-A yelled for help and LPN-B responded and called the police. LPN-A got R1 out of R2's room and LPN-B tended to R2 along with a nursing assistant. R1 got angry and went outside. LPN-A called the DON, and she wanted to send both R1 and R2 to the emergency department and get a 72-hour psychiatric hold on R1. They were both taken to the emergency department. R2 was released later that evening with no concerns and R1 was hospitalized until 10/24/24. LPN-A had not worked with R1 since 10/21/25 and was told R1 had an aide monitoring one-to-one 24 hours a day. LPN-A stated the night of the 10/21/25 the officers did not want to take R1, but LPN-A told them he did not feel safe. LPN-A stated he wondered if R1 would be under the influence again at the facility. LPN-A stated R1 still goes out and God knows what he does which was why he got violent when he returned. Upon interview on 10/27/25 at 3:38 p.m. the Administrator stated on 10/13/25 R1 was found scratching cars and deflating tires. R1 was not redirectable when staff attempted. He was unaware the nurse practitioner had not been notified and stated she should have been. He was not certain whether the staff had started monitoring R1 for signs and symptoms of substance abuse or not. He believed the staff implemented 15-minute safety checks on R1 after he assaulted RN-A and was found to have methamphetamines in his system. The administrator stated there was an all staff training a few weeks prior on de-escalation. The training was their annual training and not regarding any specific resident for any specific reason. The Administrator stated he spoke with R2 daily following the assault and each day R2 was emotionally improving with his fears. R2 had been moved to a new room and was happy with his roommate and R1 apologized to him. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy with a revision date of 4/2025 indicated the purse was to protect residents against abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse.Prevention:1. Each referral received is assessed through the pre-admission medical screening process for susceptibility to abuse by individuals and their risk of abusing others. This assessment includes risk of self-abuse. Plans are developed and measures taken to minimize risks. Ongoing assessments are completed with each quarterly care conference.2. The Interdisciplinary Care Plan Team reviews residents requiring behavioral interventions at least quarterly and/or during Target Behavior meetings to develop individual behavior plans.3. Residents and families are informed of the Residents' Rights and Grievance procedure upon admission to the facility and annually through Resident Council.4. Department Directors are updated regarding falls and resident incidents and are responsible for ongoing supervision of subordinates regarding abuse prevention.5. Identification and analysis of physical environmental factors that may make abuse and neglect more likely to occur is completed and reviewed by the QAPI committee.

Based on observation, interview and record review, the facility failed to ensure appropriate treatment and/or services were provided to 1 of 3 residents (R1) reviewed for mental health needs. R1 was assessed with a history of alcohol abuse, extreme trauma, and mental health disorders with limited interventions. R1's mental health declined resulting in abuse towards staff and a resident (R2), calls to the police, and hospitalizations.Findings include: R1's nursing progress note by social services dated 3/24/24 at 3:28 p.m. indicated R1 was cognitively intact with minimal depression. R1's goal was to be strong and go home. R1 was offered the facilities inhouse psychiatry services and declined. The note did not indicate if client was offered opportunities for autonomy, arrangements to keep R1 in touch with his prior community and alcoholic anonymous group, cultural heritage, and religious practices. R1's care plan dated 3/24/25 indicated R1 had a history and diagnosis of substance abuse: alcohol use. R1's interventions on 3/24/25 were to educate R1 on the substance abuse policy and staff was to monitor and check vitals of resident if he was found under the influence. R1's care plan failed to thoroughly describe R1's distress from a person-centered perspective, it did not describe programs and/or activities to assist R1 in reaching and maintaining his highest level of mental and psychosocial functioning. In addition, the care plan did not have measurable language that allowed assessment of its effectiveness. R1's admission MDS dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 15 indicating he was cognitively intact. R1 required moderate assistance with toileting and showering. He required set-up assistance with personal hygiene. R1's pertinent diagnoses were displaced fracture of the neck and hand, alcohol abuse and adjustment disorder with mixed anxiety and depressed mood (a mental health condition characterized by a combination of symptoms typically associated with anxiety and depression, arising in response to a significant stressor or life change). R1's facility Target Behavior Form dated 6/6/25 indicated R1 was ordered duloxetine HCl (antidepressant used to treat a variety of conditions including mood disorders and chronic pain) and Melatonin (sleep aid). Charted behaviors were documented as non-applicable (NA). Non-pharmacological interventions were redirection and one-to-one visits. The behavior assessment did not indicate the purpose of R1's redirection or one-to-one visits. R1's care plan dated 6/6/25 - 10/25/25 did not indicate intentions for redirection or one-to-one visits for R1. R1's progress note dated 10/13/10:39 a.m. during morning meeting, the DON and intradisciplinary team (IDT) were notified by a housekeeping staff that R1 was out in the parking lot letting air out of the DON's vehicle tires. The DON went out and found resident at the far end of the parking lot near a grey truck, in the act of letting air out of the tires. When she asked R1 why he was doing this he mumbled something and went around to the other side of the truck and started letting air out of the front tire. The DON asked him to stop and when he was asked why she informed him she was calling 911. While she was on the phone with 911, R1 went to her vehicle and started letting air out of writer's rear passenger tire, she told R1 to stop touching her vehicle and R1 turned and went towards the front of the parking lot, to a black truck owned by another resident and began letting the air out of the rear driver's side vehicle, at that time the police arrived and started speaking with R1. Housekeeping staff called the DON over and pointed out a scratch on the passenger side of her vehicle. The scratch was approximately 12 in length and looked to be superficial. The officer asked R1 why he was doing that, and he said something about the TV and his mental health, it was unclear what he was saying (English is not his first language). The officer asked the DON if she wanted to press charges for the scratch and was told she did not, as it was superficial. The police officer suggested that R1 go back into the facility. R1's information was provided, and the DON's contact information was provided. The IDT would review R1's chart for any medication changes, behavioral notes, and review his substance use disorder (SUD) checklist to ensure resident's care plan was appropriate and up to date. When the DON returned to office, there was a voicemail from the police stating they had observed the R1 rolling down the frontage road as they were leaving. R1 signed the leave of absence (LOA) binder but did not supply information as to where he was going or when he would return. R1's progress note dated 10/13/25 indicated at 1:38 p.m. indicated R1 was on an LOA. There were no further progress notes until 10/15/25 at 1:29 p.m. R1's progress note dated 10/15/25 at 1:29 p.m. indicated at around 12:35 p.m. during this shift registered nurse (RN)-A noted R1 moving around with his wheelchair in the hallway speaking in Spanish. A few minutes later R1 came to the nursing station and reported his roommate's TV was loud. RN-A went to the room and found the TV was off and the roommate was asleep. RN-A encouraged R1 to go and sleep with no effect. R1 continued speaking in Spanish and exhibited anger outburst, using vulgar language to staff. R1 came to the nursing station and stated, call 911 I am having pain on my lower abdomen. R1 refused to allow RN-A to take his vital signs. 911 call was initiated. R1 continued speaking in Spanish and became aggressive toward RN-A. R1 knocked the nursing station computer with his cane twice and the computer fell to the floor. He also tried to hit RN-A with his cane while on the phone with the 911 dispatcher for the second time. He then started taking photos of RN-A with his iPad and took a wireless phone and threw it toward RN-A. Soon the paramedics and police arrived and took R1 to the emergency department. The DON was notified. R1's emergency department note dated 10/15/25 at 5:11 p.m. indicated R1's clinical impressions were psychiatric illness and methamphetamine-induced mood disorder and altered mental status. R1's assessment indicated due to chronic suicide ideation, severe chronic chemical dependency/alcohol, chronic intoxication, history of multiple violence, R1 had a chronic risk of suicide, accidental overdose/death, chronic risks for violence towards self and others, unable to care for self, has chronic risks of being a danger to self/society. R1 has a history of extreme trauma. R1 denied current suicidal or homicidal contracts for safety. R1 was willing to go to chemical dependency treatment and remain sober. He made many future oriented comments. R1 did not meet the criterial for a 72-hour psychological hold therefore he would be discharged back to the facility. R1 admitted to using methamphetamines 5 days ago and then again 3 days ago. R1 had auditory hallucinations to throw things, but denied auditory hallucinations to kill self, hurt self, or others. R1's risk assessment identified: risk of violence: chronic. Suicide assessment risk factors included - being male, unmarried, diagnosis of Major Depression, Bipolar, Schizophrenia, or Schizoaffective Disorder, diagnosis of chronic medical illness and/or chronic pain, problematic alcohol or drug use (current or historical), history of sexual or physical abuse, prior suicide attempt or aborted suicide attempt, recent history of loss (particularly interpersonal), and provider or treatment changes. R1's progress note dated 10/21/25 at 9:31 indicated R1 called 911 on himself. The assistant director of nursing (ADON) spoke with the police afterwards and they stated R1 had reported that he knows the facility was tapping into his devices and posting videos of him and broadcasting it to the world and people are looking at him and laughing. In addition, R1 stated to the officers that staff were putting things in his eyes to make him see what they want him to see. R1 was provided with his case worker and the police department's business cards. The officers stated they would give the case worker the information so they could follow up with the R1. R1 also requested the name and badge numbers of the police officers that responded. R1's nursing progress note dated 10/21/25 at 8:21 p.m. indicated licensed practical nurse (LPN)-A heard someone calling for help in R2's room. LPN-A rushed to the room and witnessed R2 on the floor with his wheelchair tipped over. R1 was standing over the other client threatening to cause more harm. It was reported that R1 had approached R2 throwing him on the floor. R1 was sent to the hospital for evaluation and a 72-hour hold. R1 was agitated and appeared not himself, R1 was threatening to cause harm to staff and taking staff's video stating that he was to call someone to come harm staff. client agreed to go to hospital. R1's incident report dated 10/22/25 at 10:31 a.m. indicated on 10/21/25 at 8:20 p.m. there was a resident-to-resident altercation. The incident was reviewed with the resident, direct care staff, the medical provider, and the IDT. The incident analysis indicated R1 was exhibiting paranoid behaviors earlier in the day. R1 was in the hallway and had flipped R1 out of his wheelchair. He stated I got you'll pictures, watch, see what happens holding a camera and making threats toward staff, R1 appeared upset that staff called law enforcement to intervene. The contributing factors were R1's diagnoses of double below the knee amputation, muscle weakness, other signs involving cognitive function and awareness were fatigue, major depression disorder and adjustment disorder. R1's prescriptions were cyclobenzaprine (muscle relaxant) which R1 had not taken recently, duloxetine (anti-depressant), melatonin (natural sleep agent), metoprolol (blood pressure medication), gabapentin (for seizure and nerve pain), and Seroquel (anti-psychotic). R1 had been having refusing his mediations and having erratic behaviors in the past week. R1 had a history of substance abuse. R1's interventions indicated to see his care plan. Other interventions included R1 was taken by paramedics/police department. If he returned to the facility, he would be on 15-minute checks for safety. R1 was already on substance use monitoring. R1's medical record lacked a reassessment or if care planned interventions for support treatment or services for mental health concerns were provided to R1 as it related to his mood or behavior to attain the highest practicable mental and psychosocial wellbeing of R1. Interventions and position responsible included: MDS section D/PHQ 9 will be conducted per regulation and PRN. Date Initiated: 3/24/2025 Social Service Designee (SSD) Monitor and document mood state/behaviors upon occurrence. Date Initiated: 03/24/2025 Nursing (NSG) Redirect prn. Date Initiated: 03/24/2025 NSG Social Services to assist resident and family prn. Date Initiated: 04/18/2025 SSD Encourage utilization of social supports. Date Initiated: 04/18/2025 SSD Staff to visit with resident one on one during cares and prn. Date Initiated: 04/18/2025All Provide emotional support, validation, and comfort measures prn. Date Initiated: 3/24/2025 All Introduce resident to other residents with similar interests. Date Initiated: 04/18/2025All Monitor Target Behaviors per protocol. Date Initiated: 04/18/2025 NSG Upon interview on 10/23/25 at 3:45 R1's Nurse Practitioner (NP) stated she saw R1 on 10/16/25 because he was in the emergency department on 10/15/25. She stated R1 appeared paranoid, and she believed it was fear after he admitted he used methamphetamines. She was not certain of any changes the facility made with R1 following the assault on a staff member, damaging facility property, and a positive methamphetamine test. She was not aware of any psychosocial therapies the facility was working on with R1. Upon interview via a Spanish interpreter on 10/27/25 at 10:20 a.m. R1 stated he recalled scratching the employee cars in the parking lot of 10/13/25, getting upset and attempting to hit staff with is his cane on 10/15/25 and then on 10/21/25 pushing R2 over in his wheelchair. He stated he was hearing voices. He stated he had received psychiatric care back in his country (Ecuador) for alcohol and mental health. R1 did not recall refusing in-house therapy services he was offered upon his admission. He denied being offered treatment for his alcoholism while at the facility. He was going to alcoholics anonymous (AA) meetings when he was staying at the shelter before he ended up in the hospital. He would like to go to those meetings, but did not know how to get there. He stated the reason he drank and used drugs was because he lost his legs and realizes that he had probably rehabilitated himself to where he will be the rest of his life. He stated he drinks alcohol almost daily and refused to answer how often he used illegal drugs. Upon interview on 10/27/25 at 1:01 p.m. the director of social services (SW)-A stated R1 started having behaviors after an unplanned leave of absence on 10/10/25 - 10/11/25. On 10/13/25 R1 was letting air out of the tires of staff cars in the parking lot. On 10/15/25 R1 physically assaulted registered nurse (RN)-A. On 10/15/25 R1 was discharged from the emergency department with a lab result showing R1 tested positive for methamphetamines. On 10/21/25 R1 pushed over R2 unprovoked in his room and was assaultive to staff. The paramedics took R2 to the hospital and he was there until 10/24/25. SW-A stated every resident gets offered in-house therapy visits. She denied offering R1 chemical dependency inpatient or outpatient or any therapeutic interventions while he at the facility due to his age, English as a second language, trauma from being found frost bitten unconscious and bilateral below the knee amputations. She was not aware of any treatment offered to R1 after his behavior changed and he was found to have used methamphetamines while being at the facility. SW-A was not aware if the facility staff had knowledge of how to support R1 when he was distressed. Upon interview on 10/27/25 at 2:14 p.m. the DON stated she was aware that residents were officed in-house psychiatry upon admission and it was their right to refuse it. She stated she thought SW-A had reached out to the in-house provider to complete a diagnostic assessment on R1 following the incident on 10/15/25 when R1 assaulted staff and was found to have methamphetamines in his system. The DON denied knowledge of R1 being offered chemical dependent or other treatment outside the facility during his stay. A policy for treatment and/or services for mental and psychosocial concerns was requested however none was provided.

Based on observation, interview and record review the facility failed to assess residents for the ability to self-administer medications, or obtain orders for leaving medications at bedside and/or self-administration for 1 of 1 (R21) residents reviewed for self-administration of medications.Findings include: R21's face sheet dated 8/7/25, indicated R21 was re-admitted to facility on 7/30/25 and had the following diagnoses: end stage renal failure, fluid overload, conversion disorder with seizures, hypertension, cerebral infarction, pulmonary edema and need for assistance with personal care.During observation on 8/04/25 at 6:18 p.m., an albuterol inhaler with resident's name on the label, and a bottle of Ocean nasal spray with resident's name on the label was noted on the bedside table.During observations on 08/06/2025 at 9:49 a.m., an albuterol inhaler with resident's name on the label was observed on the bedside table.During observations on 08/06/2025 at 11:22 a.m. and 1:38 p.m., a bottle of Ocean nasal spray with resident's name on the label was noted on the bedside table.Review of R21's medical record lacked a self-administration of medications assessment, an order to self-administer medications and/or leave medications at bedside and lacked an order for Ocean saline nasal spray.During interview on 08/06/25 at 1:51 p.m., registered nurse (RN)-A stated she was familiar with R21 and worked with him often. RN-A stated if a resident had an order to self-administer medications (SAM) or leave at the bedside the order would be in the electronic medical record (EMR). RN-A confirmed there was a bottle of Ocean nasal spray on R21's bedside table and there was no order for SAM. RN-A stated R21 required a medication SAM assessment before he could have medications at the bedside or self-administer medications.During interview 08/06/25 at 4:12 p.m., director of nursing (DON) stated any resident who wished to self-administer medications needed to be competent and assessed. If found to be safe to self-administer, a SAM order would be obtained from the provider. DON confirmed R21 did not have a SAM order, lacked an order to leave medications at bedside and was unable to locate an order for Ocean Nasal spray. DON went on to say she expected staff to verify if a resident had a SAM order before allowing residents to self-administer or keep medications as the bedside. DON stated it was important to assess and obtain a SAM order to ensure resident safety and cause no harm.A medication self-administration policy was requested but not provided

Based on record review, and interview the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 5 (R12, R21) upon transfer to the hospital. Findings include: R12 face sheet dated 8/7/2025, indicated R12 was admitted on [DATE] and had the following diagnoses: wound of the lower back and pelvis, major depressive disorder, paraplegia, pulmonary embolism (blood clot in lung), gunshot wound, neurogenic bladder, incontinence, septicemia (blood infection), and neurogenic bowel. R12's hospital transfer form dated 6/2/25, indicated R12 was hospitalized on [DATE]. R12's progress notes indicated R12 was hospitalized from [DATE]-[DATE]. R12's medical record lacked evidence a written notification of transfer was sent to the office of the Ombudsman for long term care. R21's face sheet dated 8/7/25, indicated R21 was re-admitted to facility on 7/30/25 and had the following diagnoses: end stage renal failure, fluid overload, conversion disorder with seizures, hypertension, cerebral infarction, pulmonary edema and need for assistance with personal care. Review of R21's medical record indicated R21 hospitalized from [DATE] thru 7/20/25. The record lacked any documentation of notification to the Ombudsman for long term care office. Documentation of Ombudsman notification was requested for June and July 2025, however none provided On 8/7/25 at 10:37 a.m., the social services worker (SS)-A stated they were responsible for completing the ombudsman notifications by the 7th of every month, however they had only been working at the facility for two weeks, and the date in question they were not employed there. However, it would have been the responsibility of the social worker at the time and was missed. SS-A stated the importance of sending the notice to the ombudsman to limit the number of transfers and prevent re-hospitalizations if possible. On 8/6/25 at 08:24 a.m., the administrator confirmed the previous social worker had not completed the Ombudsman notifications in June or July of 2025. The facility's transfer, or discharge notice for discharged policy last reviewed 2/1/23, indicated a copy of the notice of transfer or discharge is sent to the office of the state long term care Ombudsman at the same time the notice of transfer of discharge is provided to the resident.

Based on observation, interview and document review, the facility failed to complete proper checks for 1 of 1 residents (R58) reviewed for medication administration documentation.R58's significant change MDS dated [DATE], included diagnosis of psychotic disorder and depression. R58's Moments Hospice order dated 6/7/25, included an order for lorazepam 0.5 mg by mouth every 4 hours as needed for terminal agitation (restlessness that occurs close to death). R58's Order Summary Report dated 8/6/25, included an order for lorazepam oral tablet 0.5 milligrams (mg) by mouth every 4 hours as needed for terminal agitation. Facility narcotic book included an entry for R58 for lorazepam liquid give 0.5 milliliters (mL) every 4 hours. Administrations were documented for 7/8 and 7/9. Medication record for R58 included administration for lorazepam oral tab 0.5 mg was administered on 7/8/25 and 7/9/25. During interview on 8/7/25 at 11:53 a.m., registered nurse (RN)-A stated she would review the original order if she had a question during medication administration. RN-A confirmed the medication record said oral tabs, However, the narcotic book said liquid medication for the same time and documentation. During interview on 8/7/25 at 11:59 a.m., director of nursing (DON) stated she would expect staff to complete the five rights of medication administration (right resident, right drug, right dose, right route, right time) prior to administering a medication. The DON expected staff to clarify with the pharmacy and update the medication record if there were changes. The DON confirmed a change from tablets to liquid form would require a new order. During interview on 8/7/25 at 12:21 p.m., consultant pharmacist (CP) confirmed a new order was necessary if changing from tablet to liquid form of a medication. Facility policy for medication administration dated April 2018, included a triple check of the five rights is recommended during administration. The five rights include: right resident, right drug, right dose, right route, and right time. The facility included the physician was to be contacted for a new order prior to changing from pill solid tablet to liquid dosage.

Based on interview and document review the facility failed to ensure coordination of care and communication between the facility and the dialysis center for 1 of 1 residents (R21) who received hemodialysis. Findings include:R21's admission minimum data set (MDS) dated [DATE], indicated R21 had diagnoses of anemia, hypertension, renal insufficiency, renal failure, or end stage renal disease (ESRD) and was receiving hemodialysis. Additionally, the MDS indicated R21's brief interview of mental status (BIMS) score was 15 indicating R21 was cognitively intact.During interview on 8/4/25, at 5:40 p.m., R21 stated he attended dialysis three days per week on Tuesday, Thursday and Saturday.R21's clinical physician orders report printed 8/7/25, indicated the following orders: hemodialysis scheduled every Tuesday, Thursday and Saturday at Davita Dialysis Center of [NAME], monitor dialysis site for bleeding, monitor fistula for bruit and thrill, complete post dialysis vital signs, complete dialysis communication form and send with resident to dialysis, and review post dialysis treatment report for updates; if none found call dialysis.Review of R21's care plan indicated R21 was at risk for complications due to dialysis and listed goals of attending dialysis per schedule and resident will have no uncontrolled bleeding from fistula. Care plan interventions included calling 911 for bleeding, attending dialysis per schedule, treatment and dressing protocol to dialysis site per physician order, and send communication folder/form to each dialysis appointment.During interview on 8/5/25 at 3:10 p.m., registered nurse (RN)A stated she printed out a med list on R21's dialysis days and would send it with to the appointments. She went on to say staff completed a dialysis communication form and fill out any pertinent information. RN-A then pointed to a white binder located on the desk of the nurse's station. RN-A stated she did not routinely send a dialysis communication form unless there was a change since the previous dialysis appointment and had not sent the form with R21 for that day's appointment. RN-A also stated if the resident did not bring back a form from dialysis, she would not call for an update.Review of the dialysis binder lacked any completed communication forms for R21 for the months of June, July and August 2025.Review of R21's electronic medical record (EMR) indicated staff had completed and sent the form with R21 to dialysis on the following dates: 7/1/25, 7/3/25, 7/5/25, 7/8/25, 7/10/25, 7/12/25, 7/15/25, 7/17/25, 7/19/25, 7/22/25, 7/24/25, 7/31/25, 8/2/25 and 8/5/25. The EMR also indicated staff had reviewed the post dialysis treatment report for the following dates: 7/1/25, 7/3/25, 7/5/25, 7/8/25, 7/10/25, 7/12/25, 7/15/25, 7/17/25, 7/19/25, 7/22/25, 7/24/25, 7/31/25, and 8/2/25.During interview on 8/5/25 at 3:28 p.m., the Director of Nursing (DON) stated residents on dialysis had a dialysis communication form completed by nursing staff prior to each dialysis appointment and sent with resident to dialysis. Upon the residents' return, the nursing staff reviewed the communication form for any new information or orders. DON went on to say nurses were to document in the EMR completion of and review of the communication form before/after each dialysis appointment. DON then confirmed although the EMR contained documentation of the completed/reviewed communication form, R21 had not had any dialysis communication forms completed since May 2025. DON stated her expectation was nursing staff completed the form. DON went on to state it was important to have ongoing communication with the dialysis center for resident safety, and to be sure there was no additional orders from the dialysis center.Facility policy titled Hemodialysis dated 11/22/19, indicated facility staff and the dialysis center will have ongoing communication and collaboration regarding dialysis care and services; if the dialysis run information is not received with the resident upon return, facility staff will call the dialysis unit to obtain the information; Documentation requirements will be met to assure that treatments are provided as ordered by the nephrologist, attending practitioner, and dialysis team; Documentation should include, but is not limited to, pre and post dialysis assessment/observation, daily check of access site, evaluation for signs and symptoms of infection, and fluid intake amounts for each shift with a 24 hour total, if a fluid restriction was in place.

Based on observation, interview and record review, the facility failed to properly dispose of controlled medication for 2 of 2 residents (R57, R58) reviewed for disposal of medications after discharge.R57's death in facility minimum data set (MDS) dated [DATE], included R57 was discharged /deceased on [DATE].R57's Order Summary Report printed [DATE], included an order for lorazepam oral concentrate 2 mg/ml (a medication give for anxiety) give 0.25 milliliters (mL) by mouth every 2 hours as needed for restlessness and anxiety AND give 0.25 mL by mouth every 4 hours for restlessness and anxiety.During tour of medication room on [DATE] at 1:50 p.m., assistant director of nursing (ADON) opened lock box used to store controlled substances requiring refrigeration. Lock box contained a box containing a bottle with a label that identified it as lorazepam 2mg/ml for R57. ADON was unable to locate tracking page for R57's lorazepam in narcotic book currently being used in the facility. ADON was able to locate the tracking for R57's lorazepam in an unused book in the medication room in a cupboard. The last time count of narcotics in book containing R57's lorazepam was documented as completed was on [DATE]During interview on [DATE] at 1:50 p.m., ADON confirmed R57 was no longer a resident at the facility. ADON confirmed the medication was not in any of the current narcotic tracking books in the facility and was written down for tracking in an unused book that was stored in the cupboard. ADON confirmed tracking of the controlled substance was not being completed since [DATE] when the book was retired from use.R58's significant change MDS dated [DATE], included diagnosis of psychotic disorder and depression.R58's progress note dated [DATE] at 12:45 p.m., included R58 passed away in the presence of a hospice nurse while in the facility.R58's Moments Hospice order dated [DATE], included an order for lorazepam 0.5 mg by mouth every 4 hours as needed for terminal agitation (restlessness that occurs close to death).During tour of medication room on [DATE] at 1:50 p.m., ADON opened lock box used to store controlled substances requiring refrigeration. Lock box contained a box containing a bottle with a label that identified it as lorazepam 2mg/ml for R58.During interview on [DATE] at 1:50 p.m., ADON confirmed R58 was no longer a resident at the facility and floor staff should have disposed of the medication. Destruction of controlled medications was witnessed by two licensed staff members. During interview on [DATE] at 8:13 a.m., director of nursing (DON) stated all medications were counted at shift change or any time the medication cart/narcotic keys change hands during the shift. DON stated previously all refrigerated controlled medications were tracked in a narcotic book that was kept in the medication room, however, that would be changed because it was noted the counts were not being completed every shift as required. The DON stated it was important to complete narcotic counts to prevent medication diversion and to know what medication was on hand. During interview on [DATE] at 8:56 a.m., consultant pharmacist (CP) stated medications should be disposed of or destroyed when a resident discharges or passes away. CP stated there was not a specific time frame for destruction, however believed within a week would be reasonable. CP confirmed a resident who passed away in July should have had medications destroyed. Facility policy for disposal of controlled substances dated [DATE], included all medications should have been disposed of by two licensed nurses and documented in a record book after a resident had been discharged .

Based on observation, interview and document review, the facility failed to properly store controlled substances in 1 of 1 medication rooms reviewed for medication storage.During tour of medication room on 8/6/25 at 1:50 p.m., assistant director of nursing (ADON) showed the unlocked medication refrigerator with small unaffixed lockbox. ADON removed the lockbox from the refrigerator and unlocked it to show 6 controlled medications in the lock box. During interview on 8/6/25 at 1:50 p.m., ADON confirmed the lockbox was not permanently affixed to the refrigerator. ADON stated the facility had explored options to attach the lock box but had not yet found a solution. ADON described the box as similar to the size of an iPad and about 4 inches thick. ADON confirmed the whole box could be removed from the medication room. During interview on 8/7/25 at 8:13 a.m., director of nursing (DON) stated controlled refrigerated medications were stored in the refrigerator in the locked medication room in a lock box. The DON confirmed the lock box was not permanently affixed to the refrigerator because they have not figured out how the facility would like to secure it. The DON confirmed the controlled medication are double locked, but not in a permanently affixed compartment. The DON stated this was important to prevent diversion of medications.During interview on 8/7/25 at 8:56 a.m., consultant pharmacist (CP) stated controlled substances should have been stored in a permanently affixed double lock compartment to prevent diversion. The CP stated the pharmacy does complete routine audits of the medication storage and had noted this to be an issue during a recent audit and had reported the findings to the facility.Facility provided policy for medication storage dated August 2019, included controlled substances that require refrigeration are stored within a locked box in the refrigerator that must be attached to the inside of the refrigerator.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was performed when providing wound care for 1 of 3 residents (R2) reviewed for pressure ulcer care. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment and moisture associated skin wounds. R2's care plan dated 4/6/25 indicated enhanced barrier precautions (EBP, measures intended to prevent the spread of multi-drug-resistant organisms) related to a catheter and wounds. The care plan further directed staff should don/doff personal protective equipment (PPE) per EBP when providing high contact care. The care plan was revised on 5/29/25, and indicated R2 had a pressure ulcer on the left lateral foot, and staff would monitor for signs and symptoms of infection. R2's wound care orders dated 5/27/25, indicated apply Santyl (prescription ointment to treat wounds) to the left lateral foot wound topically every evening shift every Tuesday, Thursday, and Saturday. On 6/3/25 at 4:14 p.m., during an observation, licensed practical nurse (LPN)-A performed wound care for R2. LPN-A sanitized her hands and donned gloves prior to entering the room. LPN-A moved R2's right foot away from the left foot, doffed gloves and donned clean gloves without sanitizing hands. LPN-A opened a pack of gauze, doffed gloves and donned clean gloves without sanitizing hands. LPN-A removed the dressing from the wound on the left foot, doffed gloves, and donned clean gloves without sanitizing hands. LPN-A then cleaned R2's foot wound, doffed gloves, and donned clean gloves without sanitizing hands. The director of nursing (DON) entered the room at 4:30 p.m. to assess R2's left foot wound. LPN-A stated she was going to clean the wound again because R2 put his foot in a protective boot before she dressed the wound. LPN-A donned gloves, cleaned the wound, doffed gloves, and donned clean gloves without performing hand hygiene. LPN-A applied Santyl to the wound, doffed gloves, and then donned clean gloves without performing hand hygiene. The DON asked LPN-A if she sanitized her hands before donning clean gloves, and LPN-A acknowledged she had not and stated, You have to do that? The DON instructed LPN-A to perform hand hygiene after doffing gloves and before donning clean gloves. LPN-A continued towards R2 to provide care with the same gloves, and the DON stopped LPN-A and stated, You can stop and do it now [doff gloves and sanitize hands before continuing wound care]. LPN-A doffed gloves, sanitized hands, donned gloves, applied the dressing, and started to don clean gloves without sanitizing hands. The DON instructed LPN-A to sanitize her hands. On 6/3/25 at 4:42 p.m., LPN-A stated, Oh wow. We need to sanitize between each glove change. I will have to put my bottle [of hand sanitizer] next to me when I do wound care. She acknowledged she had not performed hand hygiene between gloves changes, and stated she did not know she was required to. She should perform hand hygiene between gloves changes to prevent infection in the wound. On 6/3/25 at 4:49 p.m., the DON acknowledged LPN-A had not performed hand hygiene between gloves changes, but the expectation was to sanitize hands between gloves changes, and change gloves between clean and dirty cares. The Wound Care Treatment Procedure dated 2/2024, directed complete hand hygiene after removing gloves, and prior to donning another pair of gloves.

Based on interview and document review, the facility failed to ensure annual performance reviews were completed for 1 of 1 nursing assistants (NA-A) whose personnel files were reviewed. This deficient practice had potential to affect all residents who currently resided in the nursing home and who could receive care from this staff. Findings include: NA-A was hired on 10/27/23. NA-A's personnel record lacked evidence an annual performance review was ever completed. On 4/21/25 at 12:14 p.m., during an interview NA-A stated he was hired in October 2023, and had not had a performance evaluation. On 4/21/25 at 4:22 p.m., during an interview the director of nursing stated performance reviews were expected to be completed every 12 months, and acknowledged NA-A's performance review was due in October 2024, and had not been completed. A policy on performance reviews was requested; the facility did not have a policy about performance reviews.

Based on interview and document review, the facility failed to ensure an allegation of potential abuse for 1 of 1 resident (R1) who complained of rough care by staff, was reported immediately but no later than 2 hours to the State Agency (SA). Findings include: On 4/21/25, a review of a facility Grievance Form dated 4/6/25, indicated [NAME] police contacted the facility and spoke to the Social Services Director (SSD) and informed the SSD a Minnesota Abuse Reporting Center (MAARC) report was filed indicating a nursing assistant (NA) was rough when getting R1 into his wheelchair on 4/6/25 around 4:30 p.m., and R1's leg and abdomen were subsequently hurting. On 4/21/25, the SSD was not available for interview. On 4/21/25 at 11:51 a.m., during an interview registered nurse (RN)-A stated when she learned of any type of abuse, she was expected to report it to the director of nursing (DON) right away, and the facility had 24 hours to report it to the SA. On 4/21/25 at 12:35 p.m., during an interview NA-A stated if he saw abuse, he was expected to report it to a nurse, the assistant DON, or the DON immediately, and the facility would report to the SA within two hours. On 4/21/25 at 2:35 p.m., during an interview NA-B stated she had abuse training three weeks prior and learned she was required to report abuse to a nurse immediately when she saw or heard about it, and the facility was required to report abuse to the SA within 24 hours. On 4/21/25 at 1:40 p.m., during an interview, the DON stated the facility was aware of the SA report by another entity. The DON stated she consulted with the SSD about the incident, and inquired if the facility should file a MAARC report. The DON stated she was advised by the SSD the incident was now after the fact, someone else filed the report, so the facility was not required to file an additional report. The DON confirmed the allegation had not been reported to the SA. The DON stated she thought the facility was required to file MAARC reports within 24 hours of learning of an abuse allegation. The DON reviewed the facility Abuse Prohibition/ Vulnerable Adult policy and acknowledged the facility did not file a report, and should have filed a separate report. On 4/21/25 at 2:15 p.m., during an interview, the social services designee (SS)-A stated he was familiar with R1's incident, and knew maltreatment allegations were expected be reported to the SA, But it would depend upon the severity of the injury to the resident. SS-A stated he thought maltreatment should have been reported within 24 or 72 hours. SS-A stated the facility should have reported the incident to the SA and was unsure why the facility did not. Review of the Abuse Prohibition/Vulnerable Adult policy, updated 2/2025, indicated suspected abuse would be reported to the OHFC [Office of Health Facility Complaints] reporting process not later than 2 hours after forming the suspicion of abuse.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of 8 consecutive hours a day. This had the potential to affect all 35 residents who resided at the facility. Findings include: Review of the facility daily staffing hours and staff schedules from 2/1/24-4/30/24, indicated there was no RN scheduled on the following dates: 2/10/24, 2/17/24, 2/18/24, 2/25/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, 3/32/24, 4/6/24, 4/7/24, 4/13/24, 4/14/24, 4/20/24, 4/21/24, 4/27/24, and 4/28/24. During interview on 5/01/24 at 2:38 p.m., the staffing coordinator verified there was not an RN working 8 consecutive hours on the dates above and stated they do not have any RN's on staff except the assistant director of nursing (ADON), the director of nursing (DON), and the occasional agency/pool nurse. The staffing coordinator further stated the ADON and DON are not included on the schedule during the week so they can be pulled in if needed. They are not scheduled to work on the weekends but take turns being on call if there are questions or a licensed practical nurse (LPN) calls in. During interview on 5/2/24 at 8:38 a.m., LPN-D stated there are never registered nurses (RN) working on the floor, the only RN's we have work days and they are management. There have been times when we've needed someone higher up to explain things to us, so we call the on-call or the provider. They also have a manager on duty on the weekends but not all of the managers are RN's. During interview on 5/2/24 at 8:52 a.m., LPN-A stated there are not RN's working on the floor but the ADON and the DON are RN's. LPN-A further stated if there was a problem during the shift she would notify the on call physician.The facility doesn't notify them when there isn't an RN on shift, they just know from looking at the schedule. During interview on 5/1/24 at 3:30 p.m., the ADON verified she was an RN and stated she generally doesn't work weekends but they have a manager on duty (MOD) that was required to work 4 hours/day on the weekends. The ADON further stated not all the MOD's were RN's and the managers rotate through all the monarch managers. During interview on 5/1/24 at 3:40 p.m., the DON verified she was an RN and was not scheduled to work weekends, however she works an occasional weekend as an MOD which requires all monarch managers to work 4 hours a day on rotating weekends. The DON stated not all MOD's were RN's and she was also on-call every other weekend if the LPN's have questions or if there are call in's. During an interview on 5/2/24 10:20 a.m., the administrator verified there was no RN's working 8 consecutive hours a day on the dates listed above and if staff needed an RN on the weekends, they should call the ADON or the DON. They also have a MOD every weekend and the MOD was required to work 4 hours a day (each day) but not all of them were RN's. The administrator further stated they have been trying to hire RN's but for a long time they weren't getting any applicants and hospitals pay their employee's more. They recently switched to a new hiring platform and have been getting more applicants and they recently hired 2 RN's who are still training but will be ready to start soon. They also have some LPN's that are in school to be RN's. The facility does not have a policy on staffing.

Based on observation, interview, and document review, the facility failed to provide ordered podiatry care for 1 of 1 resident (R23) reviewed for foot care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and extensive assist required with personal hygiene and bathing. Diagnoses included of heart failure (affects blood circulation), respiratory failure, hypertension, morbid obesity, and candidiasis (fungal infection) of nail. Anticoagulant medication was taken daily. R23's care plan dated 3/29/24, identified self-care deficit related to history of repeated falls, bilateral osteoarthritis, chronic pain, weakness, morbid obesity, difficulty walking, muscle weakness, other fatigue, other abnormalities of gait. Assist of one staff was required with personal grooming and hygiene. R23's nurse practitioner order dated 7/21/23, identified consult podiatry for diagnosis of overgrown toenails. R23's medical record dated 7/21/23 through 5/2/24, lacked documentation a podiatry visit was completed. During an interview and observation on 4/29/24 at 8:38 a.m., R23 stated she needed podiatry because she couldn't reach her feet, staff had not completed nail care during her bed baths and her toenails were long, torn, yellow, and dirty looking. R23's left foot toenails measured about 1/4 inch above the pink, yellow, thickened and beginning to curve off to the side. R23's right foot toenails were slightly shorter but were also yellowed and thickened. During an interview on 4/30/24 at 1:13 p.m., nursing assistant (NA)-A stated nail care was done on bath days except for residents with diabetes or other concerns, then the nurse or podiatry did it. NA-A stated she was not sure when R23's nail care was last done. NA-A stated R23's nails were longer and thicker, and the health unit coordinator (HUC) would set up podiatry. During an interview on 4/30/24 at 1:15 p.m., the HUC stated the podiatrist came to the facility about once a month and she did not think F23 had been seen historically. The HUC reviewed R23's medical record and did not find evidence the podiatry order was initiated. During an interview on 4/30/24 at 5:16 p.m., licensed practical nurse (LPN)-A stated R23's asked about her toenails today and upon nurse evaluation of the nails, podiatry was needed due to thick nails. LPN-A stated the nails on R23's right foot were too thick to cut now with regular nail clippers and the HUC should make an appointment for podiatry. During an interview on 4/30/24 at 5:30 p.m., the director of nursing (DON) stated ancillary services including podiatry were addressed at care conferences, then the HUC was updated, and the residents were added to the visit list. The DON stated residents with diabetes, blood thinner medications, or if nails were too thick with fungus would require special tools from podiatry in order to avoid potential injury. During a follow up interview on 5/2/24 at 12:30 p.m., the DON stated at the time the nurse practitioner ordered R23's podiatry, the HUC thought transitional care unit (TCU) residents could not be seen by podiatry, but now they know that is not true, so R23 was now placed on the podiatry visit list. The undated facility policy titled Foot care identified trained staff may provide routine foot care (i.e., toenail clipping within professional standards for residents without complicating disease processes. Residents with foot disorders or medical conditions associated with foot complications would be referred to qualified professionals. Residents would be assisted to make transportation appointments to and from specialists such as a podiatrist as needed.

Based on interview and document review, the facility failed to ensure prescribed medications were available for 1 of 1 resident (R23) who was awaiting a new medication. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and extensive assist required with personal hygiene and bathing. Diagnoses included heart failure (affects blood circulation), respiratory failure, hypertension, and morbid obesity. There were no ulcers, wounds, skin problems or skin treatments identified in the MDS. R23's activities of daily living (ADL) care area assessment (CAA) dated 6/8/23, identified the CAA triggered since resident needed extensive assist with most ADLs related to her respiratory condition and morbid obesity. R23's care plan dated 8/11/23, identified an alteration in skin integrity due to multiple areas of self-inflicted skin tears. The goal was to have skin breakdown resolved by next review. Skin was to be monitored daily during cares, weekly skin inspection by the nurse, and to provide treatment to open areas as ordered. R23's provider order dated 4/25/24, identified start the medication N-acetyl-cysteine (an amino acid supplement) 1,000 milligrams (mg) three times by mouth daily for the diagnosis of skin picking. R23's medication administration record (MAR) dated 4/26/24 through 5/2/24, identified the medication had not been given since it was ordered (15 potential doses missed). R23's electronic MAR (eMAR) notes dated 4/25/24 through 5/2/24, lacked follow up documentation to obtain the medication. During an interview and observation on 4/29/24 at 8:38 a.m., R23 stated she had not received her medication that was ordered for skin picking. R23 stated I pick at myself; I can't help it. R23 had around 10 pencil eraser sized dried brownish red spots which resembled dried blood on her right and left bedgown arm sleeves. During an interview on 4/30/24 at 1:13 p.m., nursing assistant (NA)-A stated R23 had a behavior where she picked which caused bleeding. NA-A stated R23 had her own lotion to put in it. During an interview on 4/30/24 at 5:16 p.m. licensed practical nurse (LPN)-A stated R23 picked at her skin and saw psychology. LPN-A stated R23 took N-acetyl-cysteine in the past. LPN-A stated most medications came from the pharmacy; however, N-acetyl-cysteine was considered a house stock medication, so the business office manager (BOM) oversaw ordering medications. During an interview on 5/1/24 at 11:33 a.m. the pharmacy technician (PHT) from R23's pharmacy stated the N-acetyl-cysteine order was sent from the facility to the pharmacy, however, the pharmacy required a house stock medication form to be filled out by the facility. The PHT stated the facility had not followed up with the form, so no medication was sent out. During an interview on 5/1/24 at 11:37 a.m. the BOM stated she thought she had ordered some house stock medications in April but was not sure. The BOM stated she would review her records to see which medications were ordered. During an interview on 5/1/24 at 2:09 p.m., registered nurse (RN)-A stated R23 had not received the medication in almost a week, and the missing medication should have been addressed sooner. RN-A stated he had not called the pharmacy but had marked the order for someone to follow up and notify the provider. A list titled House Stock Medications dated 5/1/24 at 3:26 p.m., from the administrator, lacked notation N-acetyl-cysteine had been ordered. During an interview on 5/2/24 at 11:45 a.m., the director of nursing (DON) stated she had noticed the scabs on R23's arms from picking, and this was a long-term behavior. Additionally, if the pharmacy was not able to provide a house stock medication, then the facility staff would go out and buy the medication. The DON stated the medications should be obtained that way the same day, and before two days at the most. The Facility assessment dated [DATE], identified services the facility offered included administration of medications that residents needed, and vendors were in place to provide supplies and services.

Based on interview and document review the facility failed to follow physician orders to relieve [CONDITION(S)] and for [CONDITION(S)] stent removal, failed to comprehensively assess intake and output, and failed to consistently monitor for signs and symptoms of urinary tract infection for 1 of 1 resident (R1) who had history of urinary [CONDITION(S)]. The deficient practice resulted in harm when R1 was readmitted to the hospital for urinary [CONDITION(S)]. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, MDS indicated R1 required extensive assist by two staff for toileting. R1's pain care plan dated 5/19/2021, identified R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge summary dated 8/4/22, indicated R1 was admitted to the hospital on 7/29/22 with severe [CONDITION(S)] secondary to complicated urinary tract infection ([CONDITION(S)]) due to E.Coli (type of bacteria). Further found to have obstructive left ureter stone with hydronephrosis (buildup of urine in the kidneys) Additionally noted, R1 was at a higher risk for re-hospitalization related to infections secondary to renal stones. During the hospital course R1 had a ureteroscopy with stone basketing (procedure to break up stones) and a stent was placed in the left ureter. The discharge summary included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary also included instructions for after foley removal. R1's physician orders included order dated 8/4/22 complete infection note for [CONDITION(S)] in progress note every shift (stop date 8/27/22) R1's care plan did not identify R1's risk for urinary tract infections and/or history of urinary [CONDITION(S)] nor include interventions to prevent urinary tract infections. Further the care plan did not identify R1's [CONDITION(S)] stent placement. Although R1's record identified ongoing vital sign monitoring it was not evident R1's urine integrity was being consistently monitored for changes or monitoring for symptoms specifically related to bladder infections (examples: frequency, urgency, burning/pain during urination). R1's urology visit note dated 8/9/22, indicated visit related to follow up after URS (ureteroscopy; thin flexible scope used to treat small to medium kidney stones) for ureter stone and stent placement. The note indicated a 3 mm (millimeter) left ureter stone that was treated. Note identified R1 had large stone burden in the left kidney; stones were non-obstructing. URS and ESWL (extracorporeal shock wave lithotripsy; non-invasive treatment to break up stones) would unlikely clear the stones. Options of treatment were discussed with R1, R1 preferred observation. We will remove the [CONDITION(S)] stent in about 1-2 weeks. Review of R1's current physician orders printed 10/25/22, included schedule outpatient urology appointment dated 8/11/22, and schedule patient for follow up visit with urology within the next two weeks to discuss left [CONDITION(S)] stent removal which had an order date of 8/25/22. R1's record does not identify the appointment was scheduled nor evidence R1's stent was removed. R1's hospital discharge summary dated 8/16/22, identified R1 was admitted to the hospital on 8/11/22 for cardiac complications. R1 discharged back to the facility on [DATE]. Discharge orders directed staff to insert straight catheter every six hours as needed for no urination or if high post void residual greater than 400 ml on bladder scan if able to use bladder scan. R1's physician orders did not identify the hospital discharge summary orders for straight catheterization or bladder scan. There was no evidence R1 was catheterized or bladder scans completed according to physician's orders between 8/16/22 and 10/2/22 other than when the NP ordered. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] identified an order on 9/1/22 to perform sterile catheterization and collect urine sample; according to the record this was not completed. R1's record was reviewed between 8/16/22 to 9/4/22 it was not evident ongoing fluid monitoring and assessments of intake and output were completed and further lacked and ongoing comprehensive bladder assessments were completed to rule out [CONDITION(S)]. R1's Bladder Evaluation dated 9/4/22, identified R1 had recently had a foley catheter removed. Indicated after foley removal, R1 reported he was not always aware of urge to void or when he was incontinent of urine. The evaluation indicated R1 was on a scheduled toileting plan of check and change every 2-3 hours. The evaluation did not identify the hospital discharge instructions for straight catheterizing R1. R1's bowel and bladder care plan was revised on 9/4/22 identified R1 was incontinent of bladder with a history of [CONDITION(S)] (benign prostate hypertrophy (enlarged prostate)). Care plan identified the findings of evaluation dated 9/4/22. Care plan identified R1 did not always have urge to void or presence of urinary incontinence. The care plan identified the follow interventions: assist 1-2 with toileting, check and change every 2-3 hours and as need, and was dependent on staff for incontinent cares. R1's care plan lacked revision to identify R4 required straight catheterization or bladder scans for [CONDITION(S)] management as per the hospital discharge summary. Even though the 9/4/22 bladder evaluation and the care plan identified R1 was not always aware of the urge to void, it was not evident interventions were developed or implemented to rule out [CONDITION(S)]. Further R1's type of incontinence was not identified or assessed. R1's record was reviewed from 9/4/22 to 10/2/22, it was not evident ongoing fluid monitoring assessments of intake and output, and ongoing comprehensive bladder assessments were completed to rule out [CONDITION(S)]. Further the record continued to lack evidence of monitoring for signs and symptoms of urinary tract infection. On 9/6/22, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated was completed however, the results were not evident. MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician visit note dated 9/21/22, indicated visit was related to abdominal discomfort. Note identified history of R1's hospitalization s and was seen by urology for left [CONDITION(S)] stent placement. NP-A ordered schedule R1 a follow-up visit with Urology as soon as possible to discuss left [CONDITION(S)] stent removal as this was supposed to have happened BEFORE 9/6/22. R1's progress note dated 10/2/22, indicated R1 was found in bed having difficulty breathing and difficult to arouse. R1 was sent to the hospital. During an interview on 10/25/22, at 9:42 a.m. hospital social worker (HSW) indicated R1 was admitted to the hospital related to [CONDITION(S)] and kidney stone. R1 had a CT scan which showed left mid ureter stone that was blocking and causing infection. R1 was bladder scanned and 750 ml of urine was obtained, and a foley catheter was placed. R1's hospital discharge summary dated 10/14/22, identified R1 was admitted to the hospital on 10/2/22. The summary indicated R1 presented with lethargy. Further identified imaging studies were concerning for left [CONDITION(S)] stone causing hydronephrosis an [CONDITION(S)]. Blood cultures grew pseudomonas aeruginosa and Providencia stuartli (both types of bacteria). Urology was consulted and performed left nephrostomy tube (thin plastic tube that is passed from the back through the skin and then through the kidney to the point where the urine collects) placement on 10/4/22. On 10/24/22, at 5:37 p.m. licensed practical nurse (LPN)-B indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-B indicated staff were monitoring output while catheter was in place, but not once the catheter was removed. LPN-B indicated facility had a bladder scanner to utilize for [CONDITION(S)] if needed, but does recall R1 requiring the need to be bladder scanned. On 10/25/22, at 8:51 a.m. registered nurse (RN)-A indicated R1 was incontinent of bladder and was unsure how nursing staff were monitoring output of urine due to R1 wearing an incontinent brief it was difficult to tell, but RN-A stated they were not aware of any concerns regarding change in R1's urine that would indicate a [CONDITION(S)] or [CONDITION(S)]. During an interview on 10/25/22, at 10:58 a.m. assistant director of nursing (ADON) and regional nurse consultant (RNC) stated the stent removal never happened due to nursing entering orders instead of HUC who sets up the appointment. ADON and RNC confirmed they were not aware R1's urology follow-up appointments were not scheduled until surveyor requested urology notes. ADON and RNC confirmed R1 had not seen urology since 8/9/22. ADON and RNC stated R1 had a [CONDITION(S)] stent placed to open the tubes in the kidney to allow the stone to pass. In addition, ADON and RNC confirmed R1 returned to the facility following hospitalization on [DATE], with orders to straight cath or bladder scan R1 every 6 hours if R1 did not urinate. ADON and RNC confirmed this order was not processed and the nursing staff were not monitoring R1's voiding as expected. When asked how staff are expected to monitor R1's output, RNC stated by following physician orders of straight cathing or bladder scanning to ensure R1's urine was not being retained and cause an infection. On 10/25/22, at 11:52 a.m. NP-A indicated NP-A seen R1 on 8/9/22, 8/23/22, and 9/21/22, and wrote orders for to schedule R1 a follow-up appointment with urology. NP-A was unsure if [CONDITION(S)] stent was ever removed and stated, it was not talked about and I doubt it. NP-A stated R1 had orders to be seen for a follow-up with urology related to the risk of infection due to new placement of a [CONDITION(S)] stent. NP-A stated the [CONDITION(S)] stent could have been causing the abdominal symptoms R1 had been experiencing and there were concerns related to R1 not emptying his bladder, however R1 would be vague related to symptoms when asked. On 10/25/22, at 12:36 p.m. family member (FM)-A indicated R1 had orders to remove the [CONDITION(S)] stent but stated it didn't happen and facility was not monitoring R1's output as ordered. Further, FM-A stated R1 was readmitted to the hospital on 10/2/22, for [CONDITION(S)]. Facility policy for transcribing physician orders was requested and not received. Review of facility policy titled Bowel and Bladder assessment dated [DATE], did not address procedures for monitoring intake and output with [CONDITION(S)]

Based on interview and document review, the facility failed to ensure the provider performed a comprehensive review of medications at each provider visit for 1 of 1 residents (R4) reviewed for provider visits. The facility failure to ensure the attending physician provided a comprehensive review of R4's medications resulted in R4 not receiving orders for and being administered [MEDICATION(S)] (anti-[CONDITION(S)] medication) for a period of 6 months which resulted in harm when R4 experienced breakthrough seizures at the facility and was hospitalized for seizures. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired. The MDS further indicated R4 required the assistance of two staff for bed mobility, transfers, dressing, and toileting, and required the assistance of one staff for personal hygiene needs and feeding because he required tube feeding. The MDS indicated R4 was not able to walk. R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's care plan reviewed [DATE], lacked any mention of seizures and lacked interventions for [CONDITION(S)] management. R4's provider progress note dated [DATE], by nurse practitioner (NP)-A indicated R4 was seen for suspected seizures and indicated R4 was prescribed [MEDICATION(S)] (a medication used to prevent and treat seizures) 100 milligrams (mg) twice dally (BID) and was also prescribed [MEDICATION(S)] (a medication used to prevent and treat seizures) 2000 mg BID. The progress note from NP-A on [DATE], indicated the [MEDICATION(S)] and [MEDICATION(S)] levels were subtherapeutic (below the recommended levels) and doses were adjusted, but did not indicate the new doses prescribed. The [DATE], progress note also indicated labs and medications were reviewed during the visit. Review of provider orders revealed there were no [MEDICATION(S)] orders after [DATE]. R4's lab report dated [DATE], indicated R4's [MEDICATION(S)] level was 6.2 micrograms/milliliter (mcg/mL) with a normal range between 10 mcg/ml - 20 mcg/ml and R4's [MEDICATION(S)] level was 11.1 mcg/mL with a normal range between 6.,d+[DATE].0 mcg/ml. R4's provider progress note dated [DATE], by NP-A indicated R4's lab results dated [DATE], indicated both the [MEDICATION(S)] and [MEDICATION(S)] levels were subtherapeutic. The [DATE], progress note indicated NP-A made doses adjustments that day and indicated labs for both [MEDICATION(S)] and [MEDICATION(S)] be rechecked on [DATE]. The progress note further indicated, Both [MEDICATION(S)] and [MEDICATION(S)] are low, making dose changes today. Such a dramatic decrease in his [MEDICATION(S)] level that I wonder if medication is being administered properly. The progress note further indicated tube feeding times were changed so that [MEDICATION(S)] would be administered on an empty stomach. R4 was admitted to the hospital on [DATE] for aspiration pneumonia. There was no documentation from the facility of communication to the hospital the [MEDICATION(S)] and [MEDICATION(S)] doses were scheduled to be checked on [DATE]. R4's Provider Orders Summary for [MEDICATION(S)] ([MEDICATION(S)]) were as follows: [DATE] - [DATE] 500 mg/5 ml, administer 20 mL BID There was no dose ordered for [DATE]. [DATE] - [DATE] 500 mg/ 5 mL, administer 1500 ml BID or 15 mL [DATE] - [DATE] 500 mg/5 mL, administer 1750 mg BID or 17.5 mL [DATE] - [DATE], 100 mg/mL, administer 2000 mg, or 20 mL BID [DATE] - [DATE], 100 mg/mL, administer 20 mL every morning and bedtime [DATE] - [DATE], 100 mg/mL, administer 25 mL BID [DATE] - current, 100 mg/mL, administer 25 mL BID R4's April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] order expired [DATE], at 3:29 p.m. and was restarted [DATE], in the morning. R4's lab report dated [DATE], indicated R4's [MEDICATION(S)] level of 11.1 mcg/ml, and the dose was increased on [DATE]. R4's Provider Orders Summary for [MEDICATION(S)] ([MEDICATION(S)]) were as follows: [DATE] - [DATE] 100 mg/4 mL, administer 200 mg or 8 mL at bedtime [DATE] - [DATE] 100 mg/4 mL, administer 100 mg or 4 mL twice a day and 200 mg or 8 mL at bedtime [DATE] - [DATE] 100 mg/4 mL, administer 100 mg or 4 mL twice a day and 200 mg or 8 mL daily [DATE] - [DATE] 100 mg/4 mL, administer 200 mg or 8 mL TID. R4's provider orders dated [DATE], indicated R4's [MEDICATION(S)] dose of 100 mg/4 mL, administer 200 mg or 8 mL TID was discontinued by NP-A and no further orders for Diltatin were documented. R4's lab report dated [DATE], indicated R4's [MEDICATION(S)] level was 6.2 mcg/mL. There were no additional orders for [MEDICATION(S)] after [DATE]. R4's provider orders dated [DATE], indicated R4's [MEDICATION(S)] dose of 15 ml twice daily (BID) was discontinued and a new order was placed for [MEDICATION(S)] 17.5 ml BID. R4's provider progress note by NP-A dated [DATE], indicated the provider visit was for review of R4's labs and the NP-A reviewed R4's medications, including [MEDICATION(S)]. The progress notes included R4's history of [MEDICATION(S)] levels and dosing. The NP-A indicated the assessment and plan included, Subtherapeutic [MEDICATION(S)] level, subtherapeutic [MEDICATION(S)] [[MEDICATION(S)]] level, and also adjustments were made. The note did not indicate the new order for [MEDICATION(S)]. The NP-A further stated in the note, Labs reviewed and [MEDICATION(S)] remains subtherapeutic and [MEDICATION(S)] is WAY down. R4's provider progress note by medical doctor (MD)-C dated [DATE], instructed facility staff to fax [MEDICATION(S)] and [MEDICATION(S)] lab results to R4's neurologist. There is no evidence in the medical record the levels were faxed to the neurologist. The note indicated medications were reviewed. There was no new order for [MEDICATION(S)] after this visit. R4's nursing progress note dated [DATE], indicated R4 was hospitalized on [DATE], for aspiration pneumonia and the medication list was faxed to the hospital. R4's hospital Discharge Instructions summary and orders dated [DATE], indicated [MEDICATION(S)] was prescribed at 20 mL BID. There was no mention of [MEDICATION(S)] nor a new order for [MEDICATION(S)]. R4's provider progress note by medical doctor (MD)-C dated [DATE], the first provider visit twelve days after hospital discharge, indicated prior lab levels for [MEDICATION(S)] and [MEDICATION(S)]. The provider note further indicated medications were reviewed. The progress note indicated, Dose changes made to [CONDITION(S)] meds, and mentioned only [MEDICATION(S)]. The progress note further indicated labs were reviewed. R4's provider progress note by NP-A dated [DATE], indicated dose changes made to [CONDITION(S)] meds, [MEDICATION(S)]. There was no mention of [MEDICATION(S)]. The progress noted indicated that on [DATE], R4 had constant myoclonic movements of entire body (seizures characterized by brief, jerking spasms of muscles). Further, the progress noted indicated past labs for [MEDICATION(S)] and [MEDICATION(S)] levels, and stated medications had been reviewed. There was no new order for [MEDICATION(S)] after this visit. R4's provider progress note by NP-A dated [DATE], indicated dose changes made to [CONDITION(S)] med, [MEDICATION(S)]. Past lab levels of [MEDICATION(S)] and [MEDICATION(S)] were reviewed. The progress note indicated medications were reviewed. There was no new order for [MEDICATION(S)]. R4's nursing progress note dated ,d+[DATE]//22, at 11:36 p.m. indicated R4's feeding tube was discovered out of placement at 10:35 p.m. and R4 left to the emergency room at 11:48 p.m to replace the G-tube. R4's hospital Discharge Summary dated [DATE], at 10:09 a.m. indicated R4 was admitted on [DATE], following accidental removal of G-tube. The hospital discharge note included a list of medications, including an antibiotic, amoxicilllin-clavulanate to treat the coccyx wound infection. [MEDICATION(S)] was not listed in the discharge medications. R4's nursing progress note dated [DATE], at 4:08 p.m was a note about therapeutic recreation. The medical record lacked a nursing admitting note after hospitalization discharge on [DATE]. R4's provider progress note by NP-A dated [DATE], indicated there were no dose changes of [MEDICATION(S)] while R4 was hospitalized for gastrostomay tube (G-tube) (surgically placed device used to give direct access to the stomach for supplemental feeding) replacement, [CONDITION(S)], and a coccyx wound infection from [DATE], to [DATE]. The provider progress note reviewed past labs for [MEDICATION(S)] and [MEDICATION(S)], and in the note, NP-A stated medications were reviewed. NP-A stated in her note Current medications include [MEDICATION(S)] for 14 days. R4's provider orders lacked evidence NP-A ordered [MEDICATION(S)] for that period of time. R4's hospital Discharge Summary dated [DATE], indicated R4 was admitted to the hospital on [DATE], and discharged [DATE]. R4's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary indicated, His seizures are usually twitching of the R [right] arm. At baseline he is non-verbal but he can track with his eyes. The report further indicated R4 had been in the emergency room a few days prior to this admission after R4 had been found on the floor. R4's hospital note dated [DATE], indicated R4 was admitted for , Recurrent [CONDITION(S)] likely due to low levels of your [CONDITION(S)] medicine in your blood. The hospital noted included a note from the epileptologist from the Minnesota [CONDITION(S)] Group who stated, Prior AEDs [anti-[CONDITION(S)] drugs] include [MEDICATION(S)] ([MEDICATION(S)]) which was discontinued in [DATE] for unclear reasons. The hospital Discharge Summary dated [DATE], indicated, You were in the hospital for recurrent seizures likely due to low levels of your [CONDITION(S)] medicine in your blood. R4 was admitted [DATE], and discharged [DATE], for breakthrough generalized tonic clonic seizures (a type of [CONDITION(S)] that involves a loss of consciousness and violent muscle contractions). When interviewed on [DATE], at 10:11 a.m. family member (FM)-A stated R4 had been in the hospital due to missed doses of [CONDITION(S)] medications. When interviewed at [DATE], at 2:53 p.m. the director of nursing (DON) stated she called NP-A and NP-A stated she intended to restart [MEDICATION(S)] but had not. The DON further stated MD-B (R4's neurologist) inquired about [MEDICATION(S)] on [DATE], but there was no follow-up to that inquire by the facility. Additionally, the DON stated the NP-A had not indicated in her note what dose she intended to prescribe. When interviewed on [DATE]. at 5:03 p.m. NP-A stated she intended to increase the dose for [MEDICATION(S)] and [MEDICATION(S)] on [DATE]. NP-A stated it was her practice to first discontinue one dose, and then restart the new dose. NP-A stated she had discontinued [MEDICATION(S)] and restarted a new dose. NP-A stated she discontinued [MEDICATION(S)] with the intention to restart it at a higher dose, but failed to restart it at the higher dose as intended. NP-A stated she would normally have caught that mistake during the next weekly visit, but R4 was hospitalized instead. R4 was seen by NP-A on [DATE], and the [MEDICATION(S)] was not restarted following that visit. When interviewed on [DATE], at 3:10 p.m. pharmacist (PH)-A stated the [MEDICATION(S)] was discontinued on [DATE], and the [DATE], provider note indicated to check [MEDICATION(S)] levels on [DATE]. The PH-A stated the order to check the levels would have been an indication for the facility that the resident should have still been taking the medication. PH-A stated after a medication was discontinued from R4's list, pharmacists would no longer review that medication. When interviewed on [DATE], at 3:40 p.m. PH-B stated she had notes about [MEDICATION(S)] being followed up on by pharmacy and the provider, but there were no notes about [MEDICATION(S)], nor why [MEDICATION(S)] was discontinued. When interviewed on [DATE], at 9:45 a.m. MD-A stated the medication prescribing error could have contributed to the seizures, and the facility would have sent a medication list to the hospital that did not include the [MEDICATION(S)] that was not restarted. MD-A stated the MD-B was not notified about changes to R4's seizures or medications, including discontinuation of [MEDICATION(S)]. MD-A stated if NP-A had written the specified medication dose change in her note, it may have been found upon review, and if there was no order to reflect the content of the note, there was no way for the facility to catch it. MD-A stated it was a situation where the provider discontinued an order and failed to replace the order, and failed to catch it on review. The Physician Services policy dated [DATE], indicated The resident's attending physician participates in monitoring changes in resident's medical status. It further indicated they physician will perform timely medical assessments and prescribe an appropriate medical regimen.

Based on interview and document review, the facility failed to comprehensively assess and modify treatments and interventions to prevent further development of pressure ulcers and worsening of an existing pressure ulcer for 1 of 1 resident (R4). This resulted in an immediate jeopardy (IJ) situation for R4 who had deep tissue injury (DTI) (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) and developed a new Stage III pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue (the tissue below the skin that may extend down to, but not through, underlying fascia). The IJ began on 7/10/22, at 10:04 p.m. when R4 developed a DTI to the coccyx area and no comprehensive assessment was completed to prevent the pressure ulcer from worsening. Further, R4 developed a new Stage III pressure ulcer to the left buttock with no comprehensive assessment. The administrator and director of nursing (DON) was notified of the IJ on 8/12/22, at 2:00 p.m. The IJ was removed on 8/15/22, at 4:14 p.m. but non-compliance remained at the lower scope and severity level of D-ISOLATED indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R4's Admission Record dated 8/11/22, indicated R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact. R4 required extensive assistance for bed mobility and transfers. Further, R4 was at risk for developing pressure ulcers R4's care plan dated 7/28/22, indicated R4 was at risk for alteration in skin integrity related to immobility and incontinence with interventions to monitor skin integrity daily during cares, weekly skin inspection by the nurse, assist to turn and reposition every two to three hours, weekly measurements and assessment of wound, and document on skin condition and keep medical doctor (MD) informed of changes. R4's Wound Initial Assessment Note from Mercy Hospital dated 7/21/22, indicated R4 had a DTI to the coccyx opened with scattered eschar (a piece of dead tissue that sheds off from the surface of the skin after an injury that appears tan, brown, or black) and slough (dead cells that appear white or yellow in color found in patches in the wound or covers a large area of the wound). On 8/11/22, the VOHRA Wound Physicians assessed the pressure ulcers and noted the coccyx wound to be a Stage IV pressure ulcer measuring 6.5 x 7.5 x 0.1 cm after debridement, and indicated the wound had deteriorated. They also identified a new Stage III pressure ulcer to the left buttock measuring 2.9 x 4.2 x 0.1 cm. During interview on 8/11/22, at 1:52 p.m. the director of nursing confirmed R4's wounds had not been assessed, monitored, or measured by the facility staff since they were noted on 7/10/22. The DON stated the expectation was when a nurse observes a new wound the doctor needed to be notified immediately to obtain orders and then the resident was to be placed on the wound rounds list. The DON verified R4 was not placed on the wound rounds list and verified the pressure ulcer had deteriorated. Further, the DON stated all pressure areas should be assessed and measured weekly and to notify the physician immediately of any observed changes. Interview on 8/11/22 at 2:42 p.m., with R4's physician (MD)-B identified he assessed R4's wound the previous day. MD-B states it appeared to be infected and was not made aware of the severity of the wound prior. His expectation was staff were to appropriately assess and monitor wounds and call him immediately for any changes or the need to alter therapy. MD-B suspected a bone infection and had ordered at computed topography (CT) scan and wound cultures.They aren ' t monitoring them [wounds or pressure ulcers] like they should. During observation and interview on 8/12/22, 10:49 a.m. LPN-A completed wound care on R4. LPN-A performed dressing changes, however, the ordered Santyl (wound debrider) was not used. She then applied a bordered foam dressing over both wounds, completing the dressing change. LPN-A stated he wasn't able to apply the Santyl to the wound bed due to not having it available. R4's progress notes, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment orders for barrier cream was obtained however, no further interventions were implemented. R4 was hospitalized on [DATE] and returned to the facility on [DATE] with new treatment orders for the coccyx pressure ulcer. No assessments of the coccyx pressure ulcer were completed until 8/4/22 which at that time R4 had an unstageable DTI to the coccyx measuring 4.4 x 6.5 cm and a new Stage III pressure area to the left buttock measuring 3.4 x 4.6 x 0.1 cm. New treatment orders identified on 8/4/22, staff were to apply Santyl (wound [MEDICATION(S)] agent) to the wound bed of both pressure ulcers. In review of the pharmacy communication, Santyl was never ordered from the pharmacy. During interview on 8/12/22, at 11:18 a.m. the DON stated she had called the pharmacy and they had never received the order for Santyl for R4. Further, the DON stated the order will be pushed through to pharmacy today. The skin assessment and wound management policy dated 5/27/22, indicated when a significant alteration in skin integrity was noted, the following actions would be taken: - Notify MD for treatment order - Notify resident representative - Complete education with resident/resident representative including risks and benefits - Initiate weekly pressure wound evaluation - Notify nurse manager/wound nurse - Referral to dietary, if appropriate - Referral to therapies, if appropriate - Update care plan - Update resident care lists - Update care plan to identify risks for skin breakdown The IJ was removed on 8/15/22, at 4:14 p.m. when the facility developed and implemented a systemic plan which was verified by interview and document review: The plan included: - A root cause analysis was completed to identify how R4 obtained pressure ulcers. - The skin assessment and wound management policy was reviewed. - R4's care plans, orders, and treatments were updated to reflect the MD orders. - Santyl was ordered and obtained from pharmacy for R4's wound treatments. - Braden scale assessments were completed on all residents to identify those at high risk for skin concerns. - Skin assessments were completed on all residents to identify any new skin concerns. - Audits were completed on all residents with existing wounds to identify proper classification of the wounds, treatment orders, and care plan updates. - All nursing staff was educated on order administration and clarification of orders. - All staff were re-educated on assessing and documenting new skin concerns, and on the skin assessment and wound management policy, and the change in condition policy.

Based on interview and document review, the facility failed to ensure residents were free from sexual abuse for 1 of 2 residents (R2) reviewed for sexual abuse. This resulted in psychosocial harm for R2 when she was sexually abused by R1. Findings include: A nursing home incident report (NHIR) dated 12/29/21, at 4:00 p.m. indicated R1 was observed by nursing assistant (NA)-A in R2's room with his hands down R2's gown rubbing her chest and rubbing R2's inner thighs outside of her incontinent brief. R2's Face Sheet printed 1/5/22, indicated R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's significant change Minimum Data Set (MDS) dated [DATE], indicated R2 had a severe cognitive impairment, utilized a wheelchair, and required extensive assistance with activities of daily living. R2's care plan dated 12/22/21, indicated R2 was a vulnerable adult (VA) due to care planned dependencies. The care plan directed safety monitoring would be implemented as needed to ensure residents safety (i.e., 15 min checks, 1:1, etc.), and the local Ombudsman, Adult Protection, Police, and/or state/financial agencies would be notified of any suspected abuse or financial exploitation as needed. R1's Face Sheet printed 1/5/22, indicated R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly MDS dated [DATE], indicated R1 had a mild cognitive impairment, utilized a wheelchair, and was independent with transfers and locomotion on and off the unit. The MDS also indicated R1 had behaviors not directed towards others 1-3 days in the assessment period. R1's care plan dated 8/28/21, indicated R1 had history of unsolicited touching of female residents and following females around. Staff interventions included educating R1 on unwanted touching of female residents, encourage R1 in activities related to interests, increased supervision for any signs of or increased risk of inappropriate behavior with female residents (i.e. stalking, inappropriate touching, invasion of privacy), re-direct R1 if found to be attempting to enter any female's room. 15 minutes checks were initiated on 7/19/21, and titrated as appropriate. Mood and behavior charting initiated 7/19/21. On 12/29/21, at 6:34 p.m. R1's progress note indicated NA-A came out of the shower room at 3:05 p.m. and saw R1 in R2's room, with his hand down the front of her gown, rubbing her chest. NA-A immediately attempted to separate R1 from R2, but R1 would not comply. R1 continued rubbing R2's chest and her inner thighs. NA-A called additional staff to the room, and staff immediately separated the two residents. R1 was escorted to his room, and the director of nursing (DON) was notified. The DON immediately ensured R2 was alone in her room with the door shut, and R1 was in his room. The DON explained to R1 his behavior was inappropriate, and R1 responded by repeatedly shaking his head and saying, No. R1 was verbally unable to describe or talk about the incident due to dysphasia, and ability to understand impacted by diagnosis. Providers and families of R1 and R2 were updated. R1 was placed on 15-minute checks, and all clinical staff were informed to observe R1 when out of his room, especially when near R2's room. R2's door was being kept shut. Every shift mood/behavior charting was started on both residents. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 15 minute check documents dated 12/29/21, through 1/5/22, indicated 15-minute checks were not completed and R1 was unaccounted for on the following dates and times: 12/29/21: from 4:00 p.m. to 10:00 p.m. 12/30/21: from 12:15 a.m. to 5:45 a.m. and from 4:00 p.m. to 12:00 a.m. 12/31/21: from 12:15 a.m. to 5:45 a.m. and from 10:45 p.m. to 12:00 a.m. 1/1/22: no 15-minute check document could be located by facility. 1/2/22: no 15-minute check document could be located by facility. 1/3/22: no 15-minute check document could be located by facility. 1/4/22: from 12:15 a.m. - 5:45 a.m. R1's NA task sheet printed 1/5/22, lacked indication of R1's 15-minute checks, behavior charting, or other increased supervision as outlined in R1's care plan. On 1/5/22, from 9:00 a.m. to 10:00 a.m. R1 was continuously observed propelling his wheelchair from his bedroom into the hallway outside of his room. Staff were not observed performing 15 minute checks on R1. On 1/5/21, at 9:57 a.m. NA-B was interviewed and stated she was not aware R1 required increased supervision which included 15-minute checks. NA-B stated she was not aware of any behavioral concerns for R1. NA-B stated R1 was her resident, but she was not familiar with R1 as she was supposed to be in training, but was working the floor due to staffing concerns. On 1/5/22, at 10:10 a.m. trained medication aide (TMA)-A was interviewed and stated she was not aware R1 was on 15 minute checks, and stated R1 had behaviors of touching the women's breasts. TMA-A reviewed R1's chart and verified 15 minute checks were in place, and stated she checked R1's location when she passed his medications. TMA-A further stated the nursing assistants were supposed to complete the 15 minute checks, and would need to be told again to complete them. On 1/5/21, at 10:26 a.m. family member (FM)-A was interviewed. FM-A stated the DON had called him and stated another resident (R1) had gotten into R2's room and was rubbing R2's chest. FM-A stated he was not informed R1 was also rubbing R2's inner thighs. FM-A stated he felt that behavior was an invasion of privacy and almost rape. FM-A stated R2 had dementia and was not aware of what was going on, however, he felt if R2 could comprehend the situation, she would be very upset. FM-A stated the only intervention the DON relayed was keeping R2's door closed, which was not satisfactory to him. FM-A stated the DON had not informed him they would be doing frequent checks on R1. FM-A also stated no other interventions were offered. FM-A stated he felt the family checked on R2 more frequently than the staff and had on-going safety concerns for R2 at the facility and would like alternative placement. On 1/5/21, at 10:40 a.m. registered nurse (RN)-A stated R1 was on strict 15-minute checks which were completed and documented by the nurses, but all staff were to keep an eye out for R1. RN-A stated she was not aware of any other interventions besides 15 minute checks for R1, which she stated were working. RN-A stated she was not aware of any interventions for R2 other than keeping the door to her room closed when she was in her room. On 1/5/22, at 11:02 a.m. NA-A was interviewed and stated she was the staff who had observed R1 in R2's room rubbing her chest under her clothes. NA-A stated R2 was lying in bed awake but not speaking or moving. NA-A stated she attempted to remove R1 unsuccessfully, and requested assistance from other staff who successfully separated the residents. NA-A stated interventions included keeping R2's room door closed at all times. NA-A was not aware of R1's 15 minute checks, but stated staff have eyes on him. NA-A stated R1 wandered at night and should not be allowed into other residents' rooms. On 1/5/21, at 12:54 p.m. the administrator stated the facility had implemented interventions which included R1 was on 15 minute checks, R1's medications were reviewed with no changes, R1 was on behavior monitoring, and the facility was seeking alternate placement for R1. The administrator stated they were unable to change R1's room as there were no open male beds. The administrator stated R2's interventions included behavior monitoring, skin check, and keeping the door to R2's room closed. The administrator stated a room change was not offered to R2. The administrator verified 15 minute checks for R1 were not being completed consistently, and stated the expectation was for staff to complete and document the checks as ordered by R1's physician. The facility Abuse Prohibition/Vulnerable Adult Plan policy revised 8/26/21, identified sexual abuse as a form of abuse. The policy indicated the investigation team will review all incident reports regarding residents including those that indicate abuse. Plans are developed and measures taken to minimize risks, and submit any reports required by the State.

Based on observation, interview and document review, the facility failed to provide ongoing assessment and implementation of interventions, to reduce the risk for pressure ulcers for 2 of 4 residents (R4 and R1) reviewed for pressure ulcers. Although noncompliance at harm was previously present, and R4 and R1 sustained harm when they experienced deterioration of their pressure ulcers, the facility had implemented appropriate corrective action 8/2/19 before the survey resulting in a finding of past-noncompliance for R4 and R1. Findings include: The facility's (MONTH) (YEAR) Skin Assessment and Wound Management policy, included: A weekly skin assessment will be completed by licensed staff. When a pressure ulcer is identified staff are to initiate a weekly pressure wound evaluation, notify the nurse manager/wound nurse and update the care plan. R4's Admission Record indicated she admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In addition, pressure ulcer stage III of right buttock (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling), and pressure ulcer Stage III left buttock were added with a date of onset identified as 7/26/19. R4's Order Summary Report dated 7/17/19, directed staff to document characteristics of R4's wounds by completing the Weekly Non-Pressure Wound or Skin Evaluation in the electronic medical record. R4's admission Minimum Data Set (MDS) assessment dated [DATE], identified a stage I pressure ulcer (An observable, pressure- related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues). R4's 14 day prospective payment system (PPS) MDS dated [DATE], indicated R4 had intact cognition, required extensive assistance from two staff for bed mobility, transfers and toileting and was frequently incontinent of bowel and bladder. The MDS further identified two stage III pressure ulcers. R4's care plan dated 8/2/19, indicated an alteration in skin integrity related to stage III pressure ulcer to sacrum/right intergluteal cleft. The care plan directed staff to perform weekly assessment of the wound and record measurements, to provide treatment to open areas per orders, and to provide a pressure redistribution mattress to R4's bed. The care plan lacked interventions related to repositioning, offloading or pressure reduction device in wheel chair. Review of R4's medical record identified the following skin assessments: 7/15/19, Admit/Initial Data Collection indicated open area to coccyx. 7/18/19, Weekly Non-Pressure Wound or Skin Alteration Evaluation indicated: a wound to the right intergluteal cleft measured 2 centimeters (cm) x 0.5 cm, and a wound on the left gluteal cleft measured 2 cm x 1 cm. Further the evaluation included: Wound healing well and no opening. 7/24/19, Weekly Non-Pressure Wound or Skin Alteration Evaluation indicated: R4's wound was healing very well, no opening and measured 1 cm x 0.2 cm right buttock, and 0. 5 cm x 0.1 cm left buttock. 7/31/19, Weekly Pressure Wound Evaluation indicated: Left inter gluteal cleft, pressure ulcer stage III measuring 0.3 cm x 0.2 cm x 0.1 cm, and Right intergluteal cleft 0.4 cm x 0.3 cm x 0.1 cm stage III pressure ulcer. Pain associated with wound, managed with Tylenol. The evaluation indicated the current treatment included: A and D ointment daily and offload. During interview on 8/8/19, at 1:17 p.m. the director of nursing (DON) and assistant director of nursing (ADON) were present. The ADON stated he was the person responsible for weekly documentation of pressure ulcers. In regard to R4's pressure ulcers, the ADON stated, (R4) admitted to the facility with two stage III pressure ulcers and the nurses on the floor completed the initial skin assessment. The ADON further stated he thought the nurse who documented on a weekly Non-Pressure Skin Assessment used the wrong form. When asked why the assessment dated [DATE], indicated there were no open areas, the ADON stated at that time he had not seen the wounds and did not know whether they were open. The ADON further stated he thought the nurse who completed the initial assessments may not have been able to identify whether R4's skin had been open or not. The ADON stated, It's hard to tell sometimes. The ADON further stated R4 had previously been seen by an outside wound physician however, documentation indicated R4 had last seen the wound physician on 6/13/19, one month prior to admission to the facility. On 8/8/19, at approximately 3:00 p.m. registered nurse (RN)-A stated she was the MDS coordinator, and had completed R4's initial MDS. When asked why she'd coded R4 as having one stage I pressure ulcer, RN-A stated she'd seen the wound on 7/22/19, and had verified the wound matched what was on the initial assessment. R1's 30 day PPS MDS dated [DATE], indicated he did not have a pressure ulcer. R1's 60 day PPS MDS dated [DATE], indicated R1 was moderately cognitively impaired, required extensive assistance for bed mobility, transfers and toileting, and was frequently incontinent of bowel and bladder. The MDS also indicated R1 had a stage III facility acquired pressure ulcer. R1's care plan dated 7/30/19, identified a stage II pressure injury (dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). On 8/1/19, the care plan was revised to reflect the facility acquired coccyx pressure injury was a stage III. Interventions indicated staff were to provide wound care daily, turn and reposition, or remind to offload every two hours, and indicated the wound physician would make rounds weekly. A review of R1's medical record lacked evidence of weekly bath day skin assessments during the month of (MONTH) 2019. On 7/30/19, a Weekly Pressure Wound Evaluation identified a new stage II pressure ulcer of the coccyx measuring 3.0 cm x 2 cm x 0.5 cm. The wound contained 50% slough. On 8/1/19, the Weekly Pressure Wound Evaluation indicated the coccyx ulcer was reclassified as a stage III pressure ulcer. During interview on 8/8/19, at 1:17 p.m. the ADON stated the nurses were supposed to do skin inspections every week on bath day for each resident, and were to document their findings in the electronic record. The ADON stated he had identified weekly skin checks were not being completed, and stated this should have been identified by the floor nurses. The ADON stated when a nurse identified the concern with R1's bottom he'd initiated every two hour repositioning. The ADON stated he had staged R1's pressure ulcer as a stage II initially but when the wound doctor came in, the wound doctor had changed it to a stage III. The DON who was present during the interview stated skin audits had been conducted on all residents in the facility on 8/2/19. At 2:14 p.m. on 8/8/19, the administrator verified documentation of skin concerns had been identified, and as a result the facility had conducted staff training that included direction for the nursing assistants to report to the nurses if skin concerns were identified, and for nurses to report skin concerns to the physician. The administrator stated the training included use of the proper skin assessment forms, and included completion of facility wide skin audits 8/2/19. Although the facility failed to ensure R4 and R1 did not develop or have a deterioration of pressure ulcers, the facility had immediately identified the deficient practice, and had implemented corrective actions as of 8/2/19. Corrective action implemented, licensed and unlicensed staff were educated regarding the importance of skin assessment, and a whole house audit of residents' skin was conducted. The facility's corrective action was verified during the onsite survey on 8/8/19 as having been in place as of 8/2/19 therefore, this deficient practice is being cited at Past Non-compliance.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) received prescribed pain medication as ordered and failed to maintain pain management. R1 suffered severe pain as a result of not receiving pain medications. This resulted in actual harm for R1 who experienced uncontrolled pain which resulted in hospitalization . Findings include: R1's [DIAGNOSES REDACTED]. In addition, the orders indicated R1's condition at discharge was stabilized. R1's care plan dated 1/30/19, identified R1 was at risk for alteration in comfort/pain related to stage 4 [MEDICAL CONDITION]. The care plan goal indicated R1 was to alert staff of pain/discomfort and the goal was for R1 to show no signs and symptoms of non-verbal discomfort through the next review. The care plan directed staff to monitor and document pain, observe for non-verbal signs of discomfort, prior to [MEDICATION NAME] attempt non-pharmacological interventions, administer medications per orders, notify the physician or nurse practitioner if pain relief interventions were ineffective. During a review of R1's hospital progress note dated 1/27/19, revealed the physician had documented R1's current pain management was effective and R1 had reported improved control. R1's (MONTH) 2019, Medication Administration Record [REDACTED] -[MEDICATION NAME] 10 milligram (mg) 1 tablet by mouth once daily in the evening. Missed 1/29/19, 8:00 p.m. dose -[MEDICATION NAME] 7.5 mg by mouth two times daily. Missed 8:00 a.m. and 2:00 p.m. doses 1/30/19. During further review of R1's (MONTH) 2019 MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED] On 4/19/19, at 9:24 a.m. the consultant registered nurse (RN), administrator and the director of nursing (DON) verified R1 had not received the scheduled medications. The DON stated the facility E-Kit (emergency kit) had [MEDICATION NAME] 10 mg and staff would not have been able to get the right dose for the 7.5 mg but should have given the evening 10 mg dose from there. When asked what had been done following the incident, both the consultant RN and DON stated in the final investigation the former DON had indicated the evening nurse on 1/29/19, had been written up and the pharmacy was supposed to do an investigation to find what had gone wrong. Both verified there was no education that was provided to the staff nurses of what they needed to do in a situation like this. Both acknowledged all three nurses who had worked with R1 prior to RN-A should have been provided education and/or discipline. Surveyor requested any additional information the facility had done after the incident but none was provided. On 4/19/19, at 9:38 a.m. via telephone family member (F)-A stated R1 had been admitted at the facility early evening on 1/29/19. F-A stated to their understanding there was a problem with her scripts and there was blaming back and forth between the facility and pharmacy. F-A stated on 1/30/19, R1 was not screaming in pain but she was in pain almost to the point of tears rolling out of her eyes and R1 was grimacing and never reported the pain because she knew there was no medication available. F-A stated, The pain was bad enough and we called 911 to get her to the hospital. When she got to (emergency room ) ER she was given the pain medication right away due to un-controlled pain and it took them a while before they got her to the comfortable level. Someone dropped the ball on the pain medication scripts. The medications were being delivered when she was being transported out of the facility. The administrator was apologizing but that didn't help with her being in pain. The medication was prescribed since (MONTH) (YEAR) due to [MEDICAL CONDITION] pain and at the time the pain was not in control. Since then the medication has helped being taken that way to stay on top of the pain. F-A also stated during R1's stay at the facility the anxiety medication was not also available and this was something R1 used often to reduce anxiety caused by the pain. F-A further stated when R1 arrived at the facility she did not have the pain but later on that night she started having pain and reported it to staff but was told medication was not available. On 4/19/19, at 10:30 a.m. consultant RN stated she would expected staff nurses to contact R1's physician to let them know they were not able to give medications as ordered and check if the physician wanted to change the dosage so they could utilize what was in the E-Kit. On 4/19/19, at 10:42 a.m. via telephone the administrator asked RN-A if she remembered R1 and RN-A stated was she the lady who left because she did not think her pain was controlled? I was her nurse for only a couple hours before she left. I believe she felt her pain was not being controlled so she wanted to go back to the hospital. At 10:45 a.m. RN-A requested to come to the facility to speak in person with the surveyors. -At 10:53 a.m. RN-A stated to his knowledge a report had been filed to the State Agency (SA) by the former DON and he had been interviewed then. RN-A stated, I don't remember much about her, did she have a pain medication that she didn't have a script for. Pharmacy stated they never received it. RN-A stated that afternoon when he found out the problem he had called the pharmacy and had been on the phone felt like all day trying to fix the problem. RN-A then stated he also gave R1 PRN [MEDICATION NAME] order which took a long time to get out of the E-Kit and at that point R1 had decided she needed to go back to the hospital. RN-A stated when he got on the floor he went to meet R1 I was surprised that she was in that much pain. RN-A stated based on the report he had received from the licensed practical nurse (LPN)-A who had worked the morning shift it did not sound R1 was in that much pain. RN-A then stated, but when I came in she was in a lot of pain. When I came on the shift she was acting insane as if she was in severe pain. She did tell me she had not received the pain medications since she had been here which prompted my follow up with pharmacy. She said I'm here for pain management and I have not received my medications. On 4/19/19, at 11:36 a.m. the consultant RN and DON stated they were going to start the training right away and would make sure moving forward nothing like this happened again to any resident. R1's entire medical record lacked documentation of the physician or nurse practitioner being notified about staff not being able to administer pain medications as ordered. In addition, the medication record lacked adequate documentation of who and when the pharmacy inquiries of the missing medication was done on 1/29/19, and 1/30/19, night and morning shifts to ensure the medications were delivered timely to the facility. The facility undated Pain Management Protocol directed The staff will discuss significant changes in levels of comfort with the provider who will consider adjusting interventions accordingly which would include non-pharmacological measures and adjustments on regular and PRN [MEDICATION NAME] doses to find the best combination of effectiveness for the resident . The facility undated Patient Status Change policy directed staff Monarch Healthcare Management will notify the resident's physician and other responsible persons in the event of an accident or other significant change in a patient's emotional, mental or physical condition. The facility Medication Ordering And Receiving From Pharmacy policy revised (MONTH) (YEAR) directed staff when receiving medications from the pharmacy staff was to promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

Based on review of documentation and interviews, the facility failed to conduct an accurate and comprehensive admission assessment and provide appropriate treatment to one of one resident (resident #1) who had a peripherally inserted central catheter (PICC) site on her right forearm. Findings include: Resident #1's admission face sheet, dated 4/19/11, revealed that resident #1 was admitted to the facility from the hospital on [DATE] and remained at the facility through 4/21/11. Resident #1's [DIAGNOSES REDACTED]. x 2.0 cm.) decubitus ulcer on her left coccyx area and constipation. The hospital's Patient Care Transfer form, dated 4/16/11, which was completed at the time of resident #1's discharge from the hospital, was reviewed. The form addressed resident #1's skin integrity and identified reddened areas, bruises, rashes, wounds, recent incisions and drains that were present when resident #1 was discharged from the hospital. The form indicated resident #1 had a peripherally inserted central catheter (PICC) in her right forearm while she was in the hospital. A diagram on the form indicated the location of the site and stated the dressing covering the PICC line site was to be removed seventy-two hours after the resident's discharge from the hospital (removal should have been on the afternoon of 4/19/11.) The facility's 4/16/11 Clinical Health Status admission assessment form, which was completed by nurse (D), was reviewed. The assessment form did not address the presence of resident #1's PICC line site (condition of the skin) and the dressing that covered the site. The facility's Clinical Guide: Clinical Health Status Policy and Procedure (undated) was reviewed. It stated the clinical health status process assists in providing a thorough asessment of a resident's condition at the time of admission to the facility. It stated the data collected assists in identifying risks and appropriately establishes a plan of care. Nurse (D) was interviewed by phone on 4/28/11 at 8:30 a.m., and she stated she conducted resident #1's initial assessment when resident #1 was admitted to the facility on [DATE]. She stated she did not recall looking at the resident's PICC line site/dressing when she conducted the assessment. Employee (B)/administrative nurse was interviewed in person on 4/27/11 at 9:15 a.m., and she stated nurse (D) should have viewed resident #1's PICC line site/dressing when she conducted the admission assessment. In addition, the area should have been monitored on an ongoing basis, and the dressing should have been removed. Physician (H's) 4/21/11 progress notes/history and physical pertaining to the clinic visit with resident #1 were reviewed. The documentation revealed the following: In the medial aspect of the resident's right upper arm was a PICC line site which was still covered with a bandage. Physician (H) removed the bandage and observed that the area around the PICC line site was slightly necrotic. Physician (H) squeezed the area and some pus and blood was present. Physician (H) decided to admit resident #1 to the hospital and follow up on several issues, including the pus that was present at the PICC line site. Physician (H) was interviewed by phone on 4/29/11 at 2:50 p.m., and she confirmed that her 4/21/11 clinic notes and history and physicial findings were accurate. She stated she removed the PICC line site dressing and viewed the area which appeared to be slightly infected. She stated the resident's elevated temperature (102.1 degrees) was possibly related to the infected PICC line site. She stated she admitted the resident to the hospital on [DATE] for the purpose of ruling [MEDICAL CONDITION]. Resident #1's 4/21/11 hospital record revealed resident #1 was admitted to the hospital with [REDACTED].

Based on documentation and interviews, the facility failed to provide appropriate treatment that promoted healing and prevented infection to one of eight residents (resident #1) when the staff failed to cover resident #1's coccyx ulcer as ordered. Findings include: Resident #1's admission face sheet, dated 4/19/11, revealed that resident #1 was admitted to the facility from the hospital on [DATE] through 4/21/11. Resident #1's [DIAGNOSES REDACTED]. x 2.0 cm.) decubitus ulcer on her left coccyx area and constipation. The hospital's Patient Care Transfer form, dated 4/16/11, which was completed at the time of resident #1's discharge from the hospital, was reviewed. The form and corresponding orders provided specific instructions to the facility related to the care of resident #1's coccyx ulcer. The instructions included the following: irrigate the ulcer with normal saline, apply a thin layer of Santyl ointment and cover the ulcer with a [MEDICATION NAME] dressing. Resident #1's Immediate Plan of Care/Pressure Ulcer Risk, dated 4/16/11, listed the following interventions: pressure relieving device on chair/bed; turning/repositioning every hour; nutrition or hydration program; use mild cleansing agent and warm water to cleanse skin whenever soiled; treat dry skin with moisturizer; do not massage over bony prominences and use the proper techniques when transferring, turning and repositioning the resident. . Review of resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Santyl ointment was discontinued by physician (H) on 4/20/11. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A 4/20/11 late entry progress note, written by employee (B)/administrative nurse, was reviewed. It stated a wound assessment was completed, and the stage 2/3 left coccyx ulcer measured 4.7cm. x 2.0 cm. with a depth of 0.1 cm. A scant amount of clear drainage was present. The note indicated there was a call out to physician (H) requesting orders for wound care. The note indicated physician (H's) nurse called back and advised the facility to obtain a wound consultation. Physician (H's) 4/21/11 progress notes/history and physical pertaining to the clinic visit with resident #1 were reviewed. the documentation revealed the following: Resident #1's tympanic temperature was 102.1 degrees. Resident #1 reported having diarrhea for the last few days. The large ulcer on the resident's coccyx was open and not covered with a dressing. There was stool covering the resident's entire buttocks, as well as in the coccyx ulcer. Physician (H) admit resident #1 to the hospital for follow up related to her diarrhea. Physician (H) was interviewed by phone on 4/29/11, and she confirmed that her 4/21/11 clinic notes and history and physical findings were accurate. She stated she communicated with the facility on 4/20/11 and advised staff to cover the resident's coccyx ulcer with a dressing in an effort to keep the area clean. She stated the resident's elevated temperature was possibly caused by the resident's untreated diarrhea ([MEDICAL CONDITIONS]) and the presence of stool in the coccyx ulcer. She stated she admitted the resident to the hospital on [DATE] for the purpose of ruling [MEDICAL CONDITION]. Nursing assistant (C) was interviewed in person on 4/27/11. She stated she was assigned to resident #1 on the 4/21/11 evening shift that started at 2:00 p.m. She stated she did not check resident #1 for incontinence prior to resident #1 leaving for her clinic visit at 3:25 p.m. Employee (B)/administrative nurse was interviewed in person on 4/27/11. She stated resident #1 returned from [MEDICAL TREATMENT] at approximately 11:00 a.m. on 4/21/11. Resident #1 had been incontinent of stool, and staff changed resident #1 around noon. She stated resident #1 left for her clinic appointment at 3:25 p.m. on 4/21/11, and she was unsure when the resident was last checked and changed prior to leaving for her clinic appointment. She stated she did not agree with the resident's admission wound orders/instructions. The orders indicated the coccyx ulcer should be covered with a dressing and she felt the ulcer should be left open to the air and not covered. She stated she had a phone conversation with physician (H) on 4/20/11, and physician (H) said she wanted the ulcer covered with a dressing and did not want it left open to the air. However, the coccyx ulcer was left open to the air.