Every finding on record at The Estates at Roseville LLC

Based on observation, interview, and document review, the facility failed to ensure the proper use of beard restraints during food preparation. This practice had the potential to affect all 134 residents who received food from the kitchen.Findings include:During observation and interview on 8/5/26 at 9:33 a.m., cook (C-A) prepared carrots without wearing a beard restraint. C-A acknowledged knowing a beard restraint was required, stated management had previously instructed him to wear one, and acknowledged having been previously counseled for not wearing a beard restraint.During an interview on 8/5/26 at 9:52 a.m., the assistant director of culinary services (ADCS) stated dietary staff are expected to wear hairnets or beard restraints whenever preparing food. The ADCS confirmed C-A should have been wearing a beard restraint while preparing food.During an interview on 8/6/26 at 12:45 p.m., the administrator stated employees are expected to keep their hair covered while preparing food.A facility dietary policy dated 10/2017, directed staff to wear hair restraints, including beard restraints, while in kitchen and food preparation areas, in accordance with Minnesota Department of Health (MDH) guidelines, to prevent hair from contacting food.

Based on observation, interview, and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a roach infestation for 1 of 1 resident (R76) reviewed for environment. This had the potential to affect all 142 residents who resided in the facility. Findings include:R76's comprehensive Minimum Data Set (MDS) dated [DATE] identified R76 had diagnoses which included congestive heart failure (CHF), pulmonary edema, hyperlipidemia, and thyroid disorder. In addition, R76's MDS identified she was cognitively intact.During an interview on 8/3/26 at 11:02 a.m., R76 stated she had previously seen cockroaches in the dining room. R76 stated she had even caught some of the cockroaches about a month ago in the dining room while staff were present. R76 stated she has been seeing cockroaches in the dining room for the last year.During an observation and interview on 8/4/26 at 12:26 p.m., a roach measuring approximately 1/2 long was observed crawling across the floor by the sink in the long-term care dining room. Registered nurse (RN)-B stepped on the roach and used a paper towel to pick it up and throw it in the trash. When asked if the insect was a roach or if she had seen roaches in the dining room, RN-B shrugged and stated, Well, you know, people keep food in their rooms. During an observation on 8/4/26 at 12:50 p.m., no residents or staff were noted to be in the dining room after the lunch meal was cleared. The floor of the dining room was observed to have noodles, lettuce pieces, and carrot bits on the floor.During an observation on 8/4/26 at 12:52 p.m., inspection of the cabinets under the sink area in the dining room revealed a clear plastic bin with no cover on the lower shelf which contained a covered plate with a meal from lunch. A quarter-sized hole was noted in the top of the plate cover. Condensation was noted inside the cover. A roach measuring approximately 1/2 in length was observed crawling alongside the plate and then out of the cabinet. The floor near the adjacent refrigerator and the bases of the lower cabinets were characterized by black buildup and crumb-like debris.During an observation and interview on 8/4/26 at 3:50 p.m., the plate previously observed in the cabinet in the dining room was noted to be on the counter. Dietary aide (DA)-B stated that roaches were frequently seen in the kitchen and sometimes in the dining room. She stated that fruit fly traps were also everywhere. DA-B stated that they cleaned the counters and mopped the floors every night in the kitchen, but the roaches still came back.During an observation and interview on 8/4/26 at 3:57 p.m., a napkin, spoon and Cheerio were observed under the refrigerator in the dining room. A 6-inch long red-colored buildup was also noted under the refrigerator. Caulking was observed to be missing from around the sink and a one-foot-long section of the countertop backsplash was noted to be pulled away from the wall by 1/2. The countertop was warped and black discoloration was observed around the sink. The bottom of the cabinet underneath the sink was marked with brown coffee-colored staining. Two open boxes of cereal were found on the top shelf of one of the cabinets over the sink with the inner plastic bags unsealed and open to air. A second covered plate with remains from lunch (carrots and noodles) was found in an upper cabinet to the left of sink. When asked about this, DA-B stated, the nurses' aides hide things. She said that if the nurses' aides work a second shift, they get a free meal and so they will sometimes store meals in the cabinets in the dining room.During an observation and interview on 8/5/26 at 7:25 a.m., Housekeeper(H)-A stated that he had only seen one roach lately and had mostly been seeing fruit flies. He stated housekeeping was responsible for cleaning and mopping the floors after meals. H-A pulled out the refrigerator in the dining room and stated there was old food under the fridge and it didn't look like housekeeping had cleaned under there in a while. He also said they should be checking this every shift. During an observation on 8/5/26 at 7:27 a.m., two fruit flies were noted in the sink area. Brown-colored food crumbs were noted along the baseboard near the heater and under the steam table. Three bits of wet lettuce were found on the floor near the steam table. H-A was observed cleaning behind the refrigerator. He stated, Wow, there is a lot of stuff back here.During an interview on 8/5/26 at 7:43 a.m., the Director of Maintenance (DOM) confirmed that there was significant wearing of the laminate of the countertop around the sink in the dining room and that the caulking was missing. He also stated that he has been trying to obtain a new countertop for the past year. He mentioned that the facility recently switched from one pest control company to another and that the facility did have a pest control binder available for review. During an interview on 8/5/26 at 10:12 a.m., DA-A stated that she hads only noticed roaches in the last year. She stated that she thought they had been spraying, but it doesn't seem to be doing the trick. She said cleanliness in general was an issue in the dining room. Dirty dishes with food often get left on the counter. At night, there was no one there to monitor. When asked, DA-A stated that no education has been provided to staff on roach prevention and mitigation strategies, but she knew staff should not be leaving food in the cupboards and on the countertops and that housekeeping should be cleaning under the refrigerator and along the baseboards.During an interview on 8/5/25 at 12:30 p.m., the area supervisor for the new pest control company, stated that he was a brand-new vendor and was contacted by the facility on 8/4/26. His plan was to hit it hard. He stated that the first time they were at the facility was yesterday and he laid several traps for insects. The area supervisor stated that they now have a plan going forward to help the facility with their pest control issue, but because they need to use low toxicity methods, it may take some time to really minimize the presence of insects. The DOM, who was also present at this time, stated they had previously used a different pest control company, but they were unhappy with those services. An administrator for another associated facility stated she believed it was a couple weeks ago that they had consulted the pest control company. All three personnel were notified of the observations in the dining room related to plates of food being stored in the cupboards. The DOM stated he was unaware of this issue and would have to look into it. He further stated that he believed that food in the cabinets could worsen their pest control issues and staff shouldn't be doing that. Per an email correspondence from the Administrator on 8/5/26 at 1:30 p.m., We were with a pest control company for a long time but had to change to different pest control company a month ago because we were having issues with them coming out consistently.During an interview on 8/6/26 at 8:46 a.m., the Director of Housekeeping (DOH) stated that the daily cleaning of the four dining rooms in the facility included floors, tables/chairs, and sinks/countertops. He said housekeeping staff also checked the refrigerators for spills. The expectation was that the floors underneath any mobile equipment (e.g., steam tables) would be cleaned daily. Floors were supposed to be auto-scrubbed after the evening meal. Weekly deep cleaning of the dining rooms was expected to include cabinet interiors, refrigerator tops, and windowsills. The DOH stated he has not seen any roaches or noticed any other bugs in the facility. He expected his housekeeping staff to report any issues with pests to him, and he would forward that information to the DOM.During an interview on 8/6/26 at 10:45 a.m., the Director of Culinary Services (DCS) stated that he had maybe seen one or two roaches in the kitchen. He would expect that kitchen staff would notify him if they saw any roaches and he would then forward that information to the DOM.A Service Report dated 2/2/26 from the initial pest control company provided by the facility indicated that two units for straggler roaches had been spotted. Due to it being in memory care, glue boards were advised against. The document stated that the DOM has baited these rooms and all around for any roach issues.A second Service Report dated 3/23/26 provided by the facility indicated no pest activity was noted in the facility.Additional documentation regarding pest control measures taken by the facility in the last three months was requested but not received. Facility policies on maintenance and pest control were also requested but not received.

Based on observation, interview, and document review, the facility failed to ensure self-administration of medications was assessed and determined to be appropriate for 1 of 1 resident (R59) reviewed for the self-administration of medications. Findings include:R59's comprehensive Minimum Data Set, dated [DATE], indicated R59 was cognitively intact and required varying levels of assistance with activities of daily living and mobility. R59 was occasionally incontinent of urine and required partial to moderate assistance with toileting. Diagnoses included bilateral subdural hematomas (bleeding between the brain and skull) related to a fall, congestive heart failure, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), and chronic kidney disease,R59's care plan dated 7/30/26, failed to identify interventions related to bedside storage or self-administration of topical medications.R59's medical record, reviewed on 8/3/26, lacked evidence of provider orders for 1% hydrocortisone cream and 2% miconazole nitrate powder. Record review also lacked evidence of an assessment to determine whether it was appropriate for R59 to self-administer these medications.During observation and interview on 8/3/2026 at 11:10 a.m., an open container of 1% hydrocortisone cream and a bottle of 2% miconazole nitrate antifungal powder were observed on R59's bedside table. The medications lacked pharmacy prescription labels. R59 stated that the cream and crotch powder were given to him by staff, and that he was allowed to use these as needed. During observation and interview on 8/4/2026 at 9:22 a.m., the container of 1% hydrocortisone cream and bottle of 2% miconazole nitrate powder were again observed on R59's bedside table. R59 reiterated that staff provided these and he could use both when he wanted.During interview on 8/5/2026 at 10:30 a.m., nursing assistant (NA)-B stated that she had seen the containers of 1% hydrocortisone cream and 2% miconazole nitrate in R59's room, but she did not know how long they had been there. NA-B stated that NAs were supposed to be helping R59 apply these medications, but R59 preferred to do this himself and refused to allow staff to assist. NA-B also stated that R59 refused to allow staff to remove these medications from the room after self-administration. NA-B stated that she thought the medications were for R59's skin due to frequent episodes of incontinence, but she was unsure about the status of R59's skin as she had not seen it. During interview on 8/5/2026 at 10:55 a.m., licensed practical nurse (LPN)-C stated that orders should be in the system for all medications, including those that are topically administered. LPN-C did not know if R59 had been assessed to determine if it was appropriate for him to self-administer medications.During observation and interview on 8/5/2026 at 11:05 a.m., LPN-B stated that the 1% hydrocortisone cream should not be in R59's room. LPN-B removed the 1% hydrocortisone cream from R59's room and told R59 that it needed to be kept in the medication cart. LPN-B examined the container of 2% miconazole nitrate and stated that this particular brand was in-house. LPN-B exited R59's room without removing the 2% miconazole nitrate. During subsequent interview on 8/5/26 at 11:15 a.m., LPN-B stated that orders should be in the system for both the hydrocortisone cream and the antifungal powder. After reviewing the orders, LPN-B stated that there was an order for nystatin powder, but no orders for the 1% hydrocortisone cream or the 2% miconazole nitrate. During third interview on 8/5/2026 at 12:29 p.m., LPN-B stated that the orders for 1% hydrocortisone cream and 2% miconazole powder may be part of the standing house orders for skin and wound management. She stated that she would inform the survey team if she was able to obtain additional clarification. LPN-B also stated that a self-administered medication form should be completed at least annually for every patient who is self-administering medications. She stated that there was not a completed self-administration form for R59 and therefore, R59 should not be self-administering anything. On 8/5/26, a review of the facility's document Standing Orders for Nursing Facilities and Skilled Nursing Facilities signed by a provider on 01/07/26, did not list orders for 1% hydrocortisone cream or 2% miconazole. During interview on 8/6/2026 at 7:55 a.m., registered nurse (RN)-A stated that she was not aware of any form or assessment that needed to be completed for the self-administration of medications. She stated that residents were generally allowed to have lotions, creams, and antifungal powder at bedside.During interview on 8/6/2026 at 8:02 a.m., LPN-D stated that she thought there was a form for the self-administration of medications, but she was unable to locate it within the facility's electronic medical record system. LPN-D then stated that she did not know where the form was or when it should be filled out. During interview on 8/6/2026 at 11:50 a.m., the Director of Nursing (DON) stated that the expectation was that all residents be assessed prior to being able to self-administer medications. She also stated that the expectation was for provider orders to be in the system for any self-administered medications.The facility's policy titled Medication and Treatment Orders Policy dated 8/2021, stated that a written prescriber's order must be obtained for any treatment or medication administration provided to a client. A policy regarding the self-administration of medications was requested but not received. A copy of the facility's form titled MHM Self Administration of Medication Evaluation dated 2013, indicated the parameters that must be satisfied if a resident requests to self-administer medication.

Based on interview and document review the facility failed to ensure quarterly Minimum Data Set (MDS) was completed in a timely manner for 1 of 1 residents (R39) reviewed for MDS completion. Findings include:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified a Quarterly Assessment is a non-comprehensive assessment required no later than 92 days after the previous assessment of any type to monitor gradual changes in the resident's condition between comprehensive assessments.R39's Face Sheet located in the facility's electronic medical record (EMR) indicated an initial admission date of 3/18/24.R39's MDS dated [DATE], identified moderate cognitive impairment and diagnoses that included Alzheimer's disease, dementia with agitation, type 2 diabetes with nerve damage, and high blood pressure.During document review on 8/6/26, R39's MDS assessments identified the previous quarterly assessment was dated 3/24/26. The next quarterly assessment was due by 6/24/26; however, it was not completed until 7/23/26, 29 days beyond the required timeframe.During an interview on 8/6/26, at 12:36 p.m., the director of nursing (DON) stated quarterly MDS assessments are completed every three months in accordance with the RAI schedule and are important for monitoring resident status and quality outcomes. The DON stated the facility uses PointClickCare (PCC) to track upcoming MDS assessments and acknowledged R39's quarterly assessment was not completed within the required timeframe because the facility's assessment calendar reset and the assessment was not identified as due. The DON confirmed the facility follows the RAI Manual when completing MDS assessments.

Based on observation, interview, and document review, the facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for 1 of 1 resident (R59) reviewed for medication administration.Findings include:R59's comprehensive Minimum Data Set, dated [DATE], indicated R59 was cognitively intact and independent with eating and upper body dressing. R59 required moderate assistance with lower body dressing and toileting. He used a wheelchair for mobility. Diagnoses included bilateral subdural hematomas (bleeding between the brain and skull) related to a fall, congestive heart failure, and chronic kidney disease. R59's MDS indicated he was occasionally incontinent of urine.R59's nursing progress note dated 7/24/26 at 12:57 p.m., indicated a message was sent to the provider informing them of redness to the resident's groin upon skin inspection yesterday related to moisture. The resident wore a pull up and was incontinent at times with refusal of care noted.R59's provider order dated 7/25/26, specified nystatin external powder 100000 Unit/GM to be applied to the groin topically three times a day for 14 days for candidiasis related to rash and other nonspecific skin eruption.R59's medical record lacked evidence of a provider order for 2% miconazole nitrate powder.During observation and interview on 8/3/26 at 11:10 a.m., a container of 2% miconazole nitrate antifungal powder was observed on R59's bedside table. The medication lacked a pharmacy prescription label. R59 stated the crotch powder was given to him by staff, and he was allowed to use it as needed. During observation and interview on 8/4/26 at 9:22 a.m., the container of 2% miconazole nitrate powder was again observed on R59's bedside table. R59 reiterated that staff had provided this and he could use the powder whenever he wanted.During an interview on 8/5/26 at 10:30 a.m., nursing assistant (NA)-B stated she had seen the container of 2% miconazole nitrate in R59's room but did not know how long it had been there. NA-B stated that NAs were supposed to be helping R59 apply this medication, but R59 preferred to do this himself and refused to allow staff to assist. NA-B also stated R59 refused to allow staff to remove this medication from the room after self-administration. NA-B stated she thought the medication was for R59's skin due to frequent episodes of incontinence, but she was unsure about the status of R59's skin as she had not seen it. During an interview on 8/5/26 at 10:55 a.m., licensed practical nurse (LPN)-C stated orders should be in the system for all medications, including any topicals and/or self-administered medications. During observation and interview on 8/5/26 at 11:05 a.m., LPN-B examined the container of 2% miconazole nitrate and stated this brand was in-house. LPN-B exited R59's room without removing the 2% miconazole nitrate. During a subsequent interview on 8/5/26 at 11:15 a.m., LPN-B stated orders should be in the system for the antifungal powder. After reviewing the orders, LPN-B stated there was an order for nystatin powder but no order for 2% miconazole nitrate powder.A review of R59's medication administration record (MAR) on 8/5/26, indicated the nystatin powder was administered earlier that morning by trained medical assistant (TMA)-A. During an interview on 8/5/26 at 12:12 p.m., R59 stated he had not administered the 2% miconazole nitrate or any other powder today and staff had not administered anything either. R59 stated again that he applied this himself. When asked if staff had ever assessed him for the use of this powder or provided any education on it, he stated he did not remember that.During an interview on 8/5/26 at 12:19 p.m., TMA-A stated she was responsible for administering R59's medications. TMA-A pulled the bottle of nystatin powder she typically administered to R59 from the medication cart. She confirmed this was the correct medication listed in the order set. TMA-A stated the nystatin powder had remained in the cart this morning and was not given. She stated it was ordered to be given three times per day. TMA-A stated R59 told her he would do it later. She said she charted it as being administered, as R59 later told her he had done it himself. TMA-A then pulled a separate bottle of 2% miconazole nitrate from the medication cart which was identical to the bottle of 2% miconazole nitrate in R59's room. When asked to examine the bottle of 2% miconazole nitrate, TMA-A stated she could not really read the label, but she thought this was the same medication as the nystatin. During an interview on 8/5/26 at 12:29 p.m., LPN-B stated the orders for the 2% miconazole nitrate powder might be part of the standing house orders for skin and wound management. She stated she would inform the survey team if she was able to obtain additional clarification. On 8/5/26, a review of the facility's document Standing Orders for Nursing Facilities and Skilled Nursing Facilities signed by a provider on 1/7/26, did not list orders for 2% miconazole nitrate. During an interview on 8/6/26 at 7:55 a.m., registered nurse (RN)-A stated residents were generally allowed to have lotions, creams, and antifungal powder at bedside and orders should be in the system for all medications.During an interview on 8/6/26 at 11:50 a.m., the Director of Nursing (DON) stated the expectation was for provider orders to be in the system for all medications, including those that are self-administered and/or kept at bedside. She stated no medications should be administered without a provider order. She also stated the expectation was for staff to document medication administration accurately in the chart.The facility's policy titled Medication and Treatment Orders Policy dated 8/2021, indicated a written prescriber's order must be obtained for any treatment or medication administration provided to a client. A policy regarding the self-administration of medications was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure staff followed proper personal protective equipment was used for 2 of 3 residents (R31, R83) observed who required infection control precautions. Findings include:R31R31's comprehensive Minimum Data Set (MDS) assessment dated [DATE], was in process and was unavailable for review.R31's electronic medical record (EMR), reviewed on 8/1/26, indicated diagnoses that included acute pancreatitis (inflammation of the pancreas), acute pyelonephritis (kidney infection), and severe sepsis with septic shock.R31's provider orders dated 8/1/26, indicated the resident was on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) infection (an antibiotic-resistant infection that spreads through contact) and staff were instructed to follow contact precaution procedures.R31's care plan dated 8/1/26, indicated the resident required contact isolation precautions. The care plan instructed all staff to follow isolation precautions, implement infection control precautions according to protocol, and ensure a contact precaution sign was posted on the resident's door.During an observation on 8/4/26 at 8:35 a.m., Licensed Practical Nurse (LPN)-E entered R31's room without performing hand hygiene or donning personal protective equipment (PPE). LPN-E removed the resident's water pitcher, filled it at the ice and water machine, returned it to the resident's room, and did not perform hand hygiene or don PPE before re-entering the room.During an observation on 8/4/26 at 8:37 a.m., Nursing Assistant (NA)-D entered R31's room without performing hand hygiene or donning PPE. NA-D delivered the resident's breakfast tray, placed it on the bedside table, exited the room, and did not perform hand hygiene upon leaving.During an observation on 8/6/26 at 8:48 a.m., LPN-D entered R31's room with a portable vital signs machine without performing hand hygiene or donning PPE. LPN-D obtained the resident's vital signs and administered medications. Upon exiting the room, LPN-D did not perform hand hygiene or disinfect the portable vital signs machine before taking it into another area.During an interview on 8/4/26 at 8:51 a.m., NA-D verified a contact precaution sign was visibly posted on the door to R31's room. NA-D acknowledged she had not followed the required contact precaution procedures. She stated PPE supply bins were in the hallway but were not positioned outside R31's room. NA-D confirmed she should have performed hand hygiene and donned PPE before entering the room.During an interview on 8/4/26 at 8:54 a.m., LPN-E acknowledged she had not followed the required contact precaution procedures despite the contact precaution sign being visibly posted on R31's door. LPN-E confirmed she had not performed hand hygiene or donned PPE. LPN-E stated staff were expected to follow each resident's care plan because it contained resident-specific care instructions. She further stated staff were expected to follow provider orders because they defined the treatments required for each resident.During an interview on 8/6/26 at 10:30 a.m., LPN-D stated all staff were expected to follow the contact precaution instructions posted on the sign outside R31's room. LPN-D acknowledged she had not followed the required contact precautions and had failed to disinfect equipment when leaving the room. LPN-D stated the purpose of contact precautions was to minimize the spread of infection.R83R83's comprehensive MDS assessment dated [DATE] indicated he was cognitively intact and required maximum assistance with personal hygiene, dressing, and oral hygiene. Diagnoses included intracranial abscess and granuloma (inflammatory lesions in the brain) and sepsis due to methicillin-susceptible Staphylococcus aureus (MSSA).R83's provider orders dated 7/27/26 indicated the resident was on contact precautions.R83's care plan dated 7/28/26 indicated contact precautions were required due to the resident's current infection.During an observation on 8/5/26 at 2:16 p.m., Nursing Assistant (NA)-E entered R83's room without performing hand hygiene or donning personal protective equipment (PPE) required for contact precautions. NA-E obtained the resident's vital signs and disinfected the vital signs machine after leaving the room.During an observation on 8/6/26 at 9:22 a.m., Licensed Practical Nurse (LPN)-D entered R83's room without performing hand hygiene or donning PPE. LPN-D administered the resident's medications and exited the room without performing hand hygiene.During an interview on 8/5/26 at 2:26 p.m., NA-E stated contact precautions were only necessary when providing direct resident care. NA-E acknowledged she had not performed hand hygiene or utilized PPE before entering the room. NA-E confirmed a contact precaution sign was visibly posted on the resident's door. After reviewing the sign, NA-E stated she should have donned PPE and performed hand hygiene before entering R83's room.During an interview on 8/6/26 at 10:00 a.m., Registered Nurse (RN)-C stated all staff were expected to follow the contact precaution instructions posted on the resident's door. RN-C stated PPE was to be donned before entering the resident's room. RN-C further stated it was important to follow provider orders and the care plan to ensure resident safety and provide appropriate individualized therapeutic care.During an interview on 8/6/26 at 2:26 p.m., LPN-D acknowledged she had not worn PPE before entering R83's room. LPN-D stated that after reading the contact precaution sign, she recognized she should have followed the posted instructions by donning PPE and performing hand hygiene before entering the room. LPN-D stated contact precautions were used to reduce the risk of spreading infections.During an interview on 8/6/26 at 10:39 a.m., the Regional Nursing Consultant (RNC) stated every staff member was expected to follow all instructions posted on the contact precaution signage and understand the rationale for the precautions to help prevent the spread of infections. The RNC further stated staff received education on the different transmission-based precautions (TBP) during new hire orientation, annual skills fairs, annual training, and as needed.During an interview on 8/6/26 at 10:46 a.m., the Director of Nursing (DON) stated staff were expected to follow transmission-based precaution (TBP) protocols. The DON further stated staff were expected to follow provider orders as part of their scope of practice and provide the care necessary for each individual resident. The DON stated care plans were expected to be followed by each discipline to ensure residents received individualized care necessary for their well-being.A policy titled Contact Precautions, dated 7/31/23, directed staff to implement contact precautions to prevent the transmission of infectious agents, including epidemiologically important microorganisms spread through direct or indirect contact with the resident or the resident's environment. The policy instructed staff to perform hand hygiene, noting that multidrug-resistant organisms (MDROs) were primarily transmitted by contaminated hands of healthcare personnel. The policy further stated the single most effective method of reducing the transmission of MDROs was hand antisepsis before and after resident contact, including after glove removal. Additionally, the policy directed staff to don gloves and a gown upon entering the resident's room and to remove the gown and perform hand hygiene before leaving the resident care area.

Based on observation, interview, and document review, the facility failed to ensure resident rooms were kept in good working condition for 1 of 1 resident (R45) reviewed for a safe, clean, comfortable, and homelike environment.Findings include:R45's quarterly Minimum Data Set (MDS) dated [DATE], identified R45 was severely cognitively impaired.R45's diagnoses included Alzheimer's dementia, chronic kidney disease, hypertension, and depression.During an observation on 8/3/26 at 2:50 p.m., R45 was lying in bed. The bed was positioned with the long side against the wall. Next to R45's bed at the height of the bed, the wallpaper seam was loose to the wall light and approximately 2 feet of the wallpaper was peeling away from the seam exposing a beige wall and some loose white matter on the wall where the wallpaper had been affixed.During an interview on 8/5/26 at 11:36 a.m., the maintenance director (M)-A observed R45's room and stated the wallpaper needed to be repaired. M-A stated loose wallpaper may be a safety issue due to the possibility of lead paint in buildings but they did not believe the facility had lead paint. They stated the normal process was for staff to put in a maintenance work order for repairs.During an interview on 8/5/26 at 11:46 a.m., nursing assistant (NA)-A stated the wallpaper in R45's room had been damaged for a few months, and they had observed R45 pulling at the wallpaper and removing pieces. NA-A stated they let the nurse know when repairs are needed and the nurse enters a maintenance request on the computer.During an interview on 8/6/26 at 8:39 a.m., licensed practical nurse (LPN)-A stated they had not been told of the wallpaper damage in R45's room and they were not aware that R45 was pulling on the wallpaper. LPN-A was concerned that R45 removed pieces but stated R45 did not usually put things in their mouth. LPN-A expected staff to let nurses know when repairs were needed so a maintenance request could be entered. LPN-A stated they do not have a process to go room to room looking at the walls. During an interview on 8/6/26 at 9:31 a.m., interim director of nursing (DON) and regional nursing consultant (RNC) stated resident rooms should not have peeling wallpaper. RNC stated they needed to make sure the resident could not rip the wallpaper off and expressed a concern that anything nonedible could be a problem. RNC stated M-A informed them of R45's wallpaper, had secured the wallpaper with tape, and was working with nursing to make the room available for the painter.Maintenance work orders for R45's room were reviewed for 1/1/26 through 8/5/26. No maintenance requests were placed for wallpaper repair in R45's room.Facility maintenance policy was requested but not received.

Based on interview and document review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 residents (R1) who was identified as an elopement risk and had exit-seeking behavior. This resulted in Immediate Jeopardy (IJ) for R1 when he left the facility and independently wheeled his wheelchair approximately 0.6 miles from the facility before being found, which placed R1 at likelihood for serious harm or death.The IJ began on 6/1/26 when R1 exited the building without staff awareness through the secured unit doors and then through an unknown door to the outside of the building. After a Good Samaritan contacted the facility related to their observation of a potential facility resident, R1was found on a residential street near a highway/collector road (a road that has more traffic than a residential street because the road is used to travel through parts of the city and neighborhoods). The administrator, director of nursing, regional nurse consultant, and regional social services consultant were notified of the immediate jeopardy on 6/10/26 at 5:11 p.m. The facility had implemented immediate corrective action on 6/2/26 to prevent recurrence, so the IJ was issued at past non-compliance. Findings include:R1's admission Record identified R1 was admitted to the facility 5/11/23 with diagnoses which included dementia, major depressive disorder, and type 2 diabetes mellitus. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, required staff assistance for ambulation, and used a wheelchair. R1 had wandering behaviors and delusions.R1's Care Plan, dated 5/12/23, identified R1 was at risk for elopement related to diagnosis of dementia, and directed staff to invite R1 to activities and gatherings, keep family informed, ensure R1 followed the sign out policy when leaving facility, and to answer door alarms promptly. Additionally, R1's vulnerable adult care plan section, dated 5/25/23, indicated R1 had decreased cognitive and physical abilities related to dementia and major depressive disorder and had history of delusional thoughts, wandering, and thoughts that he would be better off dead. Interventions directed staff to implement safety monitoring as needed to ensure R1's safety and monitor for signs of emotional distress or mood and behavior changes.R1's Elopement Risk Evaluation dated 3/27/26, indicated R1 scored a 4 which identified R1 required an elopement care plan. The assessment indicated R1 was on a secured memory care unit and had no prior attempts to leave the facility.R1's progress notes dated from 3/11/26 to 6/1/26, indicated the following exit-seeking behaviors:-On 3/22/26 at 5:26 a.m., R1 was wandering and exit-seeking as he wanted to go to the bank and thought a hand sanitizer was a coin machine. R1 did not believe he had a bed at the facility and was successfully redirected after several attempts.-On 3/23/26 at 4:43 a.m., R1 was exit-seeking, pushing on unit doors, and stated, I'm going to get a haircut! and I need to get out of here!. R1 was upset with redirection.-On 4/7/26 at 6:59 a.m., R1 was near an exit door and requested the door to be opened. R1 was redirected to watch television.-On 4/17/26 at 5:20 a.m., R1 was exit-seeking, pushing on exit doors, and sounding the exit door alarms. R1 appeared agitated and was redirected multiple times.-On 5/14/26 at 6:00 a.m., R1 was trying to exit throughout the night and was awake most of the overnight shift.-On 5/19/26 at 5:03 a.m., R1 was kicking, pushing on exit doors, and sounding the exit door alarms during the overnight shift. Redirection and reassurance were provided and not effective.-On 5/27/26 at 5:30 a.m., R1 was exit-seeking and redirection from exit doors was effective.-On 5/31/26 at 6:01 a.m., R1 was exit-seeking twice.R1's progress note dated 6/1/26 at 11:17 p.m., indicated R1 was found outside of the facility by staff after someone called the facility around 8:50 p.m. to report they saw a person in a wheelchair looking confused outside. R1 stated he was visiting a friend and had no skin issues along with stable vital signs upon returning to the facility. 15-minute checks were initiated, and management was notified. Report was given to the night shift to monitor R1 closely, and R1 currently slept in his room.R2's care plan interventions dated 6/2/26, directed staff to follow elopement policy, monitor and document exit-seeking behavior, a wander guard was in place and staff were to monitor for proper functioning. R2's care plan intervention dated 6/5/26, directed staff to complete 30-minute checks.During interview on 6/8/26 at 4:17 p.m., nursing assistant (NA)-A stated R1 moved independently around the unit in his wheelchair. He always wanted to get out the door to see his daughter, go outside, and/or find his key for his car. NA-A would remind R1 the facility was his home, give him snacks or water, or turn on the television to help calm him. NA-A stated R1 was not safe to leave the unit or be outside by himself as R1 would not know where he was going.NA-A stated on 6/1/26 he saw R1 around 7:00 p.m. in the unit dining area. As staff were helping other residents to bed, they heard a resident was missing. In response, NA-A checked R1's room and did not see him. NA-A stated there was a code to exit the unit and the door alarmed when a resident pushed on the door and held it without the code or when the door was open for a certain period of time; however, the door alarm had not sounded. During interview on 6/8/26 at 5:33 p.m., NA-B stated R1 had days when he was calm and other days when he was aggressive and exit-seeking. On 6/1/26 R1 was aggressive from the beginning of her shift, which started at 2:00 p.m. R1 was pushing on the unit exit door, and NA-B redirected him away from the door about every ten minutes. NA-B reported this to the nurse, and the nurse told NA-B to monitor R1. Around 7:00 p.m., R1 had calmed; however, NA-B continued to monitor him. Around 7:40 p.m. to 7:50 p.m., R1 wanted to watch the television in his room, so NA-A wheeled him to his room and left him to watch television alone. After, NA-B went to assist another resident with a shower which took her about 30 minutes and then went to help another resident, without checking on R1 in between. While NA-B was assisting other residents, she heard a resident was in a wheelchair outside the building and the missing resident protocol was activated. NA-B stated it was 8 something when R1 was returned to the unit. R1 had been wearing pants, a shirt, and a sweater. NA-B stated the unit exit door had an alarm which sounded if a resident pushed on the door without the code; however, did not hear any alarm sound on 6/1/26. NA-B indicated another resident, whose spouse resided on the secured unit, may have entered the unit to visit their spouse, in which R1 may have exited at that time. NA-B stated the facility changed the code which staff were to safeguard since the elopement, and staff were educated to no longer give the code to family members or other visitors. Additionally, the other resident's spouse, who resided inside the secured unit, was moved off the secured unit, mitigating the risk of the secured residents exiting the unit unsupervised during visitor entry to the unit During interview on 6/8/26 at 6:54 p.m., the director of nursing (DON) stated she did not know how R1 exited the building as R1 resided on a secured unit with a door alarm, and the door would beep if it was pushed to exit the unit without the use of the code. The DON stated multiple facility exit doors were equipped with a wander guard system, and the exit door would have sounded an alarm, and locked, if R1 had a wander guard on. The DON stated facility staff completed an audit on residents in the secured memory care units and reviewed elopement assessments and care plans. The DON stated the facility had changed the secured unit door code multiple times since R1's elopement and changed the code whenever it became known to family members or visitors.During interview on 6/9/26 at 12:51 p.m., NA-C stated R1 was often more aggressive in the evening and appeared as his normal self on 6/1/26. NA-C stated they heard the code pink (term used to signify a missing resident) on 6/1/26 and helped search for R1. NA-C stated she did not know when or how R1 got off the secured unit, but there was a resident couple (spouses) who were going on and off the unit often and thought R1 could have gotten out with them or someone else. NA-C stated the facility fixed that issue by moving the two family members to the LTC area of the facility. NA-C stated R1 was returned to the unit around 9:00 p.m. or 9:15 p.m. NA-C stated she asked R1 where he was going after he returned to the unit, and R1 stated he was going to see his grandparents. NA-C stated R1 was not safe to be off the secured unit by himself because R1 had a memory diagnosis. NA-C stated the facility changed the code to exit the secured unit and were not allowed to tell family or visitors the code.During an interview on 6/9/26 at 1:10 p.m., LPN-A stated R1had a longstanding history of wandering and exit-seeking behaviors, which were exhibited on 6/1/26, and thus R1 required close monitoring, including observation by a nursing assistant, and staff awareness to prevent him from leaving the unit. LPN-A last saw R1 in the dining area around 8:00 p.m. and, after returning from break at approximately 8:30 p.m., LPN-A heard someone call a Code Pink. LPN-A responded to the code and learned staff received a report of a resident down the street. LPN-A stated staff were looking for a different resident when he was told the resident missing was R1. R1 was located by other staff and returned to the unit. LPN-A completed an assessment with no injuries or concerns noted, notified the administrator, initiated staff interviews, and implemented 15-minute checks for R1. LPN-A stated R1 was not safe to be outside the facility independently because R1 could not make appropriate decisions. During follow-up interview on 6/9/26 at 3:10 p.m., the DON stated the administrator received a phone call first about R1's elopement, and she received a call on 6/1/26 around 9:20 p.m. to 9:30 p.m. after R1 was found. In response, R1 was placed on 15-minute checks. This changed to 30-minute checks after the interdisciplinary (IDT) team review determined R1's behaviors and exit-seeking had decreased. The DON stated R1's behaviors and exit-seeking on 6/1/26 were not a change of condition. Additionally, facility staff and providers reviewed R1's medications. The DON stated the IDT team should have discussed wander guard use for R1 prior to his elopement, based on her expectation the IDT reviewed residents progress notes, such as R1's, and discussed any exit-seeking behaviors for any potential care plan adjustments. During interview on 6/9/26 at 3:45 p.m., the administrator stated they completed Code Pink drills since 6/1/26 and maintenance checked on doors and the wander guard system.During interview on 6/9/26 at 5:11 p.m., RN-B stated she was told to search the unit to make sure the residents on her unit were present and called other units to check for their residents. RN-B stated she and another staff member went looking for a missing resident in a car and headed North of the facility when they saw RN-A and another staff member with R1. RN-B stated R1 was found by himself and did not present with any behaviors.During interview on 6/9/26 at 5:20 p.m., RN-A stated they got a call from another unit that a stranger called the facility to report a male resident was on the street. RN-A stated they thought the resident on the street was one of her residents, because there was a resident she did not see on her secured unit or in the facility parking lot when she looked for him. RN-A told another staff member to call a Code Pink, and RN-A got into her car with another staff member to drive around the facility and look for the missing resident. RN-A stated she was on [NAME] Street, approximately half a mile away from the facility, when she saw a male in a wheelchair who was alone and on the side of the street. RN-A stated R1 was not the resident she was looking for but recognized him as a resident of the facility. RN-A stated R1 wore shoes, pants, and a shirt. R1 was calm and stated he was going to his grandma's house. RN-A stated the weather was sunny. RN-A and the other staff member who was with her were able to get R1 into the car and return him to his secured unit. RN-A stated the resident she initially was looking for from the secured unit was found in the unit dining area behind a door where she had not looked.During interview on 6/10/26 at 10:53 a.m., nurse practitioner (NP)-A stated the triage line was called on 6/1/26 about R1 leaving the building unattended, and the facility followed up with her on 6/2/26. NP-A stated R1 was not safe to be in the community by himself and was at risk for anything when outside the building by himself. NP-A stated she would have wanted to be contacted if exit-seeking was an on-going issue after a few resident redirections. NP-A stated she knew R1 was restless at night but not specifically exit-seeking.During interview on 6/10/26 at 1:08 p.m., the medical director stated R1's mood changed quickly, and a wander guard may have reduced the likelihood of R1's elopement. The medical director stated R1 had poor insight and was at risk for crossing roads, getting hit, hypoglycemia, and dehydration depending on weather and how long R1 was out of the facility.During follow-up interview on 6/10/26 at 4:10 p.m., RN-B verified she saw R1 with RN-A and another staff member on the left side of a residential street near a highway route/collector road approximately 0.6 miles from the facility, or about a 12-minute walk. RN-B stated she saw approximately two cars pass them while searching, finding, and returning R1 to the facility.During interview on 6/10/26 at 5:18 p.m., RN-C stated they received a call on 6/1/26 at 8:48 p.m. from a good Samaritan who stated they observed a resident rolling himself in a wheelchair heading North from the facility. RN-C stated she did not know who the caller was and knew the caller was driving. RN-C stated she told the nursing assistants to check the residents on her unit to ensure they were all in the facility. RN-C stated RN-B returned from break, and RN-C told RN-B to call the memory care units to tell staff there to check on their residents. RN-C stated RN-A and another staff member came to her and asked her about the phone call before they exited the building. A different staff member called a Code Pink approximately five to ten minutes after the phone call from the good Samaritan when staff realized a resident was missing from the facility. RN-C stated she got in her car and headed North from the facility, then saw RN-A and the other staff member had already located R1 and were returning him to the facility. RN-C stated the weather was warm and sunny but getting darker, and the time was approximately 9:30 p.m. when RN-C returned to the facility. RN-C stated the street she drove on was normally a busy street but was not at that time and about three cars passed by her while driving. The facility Elopement Policy dated 11/2025, directed staff to assure residents were assessed on an ongoing basis and had appropriate safety precautions in place quarterly, annually, and as needed due to significant changes.The past-noncompliance immediate jeopardy began on 6/1/26 and was removed on 6/2/26, when the facility implemented a systemic plan to ensure all residents were safe. The following actions were implemented prior to survey:- Immediately implemented 15-minute checks for R1.-Placed a wander guard on R1 and updated the care plan.-Changed the door code to exit the unit with focus on only staff having the code.-Moved another resident's family member outside the secured unit to decrease visitation and risks associated with unit residents eloping.-Reviewed all like-residents who reside on secured units, and implemented wander guards where appropriate, in addition to updating care plan.-Educated staff on door code and escalation of interventions, such as a wander guards, for residents identified to have exit-seeking behaviors.-Conducted elopement drills.

Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 resident (R3) observed with medications at their bedside.Findings include:R3's quarterly Minimum Data Set, dated [DATE], indicated intact cognition with a diagnosis of stroke.R3's electronic medical record lacked a self-administration form. R3's care plan dated 6/1/25, lacked indication of self-administration of medications.R3's current provider order list on 9/26/25, lacked orders for muscle rub with lidocaine and artificial tears.On 9/25/2025 at 11:38 a.m., an opened bottle of Aspercreme with lidocaine (a pain relieving cream) and an opened bottle of artificial tears eye drops were observed on R3's bedside table. R3 was interviewed and stated he applied the Aspercreme to his arm when it was sore. He administered the eye drops when his eyes were scratchy. R3 stated staff did not administer the cream or eye drops and did not know if he had a doctor order for them.On 9/25/2025 at 1:56 p.m., licensed practical nurse (LPN)-A stated a resident needed to have a self-administration of medications form filled out before they could keep medications at their bedside. LPN-A confirmed R3 should not have any medications at his bedside.On 9/26/2025 at 10:38 a.m., LPN-C was stated if a resident wanted to self-administer medications, a self-administer form needed to be completed. The resident needed a provider order for the medication requested. LPN-C was unaware of a self-administration form for R3.On 9/26/2025 at 1:40 p.m., the director of nursing (DON) was stated if a resident requested to self-administer medications the nurse manager completed an assessment, then reached out to the provider for an order for the resident to keep medications in their room. DON confirmed R3 did not have an order for the Aspercream, and the bottle had been removed from R3's room. Risks of a resident self-administering a medication were not using the correct dose or route.The Self-administration of Medications policy dated 2/2024 instructed the interdisciplinary team to assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan.

Based on interview and document review, the facility failed to monitor a skin concern and notify the provider for 1 of 3 residents (R2) reviewed for wound care.Findings include:R2's 5-day minimum data set (MDS) dated [DATE] indicated severely impaired cognition. Diagnoses included metabolic encephalopathy and peripheral vascular disease. R2 was at risk to develop pressure injuries.R2's admission form dated 9/5/25 and signed by licensed practical nurse (LPN)-A indicated coccyx foam dressing, small 2x2 area of redness.R2's Braden scale for predicting pressure sore risk form dated 9/6/25, indicated high risk for developing a pressure sore.R2's care plan dated 9/6/25, indicated alteration in skin integrity related to wounds to bilateral lower extremities (both legs) with intervention to document on skin condition and keep providers informed of changes.R2's skin evaluation and skin risk factors form dated 9/7/25, indicated coccyx wound 1 centimeter (cm), pink. Foam dressing on coccyx. R2's nursing note dated 9/9/25, indicated R2's weekly skin inspection was not completed due to R2 confusion and being uncooperative.R2's weekly skin assessment dated [DATE], indicated a small red spot on coccyx, foam dressing applied.R2's daily skilled notes lack documentation of a skin concern on her coccyx.R2's treatment administration record (TAR) lacked indication of daily monitoring to R2's coccyx.R2's provider orders from admission on [DATE] through discharge on [DATE], lack orders for a foam dressing applied to R2's coccyx.R2's provider note dated 9/17/25, signed by nurse practitioner (NP)-A, indicated R2 discharged to an assisted living on 9/17/25, and lacked indication and orders for a skin concern on R2's coccyx. On 9/25/2025 at 3:33 p.m., registered nurse from an assisted living (RN-AL) stated during R2's admission skin assessment on 9/17/25 she discovered a 5 centimeter (cm) by 5 cm pressure injury to R2's coccyx. R2's admission orders lacked information and orders for a skin concern on R2's coccyx.On 9/25/2025 at 1:56 p.m., LPN-A was interviewed and stated a skin check should be completed immediately on all new admissions. LPN-A could not recall if she informed the nurse manager or the provider about the redness on R2's coccyx.On 9/25/2025 at 4:08 p.m., LPN-B stated if a resident had a new skin concern the area of concern should be measured, documented in a nurse's note, a risk management completed, and reported to the nurse manager, provider, and family. If the area of concern was on the coccyx, the nurse should notify the provider to obtain an order for wound care. LPN-B confirmed all wound dressings needed to have a provider order even if the dressing was just for protection.On 9/26/2025 at 9:06 a.m., registered nurse (RN)-A stated a skin check needed to be completed for all new admissions. All skin concerns needed to be documented, and the nurse manager needed to be informed. On 9/26/2025 at 10:38 a.m., LPN-C stated when a new resident admitted to the facility the floor nurse should complete a head-to-toe skin check then alert either LPN-C or the RN manager of any skin concerns. The RN manager checked for orders and requested any needed provider orders. LPN-C rounded weekly with the wound nurse practitioner. If a resident had a skin concern that was not open a nursing order to monitor was placed in the TAR. LPN-C could not recall if R2 had an area of concern on her coccyx and did not have access to R2's medical record to check. If LPN-C had been notified of an area of redness she would have assessed the area and placed a nursing order to monitor in the TAR. On 9/26/2025 at 1:55 p.m., (NP)-A confirmed he was the nurse practitioner caring for R2 at the facility. NP-A stated the nurses should notify him of all skin concerns including redness on the coccyx. A nurse assessed the area of redness to determine if the redness was from pressure to the area or moisture related skin breakdown (MASD). The provider was contacted for orders related to the cause of the redness. Orders could include barrier cream or a protective dressing. NP-A stated he was not alerted to any redness to R2's coccyx. All areas of redness should be monitored at least once a day. Pressure injuries can develop quickly depending on the resident's ability to reposition self but typically not in a few hours. Risk factors for pressure ulcers include old age, frail skin, and inability to reposition self. Early identification of pressure injuries was important so the area received the proper skin care. Pressure injuries caught early were easier to heal. On 9/26/2025 at 1:40 p.m., the director of nursing (DON) stated the floor nurse completing the admission should complete a skin check. All skin concerns were documented on the admission form. If there was a wound, the nurse should look for dressing change orders and reach out to the provider for any needed orders. When a nurse placed a dressing based on standing orders a nursing note should be written about why the dressing was placed and the nurse manager and provider should be notified. DON confirmed documentation of an area of redness to R2's coccyx with no notes or orders from the provider. DON stated she was not informed of redness to R2's coccyx. Based only on the documentation it was difficult to determine if the area of redness was from pressure or moisture related. DON stated it was important to assess areas of redness and alert the provider so orders can be obtained to prevent the area from turning into something bigger.The Skin Assessment and Wound Management policy dated 2/2025 instructed to notify the nurse manager, wound nurse, provider, and resident representative for any new significant alterations in skin integrity or pressure ulcers.

Based on interview and document review, the facility failed to employ either a full-time registered dietician (RD) or a qualified culinary director (CD) to carry out the functions of the food and nutrition services. This had the potential to affect all 135 residents. Findings include: The dietician's license indicated the license was valid and expired 11/30/25. An email was sent to the administrator on 5/21/25 at 8:48 a.m., requesting timecards from September to current for the Dietician's time at the Estates at Roseville. The dietician's timecards were provided on 5/21/25 at 9:27 a.m., from September 2024, to May 2025, however, the timecards did not break down to identify what location the dietician was at per day and week, additionally, the time card showed the dietician had already clocked out at 4:00 p.m. on 5/21/25. An email from the administrator on 5/21/25 at 10:36 a.m., indicated the dietician was full time and further, she's housed out of Roseville and for Monarch 30 hours a week is full time status (she's an 80 hour a pay period full time employee). Dietitian's usually help support other buildings, she has done this and so her hours also get coded that way. An email was sent to the administrator on 5/21/25 at 10:48 a.m., requesting a copy of the ACD and CD's certifications, credentials, education, and job descriptions. An email from the administrator on 5/21/25 at 12:12 p.m., indicated attachments for the CD's degree and transcript. The attachment included CD's transcripts for Le Cordon Bleu College of Culinary Arts that indicated a certificate was awarded on 3/27/2009, that included coursework in culinary skills and sanitation, principles of butchery, baking and pastry fundamentals, [NAME] manger, flavors of the world, restaurant production, and externship. The ACD's resume was provided on 5/21/25 at 12:57 p.m., that indicated ACD had experience as a culinary director and had a Bachelor's degree in Culinary Arts, however, proof of ACD's credentials, education, and certifications were not provided. During interview on 5/18/25 betweeen 11:39 a.m., and 11:55 a.m., the assistant culinary director (ACD) stated he had been at the facility almost two weeks. ACD stated they had a culinary director who would be at the facility on 5/19/25, and further stated they had a dietician, but did not know when she came to the facility and had been introduced to the dietician once. During interview on 5/20/25 at 11:16 a.m., the corporate culinary director (CCD) stated the CD used to be the ACD, and was now the CD. Further, the CCD stated the CD was not a certified dietary manager and thought the facility signed him up for Serv Safe. During interview on 5/20/25 at 11:34 a.m., the administrator stated their dietician was a certified dietary manager (CDM), and further stated the ACD was also CDM certified. During interview on 5/20/25 at 11:45 a.m., the dietician stated she was a full time employee, but split her time between two buildings and was not a CDM. During interview on 5/20/25 at 2:26 p.m., the CCD stated the CD started on 9/5/24, in the position of CD. Further, ACD was new and had Serv Safe and Certified Food Protection Manager (CFPM) and would bring certifications because human resources didn't have any certifications on file. CCD further stated the CD had a certificate from Cordon Blue and did not think this was in the CD's file. During interview on 5/20/25 at 2:30 p.m., the dietician stated she was full time, but went between facilities and further stated that was how they did it at Monarch and stated she also covered at [NAME] and thought she worked at the Estates at Roseville three days and maybe more or maybe less. Then stated she worked 30 to 36 hours. Requested work logs since 9/1/2025, for the Estates at Roseville. During interview on 5/20/25 at 2:36 p.m., the CD stated he started in September 2024, as the CD and was not a CDM but was going to be signing up for classes soon. CD stated he graduated from Cordon Blue in 2009 or 2010 and had Serv Safe, but did not renew Serv Safe and did not have an associate's degree or higher, had not had experience in the position of a director of food and nutrition services in a nursing facility setting, and did not complete coursework in food management. During interview on 5/20/25 at 2:41 p.m., the dietician stated the administrator would email her time logs. During interview on 5/21/25 at 8:43 a.m., registered nurse (RN)-D stated they did not have human resources in the building. On 5/21/25 at 10:12 a.m., attempted to contact the ACD by the phone number provided by the administrator and received an error message the call could not be completed as dialed. During interview on 5/21/25 at 11:16 a.m., the administrator stated the ACD had a CFPM and further stated the dietician worked 30 hours at the facility. Further, the administrator stated the dietician was a salaried employee and the purple lines on the dietician's time card was already set up for 8 hours because the dietician was salaried. The administrator stated the CD had been in the director role since 9/2024, and the facility was enrolling the CD today in the CDM program. Further, the administrator stated the ACD was new and did not have anything in his personnel file and expected human resources to have complete personnel files. During interview on 5/21/25 at 11:27 a.m., the ACD stated he did not have a CDM, but was a certified food protection manager and stated he had it for years, but was just recertified approximately 6 months ago and further stated human resources had a copy. ACD further stated he had a bachelor's degree in culinary, but did not have a copy and could get a copy and had been a director for the last 10 years and had completed coursework in foodborne illness, sanitation procedures, and food purchasing and receiving and worked 40 hours per week. During interview on 5/21/25 at 2:27 p.m., the administrator stated the ACD never made it into the facility today and further stated she sent all the information she had. Additionally, the ACD started on 4/9/25, and didn't start on the floor until 5/7/25. No additional information was provided regarding staff credentials, certifications, or a break down of the dietician's actual hours worked at the facility. A job description, Culinary Services Assistant Director, signed by the ACD on 4/14/25, indicated under qualifications, must have a desire and commitment to work with geriatric residents and understand their special needs, must have strong clear communication, must be able to follow directions, must be able to perform essential functions, must qualify for employment after criminal background check, per guidelines of the Minnesota Department of Human Services. A job description, Culinary Director, indicated the CD was responsible for managing the culinary service department in providing quality food and nutritional services to residents. The position provides therapeutic meal service based on RDA requirements and standards set forth for qualifty food provision. The director provides supervision and leadership to all culinary services personnel to assure that services are provided in a consistent quality manner. Under a heading, Education and Experience, indicated must be a graduate of or currently enrolled in an approved Culinary Services Director's course that meets the requirements for State and Federal long term care regulations. Must have management and leadership qualities with a basic understanding of budgeting, food purchasing and menu planning, must have strong clear communication is a must as well as a commitment to improving the knowledge and skill of culinary services to older persons.

Based on observation, interview, and record review the facility failed to attempt alternative devices before the installation of bed rails on resident's beds, identify medical needs to be met with bed rail use, and assess potential entrapment zones for 4 of 4 residents (R76, R23, R103, and R35) reviewed for bed rails. Findings include: R76 R76's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no functional impairment to upper and lower body, partial/moderate assistance required to roll left and right, substantial/maximal assistance for sit to lying, lying to sitting on edge of bed, sit to stand and chair/bed to chair transfer. Diagnoses included stroke and depression. R76's care plan dated 1/31/25, identified an alteration in mobility related to weakness with interventions for PT (physical therapy) per MD (medical doctor) order, one staff assist for ambulation, assist with movement in/out of bed, one staff assist for transfers. Prior to 5/20/25, the care plan lacked intervention of bed rails. R76's IDT (interdisciplinary team) Care Conference dated 4/28/25, included a section for positioning devices which was left blank for type of positioning device, team reviewed risk and benefits and if bed mobility evaluation was completed. Prior to 5/20/25, R76 lacked a bed mobility device evaluation. R23 R23's quarterly MDS dated [DATE], identified severely impaired cognition, no functional impairment to upper and lower body, total dependence to roll left and right, substantial/maximal assistance for sit to lying, lying to sitting on edge of bed, sit to stand and chair/bed to chair transfer. Diagnoses included dementia, anxiety and depression. R23's care plan dated 8/22/18, identified ADL (activity of daily living) performance deficit related to dementia and pain with interventions for prn (as needed) assist of one staff, independent. The care plan lacked current use of bed rails. The care plan history showed a resolved intervention of assist bars on bed initiated 4/17/21 and resolved on 9/12/22. R23's IDT Care Conference dated 4/15/25, included a section for positioning devices which was left blank for type of positioning device, team reviewed risk and benefits and if bed mobility evaluation was completed. R23's Bed Mobility Device Evaluation dated 7/26/24, identified the resident was able to state a preference about bed mobility device and resident/representative requested a bed mobility device of grab bars. Resident/representative was informed on risks/benefits of bruising, skin tears, entrapment, entanglement). The section for alternatives attempted prior to placement of assist was marked N/A (non-applicable). The section for consideration of removal of bed mobility device or other possible alternatives was left blank. The facility had not evaluated alternatives to bed rails. R103 R103's quarterly MDS dated [DATE], identified severely impaired cognition, no functional impairment to upper and lower body, substantial/maximal assistance to roll left and right, substantial/maximal assistance for sit to lying, lying to sitting on edge of bed, sit to stand and chair/bed to chair transfer. Diagnoses included stroke and dementia. R103's care plan dated 10/24/24, identified an alteration in mobility related to TIA (transient ischemic attack; a brief period of symptoms like a stroke cause by blockage of blood flow) with interventions of one staff assist with transfer's, ambulation and movement in/out of bed. Prior to 5/20/25, the care plan lacked intervention of bed rails. R103's IDT Care Conference dated 3/25/25, included a section for positioning devices which was left blank for type of positioning device, team reviewed risk and benefits and if bed mobility evaluation was completed. Prior to 5/20/25, R103 lacked a bed mobility device evaluation. R35 R35's quarterly MDS dated [DATE], identified moderately impaired cognition, no functional impairment to upper and lower body, total dependence to roll left and right and from lying to sitting on side of bed, substantial/maximal assistance required sit to lying, sit to stand, and chair/bed to chair transfers. Diagnoses included dementia with behavior disturbance, anxiety and depression. R35's care plan dated 5/25/21, identified an alteration in mobility related to reduced mobility, syncope (fainting) and collapse, with interventions of one staff assist for transfers, one staff ext (extensive) assist with movement in and out of bed. Grab bars to aid in bed mobility was initiated on 12/19/23. R35's IDT Care Conference dated 3/25/25, included a section for positioning devices which was left blank for type of positioning device, team reviewed risk and benefits and if bed mobility evaluation was completed. R35's Bed Mobility Device Evaluation dated 3/19/24, identified the resident was able to state a preference about bed mobility device and resident/representative requested a bed mobility device of grab bars. Resident/representative was informed on risks/benefits of bruising, skin tears, entrapment, entanglement. The section for alternatives attempted prior to placement of assist bars was marked N/A (non-applicable). The section for consideration of removal of bed mobility device or other possible alternatives was left blank. The facility had not evaluated alternatives to bed rails During an observation on 05/18/25 at 1:54 p.m., R76 was in bed with bilateral bed rails identified as Assist Rail (a half rail that mounts to the midsection of the bed) in place. R76 stated he used the bed rails for exercises. During an interview on 5/20/25 at 7:33 a.m., trained medication assistant (TMA)-A stated R76 used the bed rails for transfers and bed mobility. During an interview and observation on 5/20/25 at 7:53 a.m., maintenance assistant (MA)-A stated their process was to place bed rails on a resident bed after nursing assessment. Additionally, nurses needed to let maintenance know if the rails were loose so they could adjust. MA-A accompanied surveyor into R23's room where the bed rails were observed to be loose. MA-A tightened the rails. MA-A stated the rails were the same brand as the bed frame so they were compatible, they would ensure a snug fit when installing. Next, entered R76's room together and the bed rails were loose, and were then tightened by MA-A. MA-A stated their department should have been notified about the loose rails. During an observation on 5/20/25 at 745 a.m., R76, R103, R35 and R23's rooms were observed to have bilateral bed rails in place. During an interview on 5/20/25 at 10:06 a.m., the director of rehab (DOR) stated they might give recommendations for bed rails, however nursing did the assessments and then maintenance would do the install. During an interview on 5/20/25 at 10:18 a.m., licensed practical nurse (LPN)-A, stated if a resident, family, or therapy suggested a bed rail, nursing would complete a bed mobility device evaluation, get consent, obtain an order for grab bars from the provider, and enter a request for maintenance to install. LPN-A stated maintenance was responsible to ensure the bed and rails were compliant. During an interview on 5/20/25 at 10:38 a.m., R76's resident representative (RR)-A stated she had not asked for bed rails but has seen R76 use his to get out of bed. RR-A stated the facility had not talked to her about rails prior to today. RR-A stated R76 had confusion and that was why he was in the dementia unit. During an interview on 5/21/25 at 10:07 a.m., the director of maintenance (DM) stated the resident beds came with the bed rails, and were the same brand so considered them to be compatible together. The DM stated the process for installing bed rails was for nursing to submit an order. Maintenance would install the rails onto the bed frames and look for gaps. The DM stated he was unsure of the exact measurements for entrapment zones. Manufacturer guidelines were not available for the beds or rails. During a phone call interview on 5/21/25 at 11:07 a.m., the bed and rail manufacturer customer support representative (CSR) stated the product number for the bed rails identified them as discontinued and could not provide manufactorer's guidelines, and would need to search further for the guidelines. Photos of the rails and product stickers were emailed to the CSR for review. During an interview on 5/21/25 at 1:53 p.m., the director of nursing (DON) stated there was not a current process to document alternative devices attempted before installing bed rails. Entrapment zones should be monitored by maintenance and nursing or therapy should complete an evaluation of the resident's medical need for the device. During follow up e-mails on 5/21/25 at 2:50 p.m., the CSR provided a bed user manual which identified the rails as compatible with the bed, however, noted to be a discontinued model. The CSR was not able to provide information about entrapment zones. Manufacturer's guidelines Invacare [NAME] CS Bed User Manual dated 2018 identified Patient entrapment from the use of bed side rails may cause injury or death. The Invacare mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment. Follow the manufacturer's instructions. Monitor patient frequently. Read and understand the User Manual prior to using this equipment. An increased risk of patient entrapment may occur over time due to mattress compression. Periodically monitor gaps between the bed, mattress, and/or bed rail. Where gaps occur, patient entrapment is possible and the mattress should be. The user manual lacked description of the entrapment zones measurements for the bed rails. Manufacturer's guidelines for the Invacare bed rails was requested and not provided. The Food and Drug Administration's Guide to Bed Safety, revised April 2010, indentified When bed rails are used, perform an on-going assessment of the patient's physical and mental status, closely monitor high risk patients. The FDA also identified, Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help determine how best to keep the patient safe. The facility policy titled Safe Resident Handling Program dated 3/2020, identified when residents received care and required assistance from facility employee to move (e.g. transferring, lifting, repositioning), that assistance would be provided in a manner that was safe to both the resident and employee. The policy lacked a process to attempt alternative devices before the installation of bed rails on resident's beds, identify medical needs to be met with bed rail use, and resources to assess for risk of entrapment. The Nursing Form Schedule Grid dated 4/16/25, identified a Bed Mobility Device Evaluation should be completed before the initial MDS, quarterly, annually, with significant change and as needed.

Based on observation, interview, and document review, the facility failed to ensure food items were labeled and dated, milk was discarded past the best by date, cups were not stored in food bins, dented cans did not remain on the shelf, and failed to ensure kitchen floors and equipment were clean. Findings include: An email from the administrator dated 5/20/25 at 3:16 p.m., indicated floors have been cleaned weekly, sweeping and mopping after the truck delivers so last done was on Tuesday the week prior. Further, the facility developed a formal log on 5/20/25, to show the documentation going forward. The administrator stated the brown circle in dry storage under the rack had been there for two years and they mopped it, deck scrubbed it and will have the floor tech tackle it. During the initial tour of the kitchen on 5/18/25, from 11:39 a.m., to 11:55 a.m., with the assistant culinary director (ACD), observed the following: Freezers: • A bag of fish with no label or date, ACD stated there should be a label and a date. • A bag of approximately 22 pieces of chicken with no label or date and ACD stated it looked like chicken and verified there was no label or date. • a bag of tator tots with no label or date and ACD stated it should be labeled and dated. • A garbage bag of breadsticks, ACD stated the facility had lasagna the day prior and added it should have been labeled and dated. • An opened box of approximately 15 hamburgers were opened to the air in the freezer and ACD stated they should be closed. Cooler: • A gallon of milk with a best by date of 5/11/25, ACD asked staff if the milk could be thrown out. Dry Storage: • Two cups were located in a dry storage bin of bread crumbs and ACD stated the cups should not be in the bin. • One 6 pound can of diced peaches in light syrup with multiple dents, ACD stated the can should not be in with the other cans at all. • On the floor below wheeled shelving, was approximately a 12 inch by 12 inch area with a thick brown stain, ACD stated had been in the room since he started approximately two weeks prior and looked like something that got spilled and was never wiped up. During interview on 5/20/25 at 11:16 a.m., the corporate culinary director, (CCD) stated she thought floors should be cleaned weekly, but didn't know what the facility was doing. CCD further stated she thought the brown area on the floor should be cleaned with hot water and scraped. CCD further stated cans were returned if dented and should be dept separate and not on the shelf. Verified a 6 pound 10 ounce can of applesauce that was dented and stated she would not have that on the shelf and removed it. Further, CCD stated milk should be used by the best by date and food items in bags should be closed, labeled and dated. A policy was requested for food storage handling along with logs when the floors were last cleaned. CCD stated the culinary director (CD) was not a certified dietary manager and thought they were signing the CD up for Serv Safe. During interview on 5/20/25 at 2:26 p.m., the CCD stated they implemented a cleaning log today for the CD to track and stated ACD cleaned the floor last Tuesday and verified nothing was documented. During interview and observation on 5/21/25 at 12:18 p.m., cook (C)-A stated one of the ovens didn't have a knob on it and observed and there was a brownish substance along the oven doors with brown flakey particles on the handles. C-A stated it was last cleaned a month ago and stated it was a buildup of greese on the [NAME] stove and further stated it fell mostly on C-A to clean and didn't get attended to more often due to staffing. During interview and observation on 5/21/25 at 2:01 p.m., CD verified the dirty ovens and stated they would be on a cleaning list and stated they should be done weekly and looked at the stove and stated he wiped it down Monday and stated he would be talking to the night cooks to make sure they wipe down the oven fronts and the table tops and under the tables where there was a lot of buildup. The CD verified there was no cleaning log to show ovens had been wiped down and stated he would have logs when he wasn't running around as much. A policy, Food Receiving and Storage, dated October 2017, indicated food services or other designated staff will maintain clean food storage areas at all times. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). All foods stored in the refrigerator or freezer will be covered, labeled and dated. Wrappers of frozen foods must stay intact until thawing.

Based on observation, interview and document review the facility failed to ensure call lights were within reach for 2 of 2 residents (R42, R440 ) reviewed for call lights. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 had severe cognitive impairment and diagnoses of dementia and anxiety. Furthermore, R42 required extensive assist with transfers. R42's care plan revised 3/27/25, indicated R42 had an alteration in mobility related to dementia and anxiety. The care plan directed staff to provide extensive assist of 1 for toileting and transfers and to keep call light within reach at all times. An observation on 5/18/25 at 2:05 p.m., R42 was lying in bed resting. R42's call light was lying on the floor on the left side of their bed. The call light was pushed up against the wall and was tangled in a second soft touch call light. An observation on 5/19 at 1:47 p.m., R42 was lying in awake. R42's call light was on the floor on the left side of the bed. The call light was still pushed up against the wall tangled in with a soft touch call light. When interviewed on 5/19/25 at 1:50 p.m., nursing assistant (NA)-E verified R42 did not have their call light in reach. NA-E untangled the call lights and clipped the red push button call light to R42's blanket. NA-E pushed the call light and looked outside the door to ensure that was the correct call light for R42. NA-E stated residents need to have the call lights at within reach. When interviewed on 5/20/25 at 11:26 p.m., registered nurse (RN)-B stated call lights should be within reach of residents. RN-B further stated R42 was able to communicate some and wasn't sure if they would use it, and still should be in place in case. When interviewed on 5/20/25 at 2:25 p.m., the Director of Nursing (DON) expected call lights to be in a place where residents reach them. Even if the resident may not use it all the time, it still needed to be in place. R440's admission MDS dated [DATE], indicated R440 had moderate cognitive impairment, required extensive assistance with transfers, bed mobility, locomotion in manual wheelchair and personal hygiene. R440's diagnoses included fracture of thoracic vertebra, osteoporosis with current fracture, and low back pain. R440's care plan (CP) dated 1/29/25, indicated R440 was at risk for falling due to back pain, impaired mobility, and other diagnoses. The CP instructed staff to keep room clean and free of clutter, and to ensure call light was in reach. R440's falls risk assessment on 1/30/25 indicated R440 was at risk for falls and had one to two falls in the past six months, taking narcotics, dependent for cares, incontinent and hands on assistance for mobility. During interview on 5/21/25 with family member (FM)-B on behalf of R440 stated on dates: -1/29/25 R440 called reported could not find call light, FM-B called nurses desk to ask them for assistance with R440. -2/3/25 FM-B called and talked with licensed practical nurse (LPN- E) to report call light not in reach. -2/5/25 R440 called FM-B reported needed help, unable to find call light. -2/6/25 at 4:50 p.m., FM-B observed the call light was at R440 feet in bed out of reach. A staff member stated to FM-B that the call light was under the bed earlier that day. -2/8/25 at 4:30 p.m., FM-B observed R440 in wheelchair the call light was across the room on the bed out of reach. -2/11/25 FM-C observed R440 in wheelchair the call light was across the room under the bed, out of reach. During documentation review a progress note on 2/5/25 at 5:49 a.m., FM-B called around 5:15 a.m., stated that R440 called her because she can't find the call light. FM-B went on to say that this is starting to happen every day and what are we going to do about it. Unidentified nursing assistant (NA) grabbed another call light with a clip and clipped to clothing. R440 asked NA how to use call light and NA said she demonstrated how to use. R440 had used call light shortly after to ask when breakfast is coming. During interview on 5/21/25 with LPN-E stated call lights are expected to be answered timely, they need to be next to resident, within arm reach. Confirmed conversation with FM-B about the call light being out of reach. During interview on 5/21/25 with RN-C stated the process for call lights and the location was to be answered promptly. The call light needs to be with hands reach of residents. A facility policy titled Call Light Policy revised 4/25/23, directed staff to ensure each resident has a directly call nursing staff for assistance. Call cords, buttons must be placed where they are within reach of each resident.

Based on observation, interview and record review, the facility failed to ensure freedom of movement was not restricted for 2 of 2 residents (R122, R335) who were observed during activities. Findings include: R122's admission Minimum Data Set (MDS) dated [DATE], indicated R122 had severe cognitive impairment a diagnosis of dementia. R122 required supervision assistance with verbal cues or touching/steadying when going from sitting to standing. R122's electronic medical record lacked indication an assessment was done to determine if R122 could independently unlock their wheelchair breaks. R122's orders lacked indication R122 had orders for locked brakes when in the wheelchair. R122's social service progress note dated 5/9/25 at 8:52 a.m., R133 had been attempting to self-transfer and attempting to climb up and over the wheelchair while sitting at the table. R122's nursing progress note dated 5/13/25 at 1:43 p.m., R133 continued to self-transfer in the supervised area and had been non-directable. R122's nursing progress note dated 5/13/25 at 8: 05 p.m., R122 complained of their back hurting while sitting in the wheelchair. R122 continued to self-transfer and lean forward. R122 was assisted into a broda chair for comfort and make no other attempts to self-transfer. R122's care plan dated 3/25/25, indicated R122 was at risk for falls related to dementia. Interventions included to keep R122 in the supervised area when out of bed and to ensure wheelchair in good working condition, including locks. R122's care plan lacked indication R122 required locked brakes when in the wheelchair. R335 was recently admitted on [DATE], and had diagnoses of Parkinson's Disease ( ) and dementia. R335's provider and nursing orders lacked indication R335 had orders to lock wheelchair breaks when in the wheelchair. R335's physical therapy progress note dated 5/15/25, indicated R335 was dependent to lock/unlock breaks and was able to self-propel in the wheelchair. R335's care plan dated 5/15/25, indicated R335 was a risk for falls related to Parkinson's Disease and dementia. R335 required assistance with transfers. R335's care plan lacked indication R335 required locked brakes when in the wheelchair. An observation on 5/19/25 at 2:01p.m., R122 and R335 were in the common area during an activity. R122 was sitting in their wheelchair with breaks locked pushed in at a table. R335 was sitting in their wheelchair with the breaks locked in the entrance to the back portion of the common area and just behind activities aide (AA)-A. At 2:04 p.m., R122 attempted to stand up and the wheelchair started to tip back so R122 sat back down. R122 attempted to push back and move back on the wheelchair however was not able to as the breaks were locked. Nursing assistant (NA)-M walked over and R122 needed to use the bathroom. NA- unlocked R122's breaks and pushed out of the common area. At 2:17 p.m., NA-M wheeled R122 back into the common area. R122 was pushed up to a table and NA- locked the wheelchair breaks. At 2:20 p.m., R122 was trying to stand up. R122's wheelchair tipped back some and R122 then sat back down. R122 attempted to use feet to bush back and was not able due to the breaks being locked. At 2:22 p.m., R335 was attempting to propel their chair forward with their feet, however, was not able to as the breaks were locked. At 2:25 p.m., R335 again was trying to propel their chair forward and trying to reach for the wall to assist, however was not able to move the chair and not able to reach the wall. AA-A had turned around and briefly talked with R335. When AA-A went back to baking, R335 again started to reach for the wall and attempt to move their chair with their feet. R335 then put hands on the breaks and attempted to move the handles, however, was not able to. R335 started calling out for their husband. AA-A came over to talk to R335 and R335 stopped calling out. At 2:30 p.m., R335 once again attempted to propel their chair forward with their feet and was reaching for the wall without being able to move. AA-A walked past R335 to the sink in the back of the room. R335 began asking for he husband. AA-A came back through and stopped to talk to R335 and offered a snack. At 2:39 p.m., R122 was again attempting to stand up. R122's wheelchair was tipping back some. AA-A came over and requested R122 to sit back down and R122 did. When interviewed on 5/19/25 at 2:54 p.m., AA-A and NA-L stated some residents need breaks locked so they don't fall. AA-A further stated R122 did not have anti-rollback breaks on and could tip over the chair if he pushed back. R122 was always trying to get up or self-transfer. NA-L was not sure if R122 or R335 could unlock their breaks or if having breaks on was care planned. When interviewed on 5/20/25 at 10:40 a.m., NA-K stated residents wheel chairs should not be locked as it would restrict their movement. When interviewed on 5/20/25 at 11:33 a.m., registered nurse (RN)-B stated wheelchair breaks could not be locked unless the resident could unlock them. RN-B further state R122 and R335 would not be able to unlock their breaks due to their confusion. If breaks were needed to be on, there should be an assessment done. RN-B further stated if the residents want to stand or move, they need to be able to. When interviewed on 5/20/25 at 2:24 p.m., the Director of Nursing (DON) was not aware of an assessment that was done to determine if residents could unlock their wheelchair breaks. DON further stated wheelchair breaks should not be locked unless the resident can unlock them, otherwise it would be considered a restraint. A facility document titled Informed Consent for use of Physical Restraints, no date, directed nursing staff to complete a comprehensive assessment for the use of a restraint, educate risks and benefits of the use and obtain a written order from the physician.

Based on interview and document review the facility failed to provide monthly catheter changes for 1 of 1 resident (R46) reviewed for catheters. Findings include: R46's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, diagnoses of multiple sclerosis (MS), neuromuscular dysfunction of the bladder, calculus of the kidney, and no rejection of care behaviors. It further indicated R46 was dependent on staff for toileting hygiene and had a suprapubic catheter. R46's care plan dated 4/4/25, indicated an alteration in elimination related to: neuromuscular dysfunction of the bladder and had a suprapubic (s/p) catheter. It further indicated the following interventions: -assist of 1-2 with toileting every 2 hours and as needed (PRN). -provide assistance with peri-cares (morning) AM, hour of sleep (HS), and PRN. -encourage adequate fluid intake -encourage good pericare -monitor skin integrity -keep call light within reach -monitor for signs and symptoms (S/S) of a urinary tract infection (UTI). -monitor s/p catheter output -change s/p catheter per policy -s/p catheter care per policy R46's physician's orders dated 4/10/24, indicated to change suprapubic catheter monthly and PRN. R46's Medical Adminstration Record (MAR) and Treatment Administration Record (TAR) for the months of November of 2024-April of 2025 lacked documentation R46's catheter had been changed since admission. R46's progress notes for the month of April and May of 2025, lacked documentation the suprapubic catheter had been changed. During interview on 5/21/25 9:06 a.m., registered nurse (RN)-F stated nurses should follow the physician or urology orders when determining how often a resident's catheter should be changed. During interview on 5/21/25 12:00 p.m., registered nurse (RN)-E from MN Urology stated R46 should be getting her catheter changed every 4 weeks and as needed (PRN). If it doesn't get changed every 4 weeks, it can lead to an increased risk of infection, sepsis, and hydronephrosis (swelling of the kidneys). During interview on 5/21/25 9:46 a.m., the nurse manager licensed practical nurse (LPN)-B verified there was no documentation of R46's suprapubic catheter being changed since admission. During interview on 5/21/25 at 10:06 a.m., the director of nursing (DON)/Infection Preventionist (IP) stated the doctor's orders should be followed and R46 should be getting the catheter changed according to those orders. A facility policy regarding catheter care was requested and received, however did not address the time frame of when a residents catheter should be changed.

Based on observation, interview and document review the facility failed to ensure provider orders to wean supplemental oxygen were followed for 1 of 1 residents (R34) reviewed for oxygen use. Findings include: R34's annual Minimum Data Set (MDS) dated [DATE], indicated R34 had severe cognitive impairment and diagnoses of chronic respiratory failure and dementia. Furthermore, R34 had no trouble breathing or shortness of breath and no oxygen use. R34's Discharge summary dated [DATE], indicated R34 had been hospitalized for sepsis, pneumonia and urinary tract infection. The summary indicated R34 had acute hypoxic respiratory insufficiency (low blood oxygen saturations) from the pneumonia and instructed to be weaned off supplemental oxygen as able. This summary included an order for oxygen continuous per nasal cannula and to wean as able to keep oxygen saturation greater or equal to 90%. R34's provider order dated 4/24/25, indicated R34 required continuous oxygen and directed staff to wean as able to maintain oxygen saturation greater or equal to 90%. R34's treatment administration record (TAR) dated 5/2025, indicated R34's oxygen weaning order had been checked off, however lacked indication of what R34's oxygen flow rate was for any attempts. R34's oxygen saturation summary for 5/2025, indicated R34 was on oxygen via nasal canula for all but two checks. The summary did not indicate what the flow rate was for the oxygen when checked. Two checks had R34 on RA, but the following was again on nasal canula. R34's nursing progress notes reviewed for 5/2025, lacked indication there had been an attempt to wean R34 from their oxygen. R24's care plan revised 4/21/25, indicated R24 had alteration in oxygen exchange and a goal of oxygen saturations greater than 90%. Interventions directed staff to administer oxygen as ordered. An observation on 5/9/25 at 1:57 p.m., R34 was sitting up in their bed with oxygen in place via a nasal canula. R34's oxygen tank was set at 2L. When interviewed on 5/20/25 at 11:12 a.m., registered nurse (RN)-B stated when a resident required oxygen, the providers orders were followed. When there are orders to wean oxygen, we would monitor oxygen saturations about every hour or so to see how low the oxygen rate could be. Documentation would be in the vital sign section of the medical record or in a progress note. RN-B stated R34 had been on oxygen for a long time and thought it was needed long term. RN-B verified the orders to wean R34's oxygen and stated this had not been attempted the past few days. RN-B then verified the oxygen saturations in the vital sign documentation and was not able to determine if any weaning had taken place. RN-B further stated they could not see any weaning attempts for R34's oxygen in the progress notes either and was not sure when the last time weaning was attempted for R34. When interviewed on 5/20/25 at 2:24 p.m., the Director of Nursing (DON) stated residents on oxygen had oxygen saturations checked each shift. If there were orders to wean, the nursing staff were expected to watch and titrate the oxygen and document in the chart. DON thought the order for oxygen weaning had been discontinued for R34 and verified it had been active since her last hospitalization. DON further verified nurses had not been documenting attempts to wean oxygen and would need to further investigate this. A facility policy for resident oxygen use was requested however was not recieved.

Based on interview and document review, the facility failed to ensure the provider maintained coordination of care with an outside provider in order to ensure an appropriate diagnoses and end date for an antibiotic, for 1 of 1 resident (R46) reviewed for prophylactic antibiotics. Findings include: R46's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, diagnoses of multiple sclerosis (MS), neuromuscular dysfunction of the bladder, calculus of the kidney and had no rejection of care behaviors. It further indicated R46 was dependent on staff for toileting hygiene, had a catheter, was always incontinent of bowel, and received an antibiotic on a routine basis. R46's urology after visit summary dated 3/15/25, indicated: start taking Ciprofloxacin 500 milligram (mg) tablet. Take 1 tablet (500 mg) by mouth two times daily before meals for nephrolithiasis (kidney stone). R46's monthly signed physician orders dated 3/15/25, indicated Ciprofloxacin HCl oral tablet. Give 500 mg by mouth two times a day for calculus of the kidney (kidney stones). The PA continued to sign orders for Cipro even though it lacked an end date. R46's pharmacy recommendation dated 3/27/25, indicated the resident had continued on Ciprofloxacin 500 mg. BID since 3/15/25. Please clarify duration of therapy. It further indicated the PA failed to choose/document one of the 3 options given (agree, disagree, or other) and hand wrote prohylactive-urology, signed, and dated the recommendation on 3/28/25. The DON also hand wrote noted, signed and dated on 4/2/25. R46's monthly signed physician's orders dated 4/15/25, indicated Ciprofloxacin HCl oral tablet. Give 500 mg by mouth two times a day for prophylactic related to calculus of kidney before meals. Take at least 2 hours before or 6 hours after antacids or products containing magnesium, aluminum, calcium, iron, or zinc. The orders were signed by the PA on 5/2/25. The PA continued to sign orders for Cipro even though it lacked an end date. The medical record lacked justification of continued antibiotic use. During interview on 5/21/25 at 1:52 p.m., the Assistant Director of Nursing (ADON) verified the original order for Cipro was for post surgical stent placement in regards to kidney stone removal, and was not supposed to be given past 14 days, but they continued it prophylactically. The ADON stated she got the information from what the provider wrote on the pharmacist recommendation. During interview on 5/21/25 at 9:06 a.m. RN-F stated when a resident returns from the hospital with new physician's orders, the HUC or admitting nurse were responsible for entering them and then a 2nd nurse had to verify the orders. If there was a discrepancy (doesn't have an end date) then the nurse should call the provider to clarify the order. During interview on 5/21/25 at 9:34 a.m., licensed practical nurse (LPN)-C stated when a resident returns from the hospital with new physician's orders and there was a discrepancy (an antibiotic without an end date), they should call the hospital or the provider to get clarification During interview on 5/21/25 12:00 p.m., registered nurse (RN)-E from MN Urology-stated R46 was originally prescribed Cipro twice a day for 14 days on 2/4/25, because she had an infection prior to having a scheduled medical procedure and they wanted to clear it before then. RN-E verified R46 should no longer be on the anitbiotic and the provider didn't prescribe any refills so she wasn't sure how R46 was still receiving the medication. During interview on 5/21/25 at 12:52 p.m., the physician's assistant (PA) stated the process for when a doctor's order for a medication doesn't have an end date was to call the provider and get clarification. The PA further stated he didn't think R46 should be on Cipro (antibiotic) prophylactically but had contacted the urology clinic and they never got back to him stating his hands were tied. The surveyor asked how the prescription for Cipro kept getting refilled when the original order didn't have any refills. The PA stated he didn't know. The PA also stated he documented that he contacted urology in a progress note before her appointment (unknown date) but never heard back from them. R46's medical record lacked documentation the PA had followed up with the urology clinic. During interview on 5/21/25 at 1:24 p.m., the medical director (MD) stated We don't like using antibiotics prophylactically and there was no reason to do so for UTI's. He further stated his expectation was for the provider to contact the urologist and follow through in order to get an end date for the antibiotic and doing their due dilligence. R46's progress note dated 3/17/25, indicated LPN-B placed call to the urologist office regarding stop date for antibiotic, awaiting a return call. The progress note lacked the name of which antibiotic she was referring to. R46's progress notes lacked any indication LPN-B had followed through with the urology clinic since 3/17/25. During interview on 5/21/25 9:46 a.m. the nurse manager LPN-B stated when a resident returns from the hospital with new orders, the Health Unit Coordinator (HUC) should enter the orders and leave it pending for a nurse to confirm. Ideally, it should be the nurse manager but if that's not possible, then the admitting nurse can confirm it. If there were any discrepancies (no end date for an antibiotic), they should call the provider for clarification. LPN-B further stated she was aware R46's was taking Cipro (antibiotic) and that it didn't have an end date. She had been in contact with R46's urologist and asked about an end date but she hadn't heard back from them. She had also spoken to the PA about it but verified there was no documentation regarding their conversation. R46 has had a couple of hospitalizations and each time a resident was hospitalized they discontinue the physician's orders and when they return to the facility, they need to get new orders. During interview on 5/21/25 at 10:06 a.m., the director of nursing (DON)/Infection Preventionist (IP) stated it was the nurse managers responsibility to ensure the doctor's orders are up to date and being followed. If a resident returns to the facility with physician's orders and there was a discrepancy, the provider should be called for clarification. The last time R46 went to the hospital, she reached out to the urologist and asked if they wanted the antibiotic (Cipro) stopped. The surveyor requested documentation of contact with the urologist regarding an end date for the antibiotic and none was received. No policy provided.

Based on interview and document review the facility failed to ensure there was an end date or to investigate and/or document the justification for a prophylactic antibiotic for 1 of 1 resident (R46). Findings include: R46's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, diagnoses of multiple sclerosis (MS), neuromuscular dysfunction of the bladder, calculus of the kidney, and had no rejection of care behaviors. It further indicated R46 was dependent on staff for toileting hygiene, had a catheter, was always incontinent of bowel, and received an antibiotic on a routine basis. R46's care plan dated 4/4/25, indicated an alteration in elimination related to: neuromuscular dysfunction of the bladder and had a suprapubic (s/p) catheter. It further indicated the following interventions: -assist of 1-2 with toileting every 2 hours and as needed (PRN). -provide assistance with peri-cares (morning) AM, hour of sleep (HS), and PRN. -encourage adequate fluid intake -encourage good peri care -monitor skin integrity -keep call light within reach -monitor for signs and symptoms (S/S) of a urinary tract infection (UTI). -monitor s/p catheter output -change s/p catheter per policy -s/p catheter care per policy R46's urology after visit summary dated 3/15/25, indicated: start taking Ciprofloxacin 500 milligram (mg) tablet. Take 1 tablet (500 mg) by mouth two times daily before meals for nephrolithiasis (kidney stone). R46's monthly signed physician orders dated 3/15/25, indicated Ciprofloxacin HCl oral tablet. Give 500 mg by mouth two times a day for calculus of the kidney (kidney stones). The PA continued to sign orders for Cipro even though it lacked have an end date. R46's pharmacy recommendation dated 3/27/25, indicated: resident has continued on Ciprofloxacin 500 mg. twice a day (BID) since 3/15/25. Please clarify duration of therapy. It further indicated the Physician Assistant (PA) failed to choose/document one of the 3 options given (agree, disagree, or other) and hand wrote prohylactive-urology, signed, and dated the recommendation on 3/28/25. The DON also hand wrote noted, signed and dated on 4/2/25. R46's monthly signed physician's orders dated 4/15/25, indicated Ciprofloxacin HCl Oral tablet. Give 500 mg by mouth two times a day for prophylactic related to calculus of kidney before meals. Take at least 2 hours before or 6 hours after antacids or products containing magnesium, aluminum, calcium, iron, or zinc. The PA continued to sign orders for Cipro even though it lacked an end date. The medical record lacked justification of continued antibiotic use. During interview on 5/21/25 at 1:52 p.m., the Assistant Director of Nursing (ADON) verified the original order for Cipro was for post surgical stent placement in regards to kidney stone removal, and was not supposed to be given past 14 days, but they continued it prophylactically. The ADON stated she got the information from what the PA had written on the pharmacist recommendation. During interview on 5/21/25 at 9:06 a.m. RN-F stated when a resident returns from the hospital with new physician's orders, the HUC or admitting nurse were responsible for entering them and then a 2nd nurse had to verify the orders. If there was a discrepancy (doesn't have an end date) then the nurse should call the provider to clarify the order. During interview on 5/21/25 at 9:34 a.m., licensed practical nurse (LPN)-C stated when a resident returns from the hospital with new physician's orders and there was a discrepancy (an antibiotic without an end date), they should call the hospital or the provider to get clarification During interview on 5/21/25 12:00 p.m., registered nurse (RN)-E from MN Urology-stated R46 was originally prescribed Cipro on 2/4/25, twice a day for 14 days because she had an infection prior to having a scheduled medical procedure and they wanted to clear it before then. RN-E verified R46 should no longer be on the antibiotic and the provider didn't prescribe any refills so she wasn't sure how R46 was still receiving the medication. During interview on 5/21/25 at 12:52 p.m., the physician's assistant (PA) stated the process for when a doctor's order for a medication doesn't have an end date was to call the provider and get clarification. The PA further stated he didn't think R46 should be on Cipro (antibiotic) prophylactically but had contacted the urology clinic and they never got back to him stating his hands were tied. The surveyor asked how the prescription for Cipro kept getting refilled when the original order didn't have any refills. The PA stated he didn't know. The PA also stated he documented that he contacted urology in a progress note before her appointment (unknown date) but never heard back from them. R46's medical record lacked documentation the PA had followed up with the urology clinic. During interview on 5/21/25 at 1:24 p.m., the medical director (MD) stated We don't like using antibiotics prophylactically and there was no reason to do so for UTI's. He further stated his expectation was for the provider to contact the urologist and follow through in order to get an end date for the antibiotic and doing their due diligence. R46's progress note dated 3/17/25, indicated LPN-B placed call to the urology office regarding stop date for antibiotic, awaiting a return call. The progress note lacked the name of which antibiotic she was referring to. R46's progress notes lacked any indication LPN-B had followed through with the urology clinic since 3/17/25. During interview on 5/21/25 9:46 a.m. the nurse manager LPN-B stated when a resident returns from the hospital with new orders, the Health Unit Coordinator (HUC) should enter the orders and leave it pending for a nurse to confirm. Ideally, it should be the nurse manager but if that's not possible, then the admitting nurse can confirm it. If there were any discrepancies (no end date for an antibiotic), they should call the provider for clarification. LPN-B further stated she was aware R46's was taking Cipro (antibiotic) and that it didn't have an end date. She had been in contact with R46's urologist and asked about an end date but was still waiting for a response and had not followed up with them since then. She had also spoken to the PA about it but verified there was no documentation regarding their conversation. During interview on 5/21/25 at 10:06 a.m., the director of nursing (DON)/Infection Preventionist (IP) stated it was the nurse managers responsibility to ensure the doctor's orders are up to date and being followed. If a resident returns to the facility with physician's orders and there was a discrepancy, the provider should be called for clarification. The last time R46 went to the hospital, she reached out to the urologist and asked if they wanted the antibiotic (Cipro) stopped. The surveyor requested documentation of contact with the urologist regarding an end date for the antibiotic and none was received. A facility policy on antibiotic stewardship dated 3/13/23, indicated the facility will engage the Consultant Pharmacist to provide guidance with development and implementation of antibiotic protocols and assist in reviewing antibiotic orders and usage and provide recommendations when appropriate. During monthly med reviews, the Consultant Pharmacist will identify orders for antibiotics that are not consistent with antibiotic stewardship practices and make recommendations improved outcomes. The facility will review and revise, if needed, current practices to improve antibiotic use. Action Prior to calling a provider to communicate a suspected infection, the nurse will obtain and have the following information available: . Signs and symptoms of suspected infection (based on McGreer's criteria) . History of present illness . Current medication list . Allergies . Last INR results (if currently receiving warfarin) . All pertinent lab, imaging or test results Prescribers will provide complete antibiotic orders including the following elements: . Drug name . Dose . Frequency of administration . Duration of treatment (including start and stop date or total days of treatment) . Route of administration . Indications for use If a resident is admitted to the facility with orders for antibiotic therapy, the orders will be reviewed for appropriateness and completeness. Any pertinent supporting documentation will also be reviewed and obtained for the medical record. When a resident is discharged home, the antibiotic orders will be reviewed with the resident and/or resident representative. Appropriate indications for antibiotic use include: . Criteria met for clinical definition of active infection or suspected sepsis; and . Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or treatment begun while culture is pending. . Empirical use of an antibiotic on clinical criteria may be appropriate. The Infection Preventionist, (IP), or designee, will review all antibiotic orders to determine if treatment is appropriate. Treatment is not appropriate if: . The organism is not susceptible to the antibiotic chosen. . The organism is susceptible to a narrower spectrum antibiotic. . Therapy was ordered for prolonged surgical prophylaxis. . Therapy was started awaiting culture, but no organism was isolated after 72 hours. Interventions that may resolve inappropriate treatment include: . Drug change . Dosage change . Duration change . Obtain culture . Discontinue antibiotic treatment The provider will be notified of the review findings and recommendations and a response will be documented in the resident ' s medical record.

Based on observation, interview, and document review, the facility failed to provide the ordered therapeutic diet for 1 of 1 resident (101) reviewed for provision of modified diet. Findings include: R101's quarterly Minimum Data Set (MDS) dated [DATE], indicated R101 was cognitively intact, was independent with eating, required a mechanically altered diet, and did not experience mouth or facial pain, discomfort or difficulty with chewing. R101's diagnoses included cerebral infarction due to thrombosis (clot) of left middle cerebral artery, aphasia (difficulty speaking), and type 2 diabetes. R101's care plan dated 5/15/25, indicated R101 had an alteration in nutritional status related to cerebral infarction. The care plan indicated R101 required regular diet, thin liquids, and soft, bite-sized textures (SB6). R101's dental care area assessment (CAA) dated 8/5/24, indicated R101 had inflamed or bleeding gums or loose natural teeth. R101's clinical nutritional evaluation dated 4/30/25, indicated R101 required a regular diet of SB6 texture. R101's diet order dated 1/20/25, indicated, Regular diet, IDDSI [International Dysphagia Diet Standardization Initiative] Level 6; Soft and Bite Sized texture, IDDSI level 0: Thin Liquids consistency. The order status was active. R101's dental extraction consultation note dated 5/7/25, indicated R101 should eat a softer diet for two days and resume normal diet when comfortable. R101's post-op order dated 5/7/25, indicated, Eat adequate but softer diet for first 2 days, drinking plenty of fluids but avoiding very hot or cold fluids. Resume normal diet as comfortable. The order status was active. R101's diet order history printed 5/20/25, indicated, Regular diet, IDDSI Level 5; Minced and Moist texture, IDDSI level 0: Thin Liquids consistency had a start dated of 5/7/25 and an end date of 5/9/25. The order status was completed. R101's progress notes dated 5/7/25 through 5/18/25, lacked evidence of mouth/dental comfort assessment or diet preference conversation. During interview on 5/18/25 at 4:47 p.m., R101 stated he used to get a level 6 diet due to a history of stroke and since his dental extraction, his diet was downgraded to a level 5. R101 stated a level 5 looked like mush on his plate and was not very appetizing. R101 stated he was never reevaluated or asked his comfort level in order to advance his diet. During observation and interview on 5/19/25 at 12:42 p.m., R101's lunch meal included three mounds of unidentifiable minced food. R101 stated, Oh yay and could not tell me what he was eating. R101's lunch meal ticket indicated, 5 Minced & Moist. R101 stated he would love to go back to his previous diet as his teeth feel great and that no one had assessed his mouth in two weeks. During observation and interview on 5/20/25 at 9:06 a.m., nursing assistant (NA)-A delivered R101's breakfast meal and confirmed it was a level 5 texture. NA-A meals were served according to what was on the meal tickets which were printed in dietary, and NAs just confirmed the meal matched the meal ticket. R101 stated level 5 was mush and not sure what he was being served most of the time. During interview on 5/20/25 at 10:42 a.m., trained medical assistant (TMA)-B stated residents were admitted with diet orders and changes could occur after a change of condition. TMA-B stated typically speech therapy (ST) would have to do an assessment and then order a new diet. TMA-B stated following a dental procedure the diet could be downgraded temporarily and then the resident could be reassessed by the nurse who could upgrade the diet again. During interview on 5/20/25 at 10:54 a.m., registered nurse (RN)-A stated if a diet needed to be downgraded due to a procedure, there would be a limiting order with an end date and the resident would be reassessed prior to upgrading the diet again. RN-A stated there was always a nurse in the dining room and present at meals for assessments. If the resident took meals in their room, the nurse should still assess intakes and confirm diets were appropriate. During interview on 5/20/25 at 11:07 a.m., culinary director (CD) and corporate culinary director (CCD) stated nursing would supply the kitchen with a diet communication form with any changes in diet. CD and CCD further stated the order would also be in PCC sent down by nursing and also an order would be entered into in PCC (point click care). PCC interfaced with the dietary system from where the meal tickets were printed. CCD stated the temporary order stop date should trigger a reassessment and then the original order could be restarted. CCD further stated the resident should receive the diet that was ordered and active in PCC and could not explain why R101's meal ticket printed level 5 when the current active order was for a level 6. During interview on 5/20/25 at 12:46 p.m., licensed practical nurse (LPN)-B stated would expect residents to receive the meal that was ordered. During interview on 5/20/25 at 2:42 p.m., director of nursing (DON) stated expectation diets would be provided as ordered. Facility policy Therapeutic Diets dated October 2017, indicated, Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. The policy further indicated, The dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The policy instructed the dietician and nursing staff to document in the medical record information relating to the resident's response to their therapeutic diet.

Based on interview and record review, the facility failed to ensure the consultant pharmacist performed a complete medical record review for prescribed Clozaril an antipsychotic medication for one of one residents (R1) reviewed for antipsychotic medications. The antipsychotic medication required strict monitoring of an absolute neutrophil count and dispensing from the Risk Evaluation and Mitigation Strategy to reorder and administer the medication as prescribed. R1 suffered physical withdrawal symptom and psychosocial decompensation. Findings include: U.S. Food & Drug Administration (FDA) website titled Information on Clozapine, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-clozapine identified Clozapine resources FDA Pharmacy Outreach Presentation dated [DATE], The Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program Modification, Clozapine REMS website, and Clozapine REMS information. The FDA Pharmacy Outreach Presentation identified continued absolute neutrophil count monitoring must be obtained before dispensing from the REMS Dispensing Authorization (RDA). If an RDA is rejected there will be an option to request a Dispense Rationale through the website or contact center. To obtain a Dispense Rationale, the pharmacist must have an ANC that was obtained in the last 30 days within the acceptable range. The pharmacist will need to provide the following to the REMS: Prescriber's NPI number, Blood draw date, ANC value, Dispense Rationales are limited to three per patient per year. Clozapine REMS website titled Pharmacy Materials https://www.newclozapinerems.com/Public/home/Pharmacy identified guidance titled Clozapine and the Risk of Neutropenia: A Guide for Pharmacists indicated before dispensing Clozapine an absolute neutrophil count (ANC) must be submitted before starting and during Clozapine treatment. The risks to severe neutropenia associated with clozapine can lead to serious infections and death, severe neutropenia is defined as ANC less than 500/?L, Severe neutropenia replaces the previous terms severe leukopenia, severe granulocytopenia, and agranulocytosis. The risk appears greatest during the first 18 weeks of clozapine treatment, the mechanism is not dose dependent. It is unclear if concurrent use of other drugs known to cause neutropenia increases the risk or severity of clozapine-induced neutropenia. If clozapine is used concurrently with a medication(s) known to cause neutropenia: Consider monitoring patients more closely than the treatment guidelines recommend and consult with the treating oncologist in patients receiving concomitant chemotherapy. For a complete discussion of other risks, including other Boxed Warnings, please see the full Prescribing Information available at www.clozapinerems.com. In addition, the guidance indicated patients may transition to less frequent ANC monitoring based on the number of weeks of continuous Clozapine therapy and the patient's ANC's. The role of the pharmacy is to designate an authorized representative in the Clozapine REMS by completing three steps: Step 1: Certify in the Clozapine REMS by: Reviewing Clozapine and the Risk of Neutropenia: A Guide for Pharmacists Successfully complete and submit the Knowledge Assessment for Pharmacies Complete and submit the Inpatient Pharmacy Enrollment Form and/or the Outpatient Pharmacy Enrollment Form Step 2: Ensure training for all relevant staff involved in the dispensing of clozapine on the Clozapine REMS requirements using the Clozapine and the Risk of Neutropenia: A Guide for Pharmacists Once a staff is trained on the Clozapine REMS requirements, the authorized representative may invite that staff to become enrolled in the Clozapine REMS. Step 3: Put processes and procedures in place to verify an available, current ANC is within the acceptable range for patients enrolled but not authorized to receive the drug. Clozapine REMS website titled Prescribers Materials https://www.newclozapinerems.com/Public/home/Prescriber identified guidance titled Clozapine and the Risk of Neutropenia: A Guide for Healthcare Providers instructs providers in an inpatient to submit absolute neutrophil count (ANC) into the REMS program to initiate or continue Clozapine treatment. If another prescriber has previously treated the patient with Clozapine the current prescriber must enroll the patient by completing and submitting the Patient Enrollment Form to the Clozapine REMS (online or by fax) to be able to access the patient's ANC history. R1's discharge orders from the hospital dated [DATE] indicated to continue taking Clozapine 100 milligram (mg) tablet. Instructions were to take 300 mg by mouth at bedtime. Lab results component value date white blood cells (WBC) 7.7 date [DATE] and lab results component value date absolute neutrophil count (ABSNEUTS) 4.3 date [DATE]. Minimum Data Set (MDS) assessment, dated [DATE], indicated R1's diagnoses included schizophrenia, depression, diabetes mellitus, alcohol dependence, and admitted to the Estates of Roseville on [DATE] following a left knee arthroplasty. R1's Brief Interview for Mental Status (BIMS) score was 14 of 15, indicating he is cognitively intact. R1's Consultant Pharmacist Medication Regimen Review, completed by Pharmacist (P)-A on [DATE], identified R1 was prescribed two other psychotropic medications and Clozapine instructing the facility staff to monitor for abnormal behaviors and to complete the Abnormal Involuntary Movement Scale (AIMS) assessment every 6 months to assess severity of dyskinesias. R1's medication administration record (MAR) dated [DATE] indicated Clozapine oral tablet, give 300 mg by mouth at bedtime for schizophrenia, start [DATE] at 7:00 p.m., was not administered as prescribed and denoted as a 9 on [DATE], [DATE], and [DATE]. According to the MAR's legend, a 9 indicated to read the nursing notes for further details. A progress note written by licensed practical nurse (LPN)-B dated [DATE], stated R1's Clozaril was not administered because the facility was awaiting its arrival from the pharmacy. A progress note written by LPN-A, dated [DATE], stated that an on-call provider was informed that R1 did not receive his clozapine on [DATE], and nursing staff anticipated his clozapine would arrive that evening. LPN-A reported she had contacted the facility's pharmacy, who had requested R1's absolute neutrophil count (ANC). LPN-A indicated an unspecified pharmacy employee had informed her a seven-day supply of Clozapine would be dispensed and delivered to the facility before [DATE]. LPN-A then updated an unspecified on-call nurse practitioner and the assistant director of nursing (ADON). R1's provider progress note written by Nurse Practitioner (NP)-A, dated [DATE] indicated NP-A gave an order for a weekly lab blood draw for a complete blood count (CBC) until R1 was enrolled in the REMS program. An addendum to this progress note, dated [DATE], indicated the REMS enrollment process and prescribing process needed to continue through R1's established psychiatric provider at the Veterans Affairs Medical Center. A progress note written by LPN-C, dated [DATE], stated that R1's clozapine was not in the facility. R1's provider progress note written by NP-B dated [DATE] indicated R1 missed three doses of Clozapine and is going through withdrawal was diaphoretic and chest was hurting, R1 was not in the REMS program. While on the phone with pharmacy, the pharmacy indicated they can dispense Clozapine with an ANC. The provider looked up the hospital ANC that indicated a count of 6.0, the results were faxed to the pharmacy and a seven-day transitional fill was to be dispensed. R1's psychiatrist needs to enroll R1 in the REMS program. A provider progress note addendum by NP-B, dated [DATE] indicated stated that the pharmacy had delivered R1's clozapine and facility staff were given a verbal order to administer R1's [DATE] bedtime clozapine dose as soon as possible. R1's MAR dated [DATE], indicated the facility was assessing the patient every 15-minutes for safety every shift and for any violent or anger outburst related to schizophrenia, due to medication withdrawals along with vital signs every four hours for two days. A facility form titled Medication Error Reporting Form, dated [DATE] and completed by LPN-A, indicated that R1 suffered negative physical outcomes due to the not receiving his scheduled Clozapine on [DATE], [DATE], and [DATE]. A progress note written by LPN-C, dated [DATE] indicated she began 15-minute safety checks on R1 at the instruction of an unspecified nurse manager. A progress note written by LPN-C, dated [DATE] indicated R1 was experiencing withdrawal symptoms, including diaphoresis and hypertension. LPN-C reported R1 had told her he felt safe. LPN-C did not document further psychological assessment of R1. A progress note written by LPN-C, dated [DATE], stated that R1's bedtime clozapine dose was administered at 1:28 p.m. During an interview with R1 on [DATE] at 11:28 a.m., R1 stated when he was not receiving his Clozapine, he experienced uncomfortable withdrawal symptoms and thoughts of self-harm. R1 reported sweating profusely and feeling physically weak, preventing him from completing his physical therapy exercises. R1 stated his visual and auditory hallucinations worsened, he felt emotionally unstable, and he experienced disembodied voices instructing him to hurt himself and others. During an interview with the DON on [DATE] at 2:50 p.m., she stated she was contacted by LPN-A on [DATE] and informed of the Clozapine omission on [DATE] and [DATE]. The DON stated the pharmacy intended to have the medication delivered to the facility on the evening [DATE], however the Clozapine arrived on [DATE]. The she stated nursing staff are not expected to know which medications require ongoing labs. She indicated that any medications requiring ongoing lab monitoring would be notated in a resident's electronic medication administration record (EMAR). The DON stated it is the responsibility of the pharmacist during the monthly medication regimen review to notate which medications require ongoing monitoring for nursing staff. She expects the consultant pharmacist to note these medications in the EMAR and then report their findings to as part of the Medication Regimen Review. During an interview with LPN-A on [DATE] at 9:30 a.m., LPN-A stated on [DATE] she noticed an order for CBC with differential had not been completed for R1. LPN-A reported she called the pharmacy to report the missed CBC order, who informed her that a 7-day supply of Clozapine would be dispensed that evening. LPN-A stated she then spoke with the on-call provider to communicate the issue and receive orders for a CBC with differential for R1 after the holiday weekend. During an interview with the pharmacist (P)-A on [DATE] at 2:02 p.m., she stated Clozapine required regular ANC monitoring to administer safely. She stated that it is industry standard to review ANC levels during a Medication Regimen review. P-A stated she reviewed R1's electronic medical record, including his orders and hospital discharge paperwork, and did not see any ongoing orders to monitor R1's ANC. She stated she did not include the need for ANC monitoring in her Medication Regimen Review because the hospital obtained an ANC prior to R1's discharge and the facility's pharmacy was supplying his clozapine without issue. P-A stated it was R1's primary care provider or psychiatrist's responsibility to determine ongoing labs for ANC monitoring. A facility policy titled Medication Regimen Review, dated [DATE], indicated that the consulting pharmacist is required to complete a thorough review of the resident's medical record to identify clinical irregularities. Any lapses in care or monitoring regarding the resident's medications are to be reported to the Director of Nursing.

Based on observation, interview and document review, the facility failed to follow manufacturer directions while using mechanical full body lifts, by not opening the stabilizing legs fully, for 3 of 3 residents (R1, R6 and R7). This resulted in an immediate jeopardy for R1 when the lift tipped over while R1 was being transferred, fracturing both femurs, and for R6 and R7 when staff were observed transferring them (both R6 and R7) not following the manufactures instructions. The immediate jeopardy began on 12/28/22, when R1 was transferred incorrectly using a full body mechanical lift, the lift tipped over and R1's legs were fractured. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 1/9/22, at 5:40 p.m. The immediate jeopardy was removed on 1/10/23, at 6:00 a.m. when it was verified the facility had educated staff and conducted competency evaluations for use of the full body mechanical lifts prior to the start of their next shift. However, noncompliance remained at the lower scope and severity of a D- isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, was completely dependent on staff for transfers and bed mobility and did not reject cares. Further, the MDS identified a diagnosis of age related osteoporosis. R1's fall care plan revised on 1/2/23, indicated R3 transferred with assist of three utilizing a mechanical lift following the fall on 12/28/22. The nursing home incident report dated 12/29/22, at 4:31 a.m. indicated on 12/28/22, at 11:05 a.m. R1 was being transferred from her bed to the electric wheelchair utilizing a mechanical lift and two staff members when the mechanical lift tipped over and R1 was lowered to the floor. R1 sustained an oblique fracture of the left femur. Audits were completed for each resident utilizing a mechanical lift for the correct sling sizes and accuracy of care planning. The Invacare Reliant 600 manufacturer was the lift being used during the transfer. X-ray results were obtained on 12/29/22, at 3:50 a.m. and R1 was updated on fracture and R1 requested to go to the emergency department. The physician was notified. A late entry nursing note dated 12/28/22, at 11:05 a.m. indicated R1 was being transferred from her bed to the electric wheelchair when during the transfer, R1 was distraught and leaned back in the sling and the lift became unsteady due to the weight redistribution. The note indicated R1 was lowered to the floor by staff. R1's Associated Clinic of Psychology note dated 12/28/22, indicated R1 had rumination regarding her recent fall and worried it could happen again, which was triggering from a previous incident as well. The note indicated R1 may be cautious in attempts to use the lift to transfer. R1's North Star mobile x-ray report dated 12/28/22, indicated R1 had a complete oblique fracture of the left femur with soft tissue swelling. R1's history and physical dated 12/29/22, at 8:44 a.m. indicated R1 was being transferred on 12/28/22, when the mechanical lift tipped over, causing R1 to fall on the floor. R1 was transported by emergency medical services for evaluation on 12/29/22, and was found to have bilateral femoral fractures. A facility audit form dated 12/30/22, indicated R1 required a mechanical lift with an extra large sling and assist of three persons for transfers. R1's physician progress note dated 1/4/23, indicated R1 was admitted to the hospital on 12/29/22, with bilateral subtrochanteric femur fractures after a fall from a mechanical lift at her facility. R1's hospital discharge summary dated 1/5/23, indicated R1 was admitted on [DATE], with bilateral subtrochanteric femur fractures after a fall from a mechanical lift at her facility. R1 underwent a left intramedullary nail (a rod or nail placed in the bone for stablization)on 12/30/22 and no operative intervention on the right. During interview and observation on 1/9/23, at 10:24 a.m. R1 stated the mechanical lift fell over and she fell to the floor and had two fractures and one of the fractures required a rod in her leg. R1 stated she had a dull constant pain, but did not like to take pain medication because of the side effects. R1 stated she returned from the hospital on 1/5/23, and had not gotten out of bed since she returned from the hospital. R1 stated the legs on the mechanical lift were not opened all the way when she fell . R1 stated falling from the lift was scary and started to cry. During observation on 1/9/23, at 10:45 a.m. R1 was in bed and stated to the physical therapist (PT)-C that she did not get up on 1/8/23, because she was scared. During interview on 1/9/23, at 12:33 p.m. maintenance director stated the lifts were checked monthly and routine maintenance performed per manufacturer's recommendations and would be done every two weeks due to R1's fall. The maintenance director stated the Invacare Reliant 600 mechanical lift had a low base in order to fit under beds well and when the legs are open on the lift, it is less likely to tip over. During interview on 1/9/23, at 12:58 p.m. nursing assistant (NA)-H stated she worked as a float NA and stated that usually two staff were needed for a mechanical lift and stated the legs of the lift were normally shut as a resident was transferred. NA-H stated if a resident was in bed, the legs of the lift should be shut and then the lift is pulled out and another staff member brings a chair. NA-H verified R1 required three staff to assist with transfers. R6's annual MDS assessment dated [DATE], indicated R6 was severely cognitively impaired and required extensive two plus person assistance for all transfers. R6's diagnoses included dementia and age related physical debility. R6's mobility care plan revised 10/21/22 indicated R6 required total assist of two with mechanical lift for all transfers. During observation and interview on 1/9/23, at 12:48 p.m. R6 was in wheel chair waiting to be transferred back to bed. NA-A maneuvered the full mechanical lift over R6 in the wheel chair by opening the legs fully of the mechanical lift . NA-A, NA-B and LPN-A worked together to attach R6's sling to the mechanical lift. R6 was lifted out of the wheel chair and the mechanical lift was pulled away from the wheel chair. NA-A used the manual lever to close the mechanical lift legs. The mechanical lift was pushed to R6's bed, R6 was positioned over the bed and lowered to the bed. The sling was removed. Once the mechanical lift legs were closed, they remained closed throughout the transfer. LPN-A stated R6 was a two-person extensive assist with transfers, but she was helping to ensure the NAs completed the transfer properly. R7's significant change MDS assessment dated [DATE], indicated R7 was severely cognitively impaired and required extensive two plus person assistance for all transfers. R7's diagnoses included dementia, Alzheimer's disease, difficulty walking, muscle weakness and unsteady on feet. R7's mobility care plan revised 10/18/22 indicated R7 required total assist of two with mechanical lift for all transfers. During observation and interview on 1/9/23, at 1:01 p.m. R7 was wheeled into the room to transferred to bed. NA-A positioned the mechanical lift over R7's wheel chair with the mechanical lift legs fully open. NA-A and NA-B worked together to attach the sling to the mechanical lift. R7 was lifted off the wheel chair and the mechanical lift was pulled away from the wheel chair. NA-A manually closed the mechanical lift legs and the mechanical lift was turned and moved to position over R7's bed. R7 was lowered to the bed and the sling was removed. NA-B stated the proper way to use a mechanical lift was to have the legs open over the wheel chair and then closed after the mechanical lift was moved away from the wheel chair. NA-A agreed and stated the legs of the mechanical lift were closed after it was pulled away from the wheel chair and remained closed during the remainder of the transfer for both R6 and R7 and it was the proper way to transfer a resident from wheel chair to bed. During interview on 1/9/23, at 1:21 p.m. NA-G stated she reviewed care sheets in order to know how a resident transferred. NA-G stated when transferring a resident from their bed to the chair, the mechanical lift legs are kept closed when they are lifted in bed and the resident is moved in the mechanical lift to their chair, then the legs on the lift are opened prior to lowering the resident to the chair. During interview on 1/9/23, at 1:53 p.m. NA-F stated the legs of the mechanical lift were closed when R1 was transferred prior to the mechanical lift tipping and R1 lowered to the floor. NA-F also stated the legs on the lift are closed when turning a resident and once you face the chair, the legs of the lift are opened to make room for the chair. During interview on 1/9/23, at 2:31 p.m. NA-C was making R7's bed and stated mechanical lift legs should be open the entire time a resident was in the lift. NA-C stated R7's bed had sufficient room under it for the mechanical lift legs to fit while they were fully open. During interview on 1/9/23, at 2:32 p.m. LPN-C stated the legs of the mechanical lift should always be open during a transfer. LPN-C further stated she did not see that NA-A and NA-B had done this incorrectly and that not having the mechanical lift legs fully open during the transfer could result in the mechanical lift tipping over. During interview on 1/9/23, at 2:35 p.m. the assistant director of nursing (ADON) stated R1 used an Invacare 600 lift and used this lift when she fell from it. R1 was an assist of two for transfers with the mechanical lift, but since returning from the hospital, R1 would be transferred with three person assist, but had not gotten up since returning per R1's request. The ADON stated she thought R1 was fearful because she fell and had discomfort from the fall. The ADON stated manufacturer recommendations are the legs of the mechanical lift are to be open at all times, and stated she could not recall if the legs of the mechanical lift were opened or closed when she was called to R1's room post fall. During interview on 1/9/23, at 3:02 p.m. the director of nursing (DON) stated when R1 fell , she was off balance, NA-D tried to step on the leg of the mechanical lift to prevent it from tipping over. The DON stated the legs of the lift should be open when resident is being hooked up and stated NA-D and NA-F stated the legs of the lift were open the entire time. The DON stated the legs of the mechanical lift should be open anytime anyone is in a lift because there needed to be a wider base of support if a resident shifted their weight so they wouldn't tip over. During interview on 1/9/23, at 3:47 p.m. the administrator stated there was no policy on mechanical lifts, they just used the competency. The mechanical lift competency was reviewed and lacked instruction on the position of the legs for transfers. During interview on 1/9/23, at 4:43 p.m. the DON stated for competencies on the mechanical lifts, they trained the trainer, signed them off, and went off the competency check list and verified there was no competency to verify the opening of the mechanical lift legs. During interview on 1/10/23, at 9:15 a.m. the Invacare Reliant 600 manufacturer customer service representative stated after talking to their technical support that the legs of the mechanical lift should not be in the closed position during a transfer because it could cause the lift to be unstable and fall over. She stated the use of the lift is not meant to be used in a closed position. During interview and observation on 1/10/23, at 10:47 a.m. the medical director stated R1's fall contributed to her fractures and stated R1's osteoporosis caused her to be more prone to fractures and wasn't aware the legs of the lift were not opened. 42584 A form, Competency 2.0 Mechanical Lifts dated 12/28/22, signed by NA-F indicated 18 specific steps for the skill: mechanical lifts per manufacturer guidelines and Monarch Healthcare management policy and procedure, but it lacked instruction on opening the legs of the lift during transfers. A manufacturer user manual was provided for the Invacare Reliant 450 RPL450-1/2 and Invacare Reliant 600 RPL600-1/2 battery powered patient lift that indicated danger, warning, and caution symbols used within the manual. Danger indicated an imminently hazardous situation which, if not avoided, will result in death or serious injury. Warning indicated a potentially hazardous situation which, if not avoided, could result in death or serious injury. Caution indicated a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both. A warning symbol for lifting the patient indicated the legs must be in the maximum open/locked position before lifting the patient. Under operation the warning indicated the legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The IJ was removed on 1/10/23, at 6:00 a.m. when the facility developed and implemented a systemic plan which was verified by observation, interview and document review: The plan included: - The maintenance director inspected and performed routine maintenance per manufacturer's recommendations on the facility's mechanical lifts and will continue to inspect and perform routine maintenance on the facility's mechanical lifts every two weeks. This was verified through interview and document review. - The nursing staff were educated on the manufacturer's instructions on a full body transfer utilizing a mechanical lift. -The nursing staff completed the mechanical lift competency with return demonstration. This was verified through interview and document review. -The mechanical lift manufacturer's instructions were reviewed on 1/9/23, by the DON and will be utilized as the facility policy on mechanical lift full body transfers. This was verified by interview. -R1 was observed for transfer and staff demonstrated knowledge of the manufacturer's recommendations for transfers.

Based on interview and document review, the facility failed to ensure residents were protected from abuse by staff for 1 of 4 residents (R1) reviewed for an allegation of abuse. The facility's failure to protect residents resulted in an immediate jeopardy situation. This had the potential to affect all 30 residents residing in the Lexington unit. In addition, an extended survey was completed. The IJ began on 1/16/21, when licensed practical nurse (LPN)-A allegedly grabbed R1's right arm resulting in an injury, and the facility failed to ensure all residents residing on the Lexington unit were protected from LPN-A, who was allowed to continue working on the Lexington unit after causing an injury to R1's right arm. The facility administrator was notified of the IJ on 1/21/21, at 4:30 p.m. The IJ was removed on 1/22/21, at 12:10 p.m. but non-compliance remained at the lower scope and severity of H, actual harm, that is not immediate jeopardy. Findings Include: R1's Admission Record printed 1/22/21, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, and had no physical or verbal behavioral issues. An untitled facility incident report dated 1/16/21, indicated LPN-A had entered R1's room to assist R2 with a transfer to his bed. R1 was noted to be located on his own side of the room, but had went to R1's side of the room. The report indicated R1 had been angry and upset because LPN-A had turned on the room light. R1 was noted to have been yelling at LPN-A to turn out the light, he grabbed LPN's shirt and threatened to hit her. LPN-A grabbed R1's right upper arm to push him away, in self-defense. Nursing assistant (NA)-A entered the room, verbally redirected R1, and brought R1 back to his own side of the room. At that time, R1's right upper arm was noted to have a bruise measuring 4.5 centimeters (cm) long by 7.5 cm wide. R1's right upper arm also had five 1 cm skin tears from LPN-A's fingernails, when she had grabbed R1's arm. The report further indicated R1's description of the incident, Every night she comes in room about 12 AM and turns on all the lights and I got angry. R1 stated he went over to roommates' side of the room to show her how to use the light cord to turn the light on above his bed. R1 stated he grabbed her shirt to get her attention, and that is when she grabbed my arm, caused me to bleed and this bruise. The incident report also included NA-A's description of the incident. NA-A stated he had been walking down R1's hallway to answer a call light, and he heard LPN-A yelling out from R1's room. When NA-A entered R1's room, he observed R1 yelling at LPN-A, and it appeared R1 was going to strike at LPN-A. NA-A observed R1 grab the top of LPN-A's shirt. NA-A stated he did not see LPN-A grab R1's arm, but believed LPN-A had caused the injury to R1's right arm. The report indicated the facility took immediate action that included cleansing right arm with wound cleaner and [MEDICATION NAME] was applied to R1's skin tears. R1 had refused a dressing. In addition, registered nurse (RN)-A had discussed the incident with LPN-A, and at the time of the report, LPN-A stated R1 had become angry because she turned all the lights in the room instead of just turning on the light over R2's bed. LPN-A denied touching R1, and was told to no longer provide cares for R1. On 1/21/21, at 9:55 a.m. R1 was interviewed and stated on 1/16/21, he had gotten up to walk over to R2's side of the room. R1 stated he went over to show LPN-A how to use the light cord above R2's bed, instead of turning on the main light in the room. R1 stated he grabbed LPN-A's sweatshirt hood to get her attention, and that's when LPN-A grabbed his right arm and caused the injury. A large bruise was noted on R1's right upper arm that was deep purple in color. R1's arm also had 5 skin tears. R1 stated, (LPN-A) grabbed my arm and caused this injury, and I want something done about it. R1 further stated he had seen LPN-A walking down the hallway the following day and it was very upsetting, She should have had at least a week off for doing this to my arm. On 1/21/21, at 11:01 a.m. the administrator and the director of nursing (DON) were interviewed and stated there had been an incident involving LPN-A and NA-A on 1/16/21, at approximately 11:45 p.m. The administrator stated RN-A had sent her a text message indicating there had been an issue involving LPN-A grabbing R1's arm in possible self-defense. This resulted in R1 sustaining a bruise and skin tear marks from LPN-A's fingernails. The administrator stated she had called the facility back around 12:26 a.m. and asked RN-A to explain the situation again to her. The administrator stated RN-A relayed to her in the phone conversation R1 had been upset with LPN-A regarding the light, and R1 had went over to R2's side of the room, grabbed LPN-A's sweatshirt, and threatened to punch her. The administrator also stated RN-A had told her NA-A observed R1's injury, and had told RN-A that LPN-A had caused R1's injuries. The administrator stated she instructed RN-A to go interview R1 to get his side of the story, and report back to her. The administrator stated RN-A did not call her back that night, nor was additional investigation completed by the facility related to the allegation until 1/18/21. The administrator stated R1 had not changed his story about the incident, nor did R1 have a history of physical aggression towards staff or residents. The administrator stated after the incident was reported to her, LPN-A had been instructed to not provide cares for R1, however, LPN-A was still allowed to provide cares for other residents residing on the unit. The administrator verified the incident had not been reported the State Agency (SA) until 1/18/21, at 12:17 p.m. even though RN-A had reported immediately to her that LPN-A may have caused the injuries to R1's right arm. The administrator further stated all allegations of potential or actual abuse are required to be reported immediately and no later than 2 hours to the SA. The administrator verified LPN-A was suspended on 1/18/21, related to the allegation of abuse. LPN-A's employee time punch form dated 1/21/21, indicated LPN-A worked the date of 1/16/21, from 10:00 p.m. until 3:05 p.m. the following day, 1/17/21. LPN-A's employee time punch form dated 1/21/21, indicated LPN-A worked the date of 1/17/21, from 10:00 p.m. till 6:00 a.m On 1/21/21, at 12:36 p.m. LPN-A was interviewed and stated she had been working the night of 1/16/21. LPN-A stated she had heard yelling and profanity coming from R1 and R2's room. LPN-A stated R1 and R2 were standing next to R2's bed holding each other. LPN-A stated R2 cannot walk, so she immediately thought she needed to help prevent R2 from falling. LPN-A stated she wrapped her arms around R2, and held him close to her body. LPN-A stated R1 was holding onto R2's wheelchair (W/C) out of her reach, but she was able to stretch to reach R2's W/C and place him in his chair. LPN-A stated she placed R2 in his W/C and left the room. When asked if R1 had grabbed her shirt, LPN-A stated, No one grabbed me. When asked if she had grabbed R1's arm, LPN-A stated, I have nothing to talk about. On 1/22/21, at 6:46 a.m. RN-A was interviewed and stated she was the RN supervisor the night of 1/16/21. RN-A stated NA-A had reported to her there was issue involving LPN-A and R1. RN-A stated she went to R1's room and observed R1 seated on his bed. RN-A stated R1 had told her look at my arm and she could see a large bruise with fingermarks. RN-A stated R1 repeated to her again that LPN-A did this to him. RN-A stated R1 said he was angry with LPN-A because she would come in the room every night and turn on the room light, verses the individual light over the bed. RN-A stated R1 stated he went to R2's side of the room and grabbed LPN-A's shirt. RN-A stated R1 told her LPN-A grabbed him, and caused the injuries to his arm. RN-A stated R1 kept repeating that LPN-A did this to him. RN-A stated she immediately contacted the administrator via text asking for help with the situation. RN-A started to cry, and stated she did everything she was told to do. RN-A stated LPN-A was very hard to understand, and was hysterical when she was trying to talk to her following the incident. RN-A stated getting help on the night shift is very hard, but she had given the administrator the information relating to R1's report of abuse by LPN-A causing the injuries to his arm. RN-A stated she even went to another unit to get help from RN-B. RN-A stated RN-B went and talked to R1, and he reported the same to her that LPN-A caused the injury to his right arm. RN-A stated the DON also called her later that morning, and discouraged her from sending LPN-A home. RN-A stated she was instructed to by the DON to interview R1 again to see if there were any differences in his story. RN-A stated, I had the feeling like the (DON) was trying to get him to say the injury was caused by (LPN-A) in self-defense, but R1 had already told her (LPN-A) caused the injury. RN-A stated she felt it was a reportable incident. RN-A further stated she had reported to the administrator and the DON what R1 and NA-A had told her. RN-A stated the incident was reported later to the SA, and an incident report had been filled out immediately as potential abuse. RN-A stated she believed the administrator and DON were going to report this immediately as abuse. RN-A stated LPN-A should have been sent home, however, she was instructed by the DON to allow her to continue working the night shift and the dayshift. On 1/22/21, at 7:50 a.m. RN-B was interviewed. RN-B stated on 1/16/21, she had gone to R1's room to complete an interview and assess R1's injury to his right upper arm. RN-B stated R1 told her LPN-A had come into the room around midnight to provide cares for his roommate, and LPN-A had turned the main light on instead of R2's light above his bed. RN-B stated R1 told her LPN-A would do that all the time, and it would wake him up. RN-B stated R1 told her he wanted to show LPN-A that she should use the light above the bed, and went over to R2's side of the room, where he grabbed LPN-A's jacket, and LPN-A grabbed his arm. RN-B stated the information R1 shared with her that night was the same as R1 relayed to RN-A at the time of the incident. The facility policy Abuse Prohibition/Vulnerable Adult Plan revised 7/5/19, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy directed staff to ensure residents were not subjected to 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. The policy further directed the immediate supervisor, If this is staff to resident alleged or suspected abuse, the staff person will be immediately suspended until the investigation is completed. The facility implemented corrective action to prevent recurrence on 1/22/21, at 12:10 p.m. The facility completed interviews and questionnaires with all residents regarding their rights to be free from abuse, neglect, and exploitation, specific to ensuring their safety at the facility from both other residents and staff,and that there care needs were being met. Any residents who reported concerns with abuse, neglect and/or exploitation were reported to the appropriate state agency and/or facility internal Complaint & Grievance Process. Staff were educated on how/who to report any incidents of abuse, neglect, and/or exploitation to within the facility, to the corporate compliance hotline, to the SA and Ombudsman. In addition, staff education had been initiated and will remain ongoing regarding Abuse Prevention/Prohibition specific to reporting, types of abuse including intentional and unintentional and investigation process including staff suspension(s). Staff education also included how to deescalate resident behaviors. and staff were educated on resident rights. This was verified through staff interview and documentation review.

Based on interview and document review, the facility failed to assess for and provide education related to risk prior to upgrading a diet for 1 of 3 residents (R1) reviewed with an altered diet. This resulted in harm for R1 who choked during a meal and subsequently passed away. Findings include: R1's quarterly minimum (MDS) data set [DATE], indicated he was severely cognitively impaired and required limited assistance from staff to eat. R1's care plan dated 8/7/18, identified a self care deficit related to cardiovascular accident, muscle weakness, arthritis and dementia. The care plan further identified R1 was receiving hospice care, indicated nutrition per resident request and directed staff to monitor for food and fluid intake, dietician to evaluate as needed for weight gain/loss or other problems noted and staff to monitor for choking. R1's Order Review Report dated 11/1/18 to 11/30/18, identified the following orders: 7/26/18 - 11/14/18, Regular mechanical soft diet with pureed meat texture, nectar thick liquids for patient coughing/choking. 11/14/18 - 11/18/18, Pureed texture, nectar thick liquids for patient coughing/choking. 11/18, mechanical soft texture, nectar thick liquids. A review of facility Progress Notes and hospice Facility Visit Documentation Records identified the following: 11/14/18, Progress Note written by the registered dietician indicated per staff registered nurse (RN), R1 had been struggling to tolerate mechanical soft diet. Writer consulted with hospice team who agreed to downgrade diet to pureed with a trial of honey thick liquids. Hospice coming on 11/15/18, to evaluate R1. Dietician will continue to monitor and make changes as needed. The medical record lacked evidence of follow up by the dietician. 11/15/18, Hospice Facility Visit Documentation Record indicated skilled nurse collaborated with facility nurse. R1 in bed and comfortable, no signs of pain and medications re-ordered. Please call hospice with any concerns or changes. The note lacked evidence the hospice RN assessed R1's diet or ability to eat or had a discussion with facility staff related to R1's diet. 11/18/19, Hospice Facility Visit Documentation Record indicated staff reported R1 did not like the pureed diet and was not eating as much. Staff felt like R1 could handle the mechanical soft diet. Will do a trial and monitor. The record lacked evidence monitoring of R1's intake or ability to tolerate the diet was completed. 11/21/19, facility Progress Note indicated while at the nurses station, nursing assistant called writer saying that a resident in the dining room (R1) was choking. Writer found R1 in the dining room seated in his wheel chair, he looked purple and was not coughing or talking. Writer asked him if he could cough and no response so [MEDICATION NAME] maneuver was initiated without result. Another nurse took over the [MEDICATION NAME] maneuver and writer called 911. While on the phone with 911 a nursing assistant came to the nurses station and stated R1 had no signs of life. During interview on 3/14/19, at 2:14 p.m. the hospice RN stated she had not seen R1 eat the mechanical soft diet. The hospice RN stated she spoke to the facility nurse who told her R1 did not like the pureed food and felt he could handle the mechanical soft diet. The hospice RN stated hospice did not normally complete an assessment or provide education related to the risks verses benefits of an upgraded diet then stated, we normally would do it stating, the thing is, he wouldn't eat the pureed food and I would have to look at my notes to see why a risk verses benefit wasn't done. The hospice RN stated she was at the facility the day R1 passed away and was told he choked on a piece of toast. She stated she never discussed with the facility staff which foods R1 should or should not be given prior to upgrading his diet and said, I think I just trusted them (facility). At 2:41 p.m. licensed practical nurse (LPN) -A stated R1 did not like the diet. LPN-A stated she tried to explain to him why he was on it, due to the swallowing difficulty. LPN-A stated she had not had a discussion with R1's family regarding the diet and was not part of the conversations related to upgrading R1's diet. At 2:45 p.m. RN-A stated R1 was on hospice and had been going along pretty well without many changes, then began having changes diet wise. RN-A stated R1 had issues with meat and being able to chew and he would get frustrated. RN-A stated R1 liked to take big bites so he was changed to a pureed meat to help with texture then was changed to a full pureed diet until 11/18/18, when he was upgraded back to mechanical soft. RN-A stated her understanding was the facility nurse and hospice nurse had been talking and he had not been eating as much so he was changed to mechanical soft. RN-A stated she thought hospice had talked to the family about the diet change and stated she was not part of the conversation related to the diet change. RN-A stated she did not know specifically what food R1 was having trouble eating and stated hospice made the decision to change his diet and from her understanding hospice had been there and assessed R1. RN-A stated she was never told if R1 was able to tolerate the diet and no assessments had been completed by the facility nor were risks and benefits provided by the facility. The facility's investigation of the incident dated 11/27/19, indicated staff responded to R1's choking by attempting the [MEDICATION NAME] Maneuver, calling 911 and respecting R1's wishes to not be resuscitated. The investigation lacked evidence the facility identified the lack of assessment related to the upgrade of R1's diet, the lack of adequate monitoring during meals and the failure to explain the risks of upgrading the diet.