Every finding on record at The Estates at St Louis Park LLC

Based on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 3 of 3 residents (R32, R39, R101) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all 136 residents residing in the facility. Findings include: R32's quarterly Minimum Data Set (MDS), dated [DATE], indicated R32 had moderate cognitive impairment. R39's quarterly MDS assessment, dated 6/15/26, indicated R39 was cognitively intact. R101's quarterly MDS assessment, dated 7/11/26, indicated R101 was cognitively intact. During a resident council meeting on 8/26/26, at 10:30 a.m., R32 stated mail was not delivered to residents on the weekends. R39 stated mail was not delivered to residents on Saturdays. R101 stated mail was delivered to the facility on Saturdays; however, staff did not deliver it to residents until Monday. During an interview on 8/27/26 at 8:39 a.m., business office assistant (BOA) stated the post office typically delivered mail between 10 a.m. and 4 p.m. BOA stated if mail arrived before 4 p.m. she would deliver it the same day, however, if it came later, she would deliver it the following day. BOA stated she did not work weekends and was unsure who, if anyone, delivered the mail on the weekends. BOA stated the mail was usually in the mail bin located by the front desk when she came to work on Monday morning and she delivered it then. During an interview on 8/27/26 at 1:26 p.m., administrator stated the receptionist received, sorted and delivered the mail to the residents. Administrator stated on the weekends, it was the responsibility of the manager on duty or nurse manager to sort and deliver the mail. Administrator stated staff were expected to deliver mail to the residents the same day it was delivered to the facility. A policy was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure smoking aprons were worn for 1 of 1 residents (R110) who were assessed as requiring a smoking apron for safety.Findings include: R110's quarterly Minimum Data Set (MDS), dated [DATE], indicated R110 had moderate cognitive impairment and was independent with activities of daily living (ADLs). R110's diagnoses included schizoaffective disorder, Alzheimer's, hypertension, knee pain, nicotine dependence, diabetes, and chronic obstructive pulmonary disease (COPD). R110's smoking evaluation, dated 8/11/26, indicated R110 identified as a smoker, and had no cognitive loss or visual deficit. The evaluation further indicated that R110 was educated on safety and storage. R110 was assessed to be independent with smoking while wearing a smoking apron to protect her clothing because R110 had clothing with burn holes from old burns to clothing. R110 agreed to wear the smoking apron. R110's care plan, printed 8/27/26, indicated R100 currently smoked, used an apron for smoking independently, and had clothing that had holes in them. During an interview on 8/24/26 at 4:28 p.m., R110 stated she was able to go outside to smoke, had to wear a smoking apron, and she did not burn herself. R110 stated burn holes in her clothing were from when ashes landed on her clothing when flicking off the ash. R110 stated she took the apron with her when she went downstairs and put it on before she went out the door. During an observation on 8/24/26 at 4:32 p.m., R110 was outside on the smoking patio smoking a cigarette. However, R110 was not wearing the smoking apron. During an observation on 8/25/26 at 1:15 p.m., R110 was observed placing a cigarette butt in cigarette receptacle. However, R110 was not wearing a smoking apron. During an observation on 8/26/26 at 12:02 p.m., R110 was outside on smoking patio smoking a cigarette. However, R110 was not wearing her smoking apron. During an observation on 8/27/26 at 10:56 a.m., R110 self-propelled her wheelchair to the elevator with cigarette and lighter in her hand, and a smoking apron was rolled up and tucked between R110's left side and wheelchair armrest. During an observation on 8/27/26 at 10:58 a.m., R110 was outside on the smoking patio, smoking a cigarette with smoking apron rolled up tucked between herself and wheelchair armrest. At 11:01 a.m., R110 continued to smoke when an unidentified staff member walked into smoking patio. However, the staff member did not approach R110 regarding not wearing the smoking apron. Between 11:01 a.m. and 11:04 a.m., 3 staff separate staff members had walked in the smoking patio, however, none of them had reminded R110 to wear the smoking apron. At 11:06 a.m., R110 appropriately disposed of the cigarette, and the smoking apron remained rolled up and tucked next to R110's left side. During an interview on 8/27/26 at 11:30 a.m., registered nurse (RN)-B stated smoking assessments were completed to ensure the resident was safe to smoke. RN-B stated R110 needed to wear a smoking apron whenever she went outside to smoke, and the nurses were responsible to make sure the apron was on. RN-B stated she was not aware R110 had not worn the smoking apron. During an interview on 8/27/26 at 11:52 a.m., RN-C stated smoking assessments were completed quarterly, and if a resident required a smoking apron it was added to the care sheets so staff were aware. RN-C stated all staff were aware R110 required a smoking apron when smoking. RN-C stated R110 did not take the wind into account to make sure ashes did not blow back onto her clothing, R110 had not burned her fingers, but did have old burn holes in her clothing. During an interview on 8/27/26 at 12:38 p.m., director of nursing (DON) stated R110 had come to the facility with burn holes in her clothing and was assessed to need a smoking apron for safety. DON stated R110 had not had any burn incidents while a resident in the facility. DON stated she was not aware R110 was observed without a smoking apron as R110 was very aware of the need to wear it. The facility's Resident Smoking policy, dated 11/2025, indicated residents who smoke would be evaluated to the need of adaptive equipment, upon admission, quarterly, annually and with any significant change in cognition or resident exhibits inability to follow safe smoking practices.

Based on interview and document review, the facility failed to follow physician-ordered medication parameters for 1 of 3 residents (R48) reviewed for medications with administration parameters.Findings include:R48's quarterly Minimum Data Set (MDS), dated [DATE], identified R48 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R48's diagnoses included nontraumatic intracerebral hemorrhage (bleeding within the brain), non-Alzheimer's dementia (a condition causing impaired memory, thinking, and judgment), hemiplegia (paralysis affecting one side of the body), anxiety disorder, and depression.R48's signed physician orders, dated 8/17/26, included an order for metoprolol succinate extended-release 12.5 milligrams (mg) by mouth once daily for paroxysmal atrial fibrillation (an irregular heart rhythm that started and stopped intermittently). The order, initiated on 3/26/26, directed staff to hold the medication for a systolic blood pressure (SBP) less than 100 millimeters of mercury (mmHg) or a heart rate (HR) less than 60 beats per minute (BPM).R48's medication administration records (MARs), reviewed from 3/26/26 through 8/26/26, identified metoprolol was administered on seven occasions when R48's documented HR was below the physician-ordered hold parameter of 60 beats per minute, as follows:On 4/9/26, metoprolol was administered when R48's blood pressure (BP) was 122/68 mmHg and HR was 58 BPM.On 5/26/26, metoprolol was administered when R48's BP was 128/74 mmHg and HR was 58 BPM.On 6/21/26, metoprolol was administered when R48's BP was 134/73 mmHg and HR was 55 BPM.On 6/25/26, metoprolol was administered when R48's BP was 150/72 mmHg and HR was 56 BPM.On 7/8/26, metoprolol was administered when R48's BP was 151/72 mmHg and HR was 57 BPM.On 7/21/26, metoprolol was administered when R48's BP was 142/74 mmHg and HR was 55 BPM.On 8/25/26, metoprolol was administered when R48's BP was 151/67 mmHg and HR was 56 BPM.However, R42's MARs identified R48 received metoprolol on seven occasions between 4/9/26 and 8/25/26 when R48's documented HR ranged from 55 to 58 beats per minute, despite the physician's order to hold metoprolol when the HR was less than 60 BPM.During an interview on 8/27/26 at 2:30 p.m., the director of nursing (DON) stated nursing staff were expected to know how to read and follow provider orders. The DON stated that administering a medication when it should have been held could cause harm to a resident. The DON further stated when a provider's order directed staff to hold a medication for a reading outside the ordered parameters, the nurse should not have administered the medication.During an interview on 8/27/26 at 4:32 p.m., licensed practical nurse (LPN)-B stated that if a resident's blood pressure or pulse was outside the ordered parameters, the medication should have been held. LPN-B stated the provider should be notified for further orders, and the medication hold and provider notification should be documented in the resident's medical record.The facility's Medication and Treatment Orders policy, dated 2/24, indicated medication and treatment orders would be consistent with the principles of safe and effective order writing. The policy indicated medications would be administered only upon the written order of a person duly licensed and authorized to prescribe medications in the state.

Based on observation, interview and document review, the facility failed to ensure resident Minimum Data Set (MDS) accurately reflected residents' smoking status for 3 of 6 residents (R9, R14, R21) observed for smoking. Findings include: R9's significant change Minimum Data Set (MDS), dated [DATE], identified R9 had intact cognition and required assistance with activities of daily living (ADLs). R9's diagnoses included schizophrenia (a mental health disorder that can affect thinking, perception, and behavior), bipolar disorder (a mood disorder characterized by changes in mood and activity), post-traumatic stress disorder (PTSD) (a condition that can develop following a traumatic event), and chronic obstructive pulmonary disease (COPD - a chronic lung disease that can cause difficulty breathing). Additionally, the MDS indicated R9 was not a current smoker. During an interview on 8/24/26 at 4:40 p.m., R9 stated he regularly smoked cigarettes, kept his smoking supplies in his room and on his person, and went to the facility's designated smoking area several times during the day and evening to smoke. During multiple observations from 8/24/26 through 8/27/26, R9 was observed in the facility's designated outdoor smoking area. R9 independently lit, smoked, ashed, and extinguished his cigarettes. R9's care plan, printed 8/27/26, indicated R9 was a chronic smoker and declined to use smoke cessation aids. R9's Smoking Evaluation, dated 7/2/26, indicated R9 identified as a current smoker, smoked during the mornings, afternoons, and evenings, and required no adaptive equipment for smoking. R9's significant change MDS, dated [DATE], Section J, subsection J1300, Current Tobacco Use, was coded No. However, the MDS coding was inconsistent with observations, interviews, and R9's smoking evaluation. R14's annual MDS, dated [DATE], identified R14 had intact cognition and required assistance with activities of daily living (ADLs). R14's diagnoses included anxiety disorder (a condition characterized by excessive anxiety or worry) and depression (a mood disorder that can cause persistent feelings of sadness and loss of interest). Additionally, the MDS indicated R14 was not a current smoker. During an interview on 8/24/26 at 6:29 p.m., R14 stated he regularly smoked cigarettes, kept his smoking supplies in his room and on his person, and went to the facility's designated smoking area several times during the day and evening to smoke. During multiple observations from 8/24/26 through 8/27/26, R14 was observed in the facility's designated outdoor smoking area. R14 independently lit, smoked, ashed, and extinguished his cigarettes. R14's care plan, printed 8/27/26, indicated R14 was a current smoker who smoked cigarettes independently. R14's Smoking Evaluation, dated 6/8/26, documented R14 identified as a current smoker, smoked during the mornings, afternoons, and evenings, and required no adaptive equipment for smoking. R14's comprehensive MDS, dated [DATE], Section J, subsection J1300, Current Tobacco Use, was coded No. However, the MDS coding was inconsistent with observations, interviews, and R14's smoking evaluation. R21's admission MDS, dated [DATE], indicated R21 had moderate cognitive impairment, diagnoses included hemiplegia and hemiparesis, stroke, major depression, anxiety disorder and epilepsy. Additionally, the MDS indicated R21 was not a current smoker. During an interview on 8/24/26 at 2:20 p.m., R21 stated he smoked cigarettes, but preferred cigars, kept smoking supplies in his room, and went out several times daily to smoke. R21 stated he had smoked at the facility since he admitted . During multiple observations of R21 from 8/24/26 through 8/27/26, in the facility's outside smoking area, R21 was observed as able to light, ash and extinguish his smoking materials independently. R21's Smoking Evaluation, dated 5/27/26, documented R21 identified as a smoker, smoked mornings and evenings, and required no adaptive equipment when he smoked. R21's MDS, dated [DATE], Section J, Subsection J1300 Current Tobacco Use, the facility had marked No. However, the MDS coding was inconsistent with observations, interviews, and R21's smoking evaluation. During an interview on 8/26/2026 at 2:31 p.m., the director of nursing (DON) stated R21 was able to smoke independently and mainly smoked cigars. DON stated MDS staff were uncertain if cigars were considered tobacco for the purpose of MDS section J1300. During interview on 8/27/26 at 10:46 a.m., registered nurse (RN)-B stated R9 and R14 frequently went outside to smoke and were able to smoke independently. During interview on 8/27/26 at 10:55 a.m., registered nurse case manager (RN)-C confirmed R9 and R14 regularly smoked cigarettes and were independent with smoking. During interview on 8/27/26 at 1:05 p.m., MDS coordinator (RN)-A stated nurse managers completed residents' smoking assessments, and information from the smoking assessments was used to complete the residents' MDS assessments. RN-A reviewed R9's MDS and confirmed Section J1300 was coded No. RN-A stated the coding was incorrect because R9 smoked. RN-A reviewed R14's MDS and confirmed Section J1300 was coded No. RN-A stated the coding was incorrect because R14 smoked and acknowledged the inaccurate coding of R14's MDS. During an interview on 8/27/26 at 1:26 p.m., RN-A stated she was not the MDS Coordinator for R21 but acknowledged R21 smoked and R21's 5/22/26 MDS section J1300 was incorrectly coded. During interview on 8/27/26 at 2:30 p.m., DON stated MDS assessments needed to be accurate to ensure accurate care planning and for reimbursement purposes. The facility's policy related to MDS assessment accuracy was requested but was not received.

Based on observation, interview, and document review, the facility failed to ensure resident was assessed for self-administration of medications before medications were left at the bedside for 1 of 1 resident (R132) reviewed for self-administration of medications.Findings include:R132's quarterly Minimum Data Set (MDS), dated [DATE], identified R132 had intact cognition and was independent with activities of daily living (ADLs). R132's diagnoses included chronic obstructive pulmonary disease (a chronic lung disease that caused airflow limitation and difficulty breathing).R132's electronic medical record (EMR) included a Self-Administration of Medication Evaluation, completed on 8/11/26, which determined R132 was capable of self-administering inhalation medications, including medications administered by nebulizer. The evaluation did not identify R132 as capable of self-administering other medications.During an observation on 8/27/26 at 10:41 a.m., two medication cups containing medications were observed on R132's bedside table.During an observation and interview on 8/27/26 at 11:40 a.m., the two medication cups containing medications remained on R132's bedside table. Registered nurse manager (RN)-C confirmed the medications were present and stated the medication in the medication cup appeared to be calcium carbonate (TUMS). RN-C stated a self-administration assessment was required before medications could be left at a resident's bedside to determine whether the resident was capable of independently and safely self-administering the medications. RN-C confirmed R132 had not been assessed to self-administer the medications observed at the bedside and was not authorized to have the medications left at the bedside.During an interview on 8/27/26 at 11:45 a.m., registered nurse (RN)-D confirmed she had left the medications on R132's bedside table. RN-D stated she was newer here and was unaware R132 could not self-administer the medications.During an interview on 8/27/26 at 2:30 p.m., the director of nursing (DON) stated when a resident requested to self-administer and manage medications, staff were expected to complete a self-administration of medications assessment to determine whether the resident was capable of safely self-administering the medications. The DON stated staff would then notify the provider and obtain an order if the provider determined self-administration was appropriate. The DON confirmed a self-administration assessment was also required for medications that could be purchased over the counter (OTC).The facility's Self-Administration of Medications policy, dated 2/2024, indicated residents had the right to self-administer medications when the interdisciplinary team (IDT) determined self-administration was clinically appropriate and safe. The policy indicated IDT assessed the resident's cognitive and physical abilities, including the ability to understand the medication's purpose, dosage, administration times, and potential side effects; physically administer the medication; and safely and securely store the medication. When self-administration was determined to be safe and appropriate, the determination was documented in the resident's medical record and care plan.

Based on observation, interview and document review, the facility failed to obtain weekly weights as ordered for 1 of 1 residents (R3) reviewed for weight monitoring. Additionally, based on interview and document review, the facility failed to update the provider of elevated blood sugar levels per physician order for 1 of 2 residents (R134) reviewed for blood sugar monitoring. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R3 had intact cognition and required assistance with activities of daily living (ADLs). R3's diagnoses included congestive heart failure (CHF - a condition in which the heart does not pump blood effectively and can result in fluid buildup). R3's August 2026 medication administration record (MAR) identified orders for Lasix (a diuretic) 60 milligrams (mg) by mouth once daily for CHF, initiated on 5/24/26, and spironolactone (a diuretic) 25 mg by mouth every morning for CHF, initiated on 6/3/26. Additionally, an order for weekly weights every Sunday on the evening shift was initiated on 6/14/26. R3's weight records identified R3 weighed 237.2 pounds on 5/31/26 and 225.4 pounds on 7/26/26, an 11.8-pound decrease. The weight obtained on 7/26/26 was the most recent documented weight. R3's medical record lacked evidence weekly weights were obtained from 7/27/26 through 8/26/26, despite the provider's order for weekly weights. During an observation on 8/25/26 at 1:38 p.m., R3 was out of bed and seated in his wheelchair in his room, eating lunch. During an observation on 8/26/26 at 8:52 a.m., R3 was out of bed and seated in his wheelchair in his room, eating breakfast. During an interview on 8/27/26 at 10:46 a.m., registered nurse (RN)-B stated R3 did not like to get out of bed, and staff obtained R3's weight when he got up for therapy, which occurred several times per week. During an interview on 8/27/26 at 10:55 a.m., registered nurse case manager (RN)-C confirmed R3's last documented weight was obtained on 7/26/26 and that R3 had an order for weekly weights. RN-C reviewed R3's MAR and confirmed staff had documented the weekly weight task as completed; however, no corresponding weights were documented. RN-C stated weight monitoring was important for R3 because he received diuretic medications and the provider based treatment decisions on R3's weights. RN-C stated R3 did not like the Hoyer lift because it was painful for him, and R3 remained in bed most of the time. RN-C stated R3 got up for therapy a couple of times per week and staff could have obtained his weight when he was up for therapy. During an interview on 8/27/26 at 2:30 p.m., the director of nursing (DON) stated staff were expected to obtain weekly weights when ordered and document the weight obtained. The DON stated if a resident refused to be weighed, staff were expected to document the refusal and reattempt to obtain the weight. The DON stated R3's weights were important because he received diuretic medications and the weights had been ordered by the provider. The facility's Weight Policy, dated 5/1/24, indicated the facility was to obtain accurate weights and provide monitoring. R134's annual Minimum Data Set (MDS), dated [DATE], indicated R134 was admitted on [DATE], had severe cognitive impairment, and diagnoses included hypertension (HTN - high blood pressure), renal insufficiency, diabetes, hyperlipidemia (elevated levels of fat in the blood), anxiety, and non-Alzheimer's dementia. R134's Order Summary Report, dated 8/27/26, indicated an order for blood sugar monitoring four times a day before meals and bedtime. Call physician or nurse practitioner for blood sugars less than 75 or greater than 400, initiated 7/23/26. R134's weights and vitals documentation, dated 8/27/26, indicated the following elevated blood sugars (greater than 400): On 8/26/2026 at 11:50 a.m., blood sugar = 411 On 8/1/2026 at 07:52 a.m., blood sugar = 461 On 7/31/2026 at 12:42 p.m., blood sugar = 403 On 7/29/2026 at 07:13 a.m., blood sugar = 511 However, R134's medical record lacked evidence the provider or nurse practitioner was updated, as per the physician orders, of the elevated blood sugars. During an interview on 8/27/26 at 4:19 p.m., the administrator and the regional consultant (RC) confirmed they could not find any evidence the provider had been notified of the elevated blood sugars as per the physician orders. The administrator and RC stated staff were expected to follow the physician orders, and the provider should have been updated each time R134's blood sugar was greater than 400, and staff should have documented it in the chart. During an interview on 8/27/26 at 4:32 p.m., licensed practical nurse (LPN)-B stated in the event R134 had a blood sugar reading less than 70 or over 400, staff should have ensured the resident was stable, updated the provider, and written a note in the chart with any information or new orders given by the provider. During an interview on 8/27/26 at 4:38 p.m., the director of nursing (DON) stated staff were expected to update the provider per the provider orders and standards of practice. A provider update policy was requested, and none was provided.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff used hair restraints while serving food. This had the potential to affect all the residents who reside on 2 South wing who receive eat meals. Findings include:During observation and interview on 8/7/25 at 8:33 a.m., cook (C)-A served food from a steam table on the 2 South unit. C-A had a full head of hair and facial hair on chin and cheeks approximately 1/4 inch long. C-A did not wear a hair net or beard guard. C-A stated he was supposed to wear a hair net but forgot to don one, but was not familiar with a beard guard. C-A left the unit. During observation on 8/7/25 at 8:43 a.m., C-A came back to unit with hair net on and a beard guard and continued to serve food from the steam table. During interview on 8/7/25 at 8:54 a.m., culinary director (CD) stated expectation for servers to wear hair nets and beard guards when dishing up food from the steam table. During interview on 8/7/25 at 9:48 a.m., director of nursing (DON) stated would expect hair nets on when serving food but was unfamiliar with the regulations regarding beard guards. DON further stated would expect staff to follow the policy. Facility policy on hair restraint was requested but not provided. Email received on 8/7/25 at 10:30 a.m., indicated, We do not have a specific policy related to hairnets. Here is a snippet from our handbook: Hairnets must be worn when walking in or through the kitchen areas.

Based on observation, interview, and document review, the facility failed to comprehensively assess and monitor a skin condition for 1 of 1 resident (R88) reviewed for red areas on chin. Further, the facility failed to ensure a critical lab was followed up on timely for 1 of 1 resident (R138) reviewed for labs. Findings include: R88‘s quarterly Minimum Data Set (MDS) dated [DATE], indicated R88 had short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. R88 was independent for most activities of daily living. R88‘s diagnoses included coronary artery disease, heart failure, hypertension, diabetes mellitus, dementia, anxiety, and depression. R88 had no skin condition concerns. R88‘s care plan had a focus area for skin initiated 7/23/20 and indicated R88 was at risk for alteration in skin breakdown secondary to diagnosis of diabetes and refusals of cares: showers/baths, etc R88 had history of rash to arms, upper back, and body which healed up and returned after a few days to months. The focus area included an update dated 8/5/25 which indicated R88 had red spots on her face around her mouth. Interventions included to encourage and reapproach if refusing shower, R88 had a pressure reducing mattress to bed, skin assessment to be completed per policy, treatments as ordered as needed, and R88 turned and repositioned independently. An intervention dated 8/6/25, indicated R88 tended to scratch her head and skin and refused nail care and directed staff to keep nails trimmed. A provider encounter dated 6/30/25, indicated R88 had a past medical history of seborrheic dermatitis (itchy, scaly skin patches and flakes on oily areas of skin), rash and other nonspecific skin eruption, pruritus (sensation of itching). The encounter indicated R88 had no new rashes, lumps, sores, dryness, pruritic lesions, or skin breakdown. Progress notes reviewed did not indicate R88 had red areas on her chin prior to 8/5/25. Physician orders did not indicate R88 had red areas on her chin prior to 8/6/25. A physician order dated 8/6/25, directed staff to apply triamcinolone acetonide external cream 0.025% (percent) to R88‘s rash/lesions on face two times a day for two weeks and monitor for worsened skin condition. R88‘s skin assessments dated 6/30/25 to 8/4/25, indicated R88 refused skin checks/showers at times, but R88‘s visible skin was intact with no new skin issues. During observation and interview on 8/4/25 at 4:03 p.m., R88 had approximately five to six red circular spots on and around her chin. The red areas were not raised. R88 stated she would use lotion if given to her, and red areas on skin had been happening for “forever”. During observation and interview on 8/5/25 at 1:54 p.m., R88 was sitting in her room in a chair watching television. The red areas around R88‘s chin appeared unchanged from previous observation. R88 stated the areas were not painful and did not itch. R88 was not sure if the red areas were better or worse than prior. R88 stated she got the red areas from resting her chin on her hands while watching television. During observation and interview on 8/5/25 at 2:08 p.m., registered nurse (RN)-B stated they were not aware of the red areas on R88‘s face. RN-B stated residents had weekly skin checks on their shower days. RN-B stated staff documented new skin concerns, called the provider, and monitored the area of concern. RN-B looked at R88‘s face and stated the red areas looked like R88 picked her skin. RN-B stated R88 scratched her head and scratching her chin may be new. RN-B stated they encouraged R88 to stop scratching herself and observed for bleeding or redness when they saw R88 scratch her forehead. During interview on 8/6/25 at 10:25 a.m., nursing assistant (NA)-D stated R88 required minimal or set-up assistance for cares and worked on the unit frequently. NA-D stated R88 did not scratch her head often, and NA-D distracted her with television and coffee. NA-D stated they saw the red areas on R88‘s chin “some time back”. During interview on 8/7/25 at 11:07 a.m., licensed practical nurse (LPN)-C stated staff noted the red areas on R88‘s face two days ago and called the provider. LPN-C stated R88 had a history of rashes on her body and requested the provider look at the red areas around R88’s chin to determine what treatment was needed. LPN-C stated they had never seen R88 scratch her head or skin but added the scratching to the care plan when they were made aware by other staff. During interview on 8/7/25 at 1:08 p.m., the director of nursing (DON) expected staff to call a provider for possible treatment and monitor residents with a new skin concern. The DON stated it was important for staff to manage skin concerns. The facility’s Skin Assessment and Wound Management policy dated 2/2025, directed staff to notify a nurse when skin changes were identified and implement appropriate preventative skin measures. See also F698. R138's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have behaviors or reject care, had a wheelchair for mobility, required substantial assistance with dressing, toileting hygiene, and personal hygiene, had anemia (low hemoglobin or HGB), end-stage renal disease (ESRD), a coagulation defect (a bleeding disorder affecting the blood's ability to clot), and thrombocytopenia (a condition of a low platelet count in the blood which can lead to increased bleeding and bruising). Further, R138 was on dialysis. R138's Physician's Orders form indicated the following orders: 7/16/25, dialysis every Monday, Wednesday, and Friday. 8/5/25, lab CBC (complete blood count which includes a HGB), CMP, Mg, PTH, CRP, INR (a blood test that indicates how well the blood is able to clot), Phosphorus on 8/5/25. R138's hospital discharge orders dated 7/27/25, indicated a CBC, INR, and CMP was recommended on 7/30/25. R138's care plan dated 7/14/25, indicated R138 was at risk for complications related to dialysis and interventions included to call the physician if any changes in the dialysis port line, fistula to left forearm, excess bleeding, notify dialysis of any concerns, send communication folder to dialysis with each run. Additionally, an intervention dated 8/6/25, indicated to monitor the central dialysis port line on the right upper chest for signs of bleeding every shift. R138's care plan dated 7/15/25, indicated R138 had a nutritional problem related to ESRD and interventions included obtaining and monitoring lab and diagnostic work as ordered and report the results to the physician and follow up as indicated. R138's labs collected on 8/5/25 at 6:05 p.m., with a fax time stamp at the top of the form dated 8/5/25 at 8:53 p.m., indicated the following: HGB 6.7 (LL) and the normal reference range was 13.5 to 17.5 g/dl (grams per deciliter). Platelets (platelets are essential for blood clotting) 78 (L) and the normal reference range was 150 to 450 x 10(9)L. A legend at the bottom of the lab form indicated an (LL) was a critically low lab value and an (L) value was a low lab value. Further, the lab result form contained an illegible signature. R138's labs collected on 8/5/25 at 6:55 p.m., with a fax time stamp at the top of the form dated 8/5/25 at 9:33 p.m., indicated the following: INR: 3.2 (H) with a reference range of 0.9 to 1.1. The legend at the bottom of the lab form indicated an (H) was a high level. Further, the lab result form contained an illegible signature. R138's nurse practitioner (NP)-E notes dated 8/4/25 at 2:25 p.m., indicated on 7/29/25 R138 had chronic, stable anemia of chronic disease and required multiple transfusions during hospitalization with no signs of bleeding. The note further indicated to check HGB as soon as possible (lab can't come until tomorrow), and discussed low HGB during dialysis can cause aches due to blood pull off and if abdominal pain is severe before work up can be completed by lab, can discuss hospitalization for uncontrolled pain and suspected symptomatic anemia. Additionally, the note indicated R138 received 2 units of packed red blood cells the week of 7/20 and R138's HGB at the time of discharge was 7.8. NP-E indicated R138 was visibly uncomfortable duet o lower abdominal pain and was concerned about symptomatic anemia and R138's code status was a full code and was unclear what R138's baseline HGB was but, the note indicated r138's HGB was stable at 7 to 8 now. R138's progress notes dated 7/21/25 at 10:46 p.m., indicated R138 was transferred to the hospital with a HGB of 6.3. R138's progress notes dated 7/27/25 at 10:25 p.m., indicated R138 was readmitted from the hospital. During interview on 8/4/25 at 1:42 p.m., family member (F)-B stated R138 went to the hospital with a low HGB and the physician put notes in for discharge to check a HGB on 7/30/25, and when asked, the facility did not have the labs set up until Monday so the labs will be drawn on 8/5/25, and added R138 had transfusions every two to three weeks because his HGB dropped. During interview on 8/6/25 at 12:16 p.m., licensed practical nurse (LPN)-E stated R138 had low HGB's and health unit coordinators (HUC's) collect lab results and if a lab was critical, staff received a call from the pathway and then staff were to contact the provider as soon as possible. During interview on 8/6/25 at 12:29 p.m., HUC-H stated when lab results came back she prints the lab and verified she received orders for labs from the NP on 7/30/25 but did not see any results. HUC-H added R138 came back on a weekend and they did not work on the weekend so nursing processed the orders. HUC-H stated R138's HGB was 6.7 on 8/5/25 and stated the lab was not critical and if there were critical results, the lab calls to report the results to the nurse. HUC-H further stated the lab reports had a reference range on the report that indicated the HGB should be 13.5 to 17.5 and if it was above or below that range, they called the provider. HUC-H stated they faced the results to NP-E on 8/5/25. During interview on 8/6/25 at 12:46 p.m., nursing assistant (NA)-H stated R138's wheelchair came back from dialysis, but he thought R138 went to the hospital because the chair came back but R138 did not. During interview on 8/6/25 at 1:58 p.m., registered nurse (RN)-E stated the lab calls to inform of a critical lab and then staff are supposed to call the provider right away. If a lab is not critical staff fax the provider. Further, RN-E stated if they receive a lab it was documented in the electronic medical record (EMR). RN-E viewed R138's labs and verified R138's HGB was low and stated LL meant the HGB was low and added maybe the lab was low from the previous lab. RN-E verified a lab value of LL indicated it was critically low and opened NP-E's note dated 8/4/25 that indicated R138's HGB was 7.8 on 7/26/25, and verified R138's HGB on 8/5/25, was 6.7 and stated she had to check the progress notes. RN-E verified the progress notes lacked evidence the physician was called and stated a HGB of 6.7 was a critical lab and stated the nurse should have called the provider. During interview on 8/6/25 at 2:32 p.m., LPN-E stated she had not heard the results of R138's labs and stated staff observe the lab results and call the provider right away when a lab was critical versus faxing and is documented in a progress note and stated the HGB result should have been called to the provider already. LPN-E stated when a lab result is received, the HUC collects them and scans them and puts them in the nursing station and the nurses should have visual checks to send information to the provider. If a lab is normal it will be faxed. LPN-E clarified the lab will be received at the nursing station and whoever sees the fax reads it and stated the physician should have been contacted right away. During interview on 8/6/25 at 2:35 p.m., with the director of nursing (DON) and LPN-E, LPN-E verified RN-F signed R138's lab form. The DON stated the NP should have been notified immediately. During interview on 8/6/25 at 2:39 p.m., RN-F stated he worked on the evening of 8/5/25, and viewed R138's lab results, however did not call the provider. During interview on 8/6/25 at 2:41 p.m., NP-E stated she has not received a call on R138's labs and stated usually critical lab results were called to the provider and had not seen anything from the on call provider either. During interview on 8/7/25 at 10:43 a.m., the DON stated R138's baseline HGB on follow up notes were 7 to 7.2 and further stated RN-F was suspended and added the lab always called when there was a critical lab and RN-F did not receive a call, however expected if a nurse put a signature on a lab, they had to review it and still expected if a nurse placed their name on something they had to look at what the report indicated and further stated they conducted house-wide education and added, the lab didn't do their part, but that didn't excuse the nurse from doing their part. A policy on critical lab results was requested on 8/7/25 at 1:30 p.m., however was not provided. A PDF form provided on 8/8/25 at 3:02 p.m., indicated education was provided to RN-F the provider of a critical lab must be notified immediately, ensure monitoring is in place for the critical lab, notify the guardian and representative, call the DON, and if hospitalization is recommended, it must happen immediately.

Based on observation, interview and document review, the facility failed to ensure range of motion (ROM) was completed on 2 of 2 residents (R3, R35) reviewed who had limited range of motion. In addition, the facility failed to ensure the regular use of a palm protector for 1 of 1 residents (R3) reviewed for splint/brace use. Findings include: R3’s annual Minimum Data Set (MDS) dated [DATE], indicated R3 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). R3’s MDS indicated zero minutes of restorative nursing to include passive and active range of motion (ROM) and splint or brace assistance. R3’s MDS further indicated “Behavior not exhibited” for rejection of care assessment. R3’s diagnoses include hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction affecting right dominant side, Parkinson’s, dementia, contracture of muscle, aphasia (conditioning affecting speech) and depression. R3’s care plan (CP) dated 7/8/25, indicated R3 had hemiplegia/hemiparesis and Parkinson’s and required “Range of motion (active or passive) with am/pm care daily.” R3’s CP further indicated R3 often refused donning of or often removed splint from right hand. The CP indicated R3 had a history of and was at risk for skin breakdown on right hand due to contracture and instructed staff to keep a [NAME] hand guard on at all times. R3's nursing care sheet updated 8/6/35, instructed staff, Perform Passive ROM LE [lower extremity] and upper twice daily. The care sheet indicated, Palmar guard on. R3’s Restorative/Functional Maintenance Program dated 6/21/24, indicated, “Right Hand…Palmar hand guard…please keep palmar hand guard on at all times…” R3’s physician order dated 12/13/24 indicated, “Perform PROM twice a day every day and evening shift.” R3’s physician order dated 7/15/25 indicated, “Protection from skin breakdown: Please keep Palmar Hand Guard on R hand on at all times. Okay to remove to wash or during bathing tasks.” R3’s physician order dated 7/23/25 indicated, “PROM [passive range of motion] to Bilat [bilateral] UE’s [upper extremities] once daily – work within pt’s pain tolerance.” During observation on 8/4/25 at 1:36 p.m., R3 in room in Broda type chair and has a piece of gauze in right contracted hand. dry lips. During interview on 8/4/25 at 4:14 p.m. family member (FM)-A, stated facility was supposed to be getting a brace or splint for R3’s right hand but could not recall ever seeing one. FM-A stated R3’s right arm and hand were severely contracted. FM-A stated R3 should be receiving ROM and that his right palm required protection from skin breakdown. During observation on 8/5/25 at 1:21 p.m., R3 was awake and up in wheelchair in room. R3 did not have a brace or palmar hand guard on right hand. During observation and interview on 8/6/25 at 8:38 a.m., licensed practical nurse (LPN)-B, nursing assistant (NA)-B, and NA-C into R3’s room for morning cares and transfer to shower chair for weekly shower. NA-B and NA-C performed peri care and prepped R3 for a shower. NA-B stated he worked with R3 regularly and had not seen R3’s palmar guard for about two weeks. NA-C stated had last seen a brace or palmar guard on R3 a long time ago. NA-B had to move the foot of R3’s bed in order to access the top drawer of R3’s nightstand. R3’s palmar guard was in the drawer. NA-B stated R3 should have it on at all times when not in shower. R3 was transferred to shower chair via Hoyer lift and then taken to the shower room. No ROM observed. During interview on 8/6/25 at 9:12 a.m., LPN-B stated she trimmed R3’s fingernails the previous day and did notice he was not wearing a brace or palmar protector. LPN-B stated she placed a piece of gauze in R3’s hand since she could not find the protector. LPN-B stated R3 should have at least two palmar protectors so he would have one available while they washed the other one, and that one should be on at all times. During observation on 8/6/25 at 9:14 a.m., NA-B and NA-C wheeled R3 back to room in shower chair. R3 was transferred back to bed. NA-B and NA-C dried R3, placed a new brief, and donned a new gown. NA-B left the room while NA-C finished performing morning cares on R3. NA-C applied body lotion, but did not perform any ROM. The palm protector that NA-B found earlier remained on top of R3’s nightstand and was not applied. NA-C left the room. During observation and interview on 8/6/25 at 10:37 a.m., LPN-A into R3’s room to apply face cream and done a neck brace. LPN-A also placed R3’s palm protector on right hand by prying open each of R3’s fingers and actively wrap R3’s hand around it. LPN-A stated sometimes R3 would not have the palm protector in place because he would sometimes remove the palm protector himself. LPN-A stated the palm protector was to prevent skin breakdown on R3’s palm and to prevent the contracture from getting worse. During observation on 8/6/25 at 1:34 p.m., LPN-B and NA-C in R3’s room providing cares. No ROM observed. During observation on 8/7/25 at 8:16 a.m., R3 was awake lying in bed in room. R3 had the palm protector on and did show evidence of rejecting the splint or trying to remove it. During interview on 8/7/25 at 8:26 a.m., registered nurse (RN)-A stated R3 should receive ROM on arm and hands daily and should have his hand guard on all the time. During interview on 8/7/25 at 8:31 a.m., LPN-B stated would expect R3 to receive ROM twice a day as ordered and to have the palmar grip on all the time. During interview on 8/7/25 at 8:59 a.m., physical therapist (PT)-A stated would expect restorative nursing orders to be carried our as written. PT-A stated continuous refusal, or noncompliance should be communicated to therapy and a new assessment could be completed to determine if the ROM and/or the protector was still appropriate. During interview on 8/7/25 at 9:08 a.m., occupational therapist (OT)-A would expect [NAME] guard on for skin protection if ordered and would expect ROM to be completed as ordered or recommended. OT-A stated the goal of long term care restorative nursing was to maximize the functioning yet understood that as residents approached end of life, they were allowed to refuse treatment or services. During interview on 8/7/25 at 9:48 a.m., director of nursing (DON) stated expectation for ROM to be completed as ordered for R3 and that a palm protector would be on at all times. DON stated if staff were unable to locate the palm protector, she would expect to be notified so a replacement could be ordered. DON further stated if a resident always continuously refused or rejected care, that would be documented and communicated to therapy so they could re-evaluate the need for treatment. Facility policy requested but not received. Per email received on 8/7/25 at 10:30 a.m., “Related to ROM/maintenance policy, we also do not have one. Each program is individualized for the resident, and we would follow therapies recommendations related to that resident.” R35’s Optional State Assessment (OSA) dated 7/15/25, indicated intact cognition, did not have behaviors, and did not reject cares. Additionally, R35 required extensive assistance with bed mobility, toileting, and was dependent on staff for transfers. R35’s quarterly Minimum Data Set (MDS) dated [DATE], indicated an impairment in range of motion to one side on the upper and lower extremities. R35’s medical Diagnosis form indicated the following diagnoses: discitis unspecified lumbosacral region (inflammation of discs in the spine), other paralytic syndrome following unspecified cerebrovascular disease bilaterally (both sides), hemiplegia (paralysis on one side of the body), major depressive disorder, and chronic pain syndrome. R35’s physician orders saved 8/5/25 at 12:07 p.m., lacked orders resident was on a range of motion program. R35’s care sheet dated 8/2025, indicated R35 required assist of 1 with dressing, grooming, oral cares, and bathing. The care sheet lacked information R35 was on any type of range of motion program or that R35 had a contracture. R35's care sheet updated on 8/5/25, lacked evidence R35 was on any type of range of motion program or that R35 had a contracture. R35’s care plan revised on 8/5/25, indicated R35 had an alteration in mobility related to a history of stroke with paraparesis and pain. Interventions indicated R35 required encouragement to perform bilateral lower extremity and right-hand range of motion to prevent further contracture and assist as needed. Further, interventions indicated to follow handouts in the closet door. All physical therapy (PT) and OT evaluations and progress notes were requested on 8/7/25 at 1:30 p.m. The following notes were provided: R35’s occupational therapy (OT) evaluation and plan of treatment form dated 4/22/22, indicated R35 had an evaluation only and reached a plateau and utilized a Hoyer lift. R35’s right and left upper extremity range of motion was within functional limits and there were no functional limitations were present due to contractures. The notes lacked information a range of motion program was recommended or initiated, or that R35 refused a ROM program. R35’s OT evaluation and plan of treatment form dated 8/26/22, indicated a referral was made due to wheelchair seating and positioning. R35’s assessment indicated right upper extremity range of motion was within normal limits, and the left upper extremity range of motion was impaired. Further, left upper extremity range of motion to the shoulder, wrist, and forearm was impaired OT did not try range of motion to the left upper extremity hand. Further, no functional limitations were present due to contractures. Additionally, R35 could not propel the wheelchair due to a flaccid left upper extremity due to a stroke. The notes lacked information a range of motion program was recommended or initiated, or that R35 refused a ROM program. R35’s OT evaluation and plan of treatment form dated 10/9/25 through 11/7/24, indicated nursing reported an ill-fitting wheelchair and was referred for wheelchair positioning. Further, R35’s right and left upper extremity range of motion was within functional limits and did not have functional limitations [NAME] to a contracture. The notes lacked information a range of motion program was recommended or initiated, or that R35 refused a ROM program. R35’s OT evaluation and plan of treatment form dated 5/2/25 to 5/31/25, indicated R35’s back rest was uneven due to a broken piston. Further, R35’s right and left upper extremity range of motions was within functional limits and did not have functional limitations due to contractures. Additionally, adjustments to current wheelchair were beyond the scope of OT, but R35 would require additional services to assess and correct positioning after repairs are made. The notes lacked information a ROM program was recommended or initiated, or that R35 refused a ROM program. R35’s OT evaluation and plan of treatment forms from 4/22/22, to 5/31/25, lacked information R35 refused treatments. An OT evaluation and plan of treatment form dated 8/6/25, and completed by OT-B, indicated R35 was referred to therapy by staff for bilateral hand contractures R35 had previously refused range of motion or splinting to address the issue and would benefit from skilled OT to assess bilateral upper contractures and develop passive range of motion (PROM) to maintain function. Further no contraindications were present. R35’s evaluation indicated R35’s ROM to index finger had a resting contracture, and middle, ring, and little finger was impaired. Further, R35’s left upper extremity ROM indicated the index and ring finger was impaired. Further, functional limitations were not present due to a contracture. R35’s PT (physical therapy) evaluation and plan of treatment notes dated 4/22/22, indicated R35 had functional limitation present due to contractures of both ankles and had PRAFO boots and PT was not treating contracture however nursing managed the contracture with the PRAFO boots. The form lacked information regarding R35’s upper extremities. R35’s PT evaluation and treatment plan dated 9/13/22 to 10/12/22, indicated nursing managed R35’s contractures with an AFO (foot and ankle brace) for bilateral lower extremities that were worn daily. The form lacked information regarding R35’s upper extremities. R35’s PT progress report forms dated 9/13/22 to 9/27/22, were reviewed and lacked information PT addressed upper extremity ROM or whether R35 had contractures to upper extremities. R35’s PT evaluation and treatment plan form dated 11/15/23, indicated R35 was referred to therapy for strengthening and assessment for an upgrade in transfers. R35 had PRAFO boots for contracture management by nursing staff and the contractures were too advanced that standing and ambulation was not realistic and was at maximum potential. The form lacked information regarding R35’s upper extremities. R35’s PT evaluation and treatment plan form dated 10/11/24, indicated R35 was referred for a PT evaluation and treatment and prior functioning indicated R35 required a Hoyer lift for transfers and nursing managed R35’s bilateral ankle contractures with PRAFO boots. The notes lacked information regarding R35’s upper extremities. R35’s progress notes were reviewed from 4/21/22, to 8/6/25, and lacked evidence R35 refused a passive range of motion (PROM) program, until 8/6/25 at 12:26 p.m., when a therapy note was entered indicating R35 was assessed for bilateral contractures by OT and acknowledged previous refusals to develop a PROM program but was now willing to participate and design a PROM program and further education to nursing and to aides on administration to promote maximal function. R35’s nurse practitioner (NP) notes dated 5/23/24, 5/28/24, 5/29/24, 8/9/24, 9/26/24, 12/2/24, 1/1/25, 1/9/25, 1/16/25, 1/23/25, 3/5/25, 3/19/25, 4/17/25, 6/9/25, 6/25/25, and 8/6/25, indicated R35 had contractures to his left-hand fingers. During interview and observation on 8/4/25 at 2:59 p.m., R35 stated sometimes staff did exercises. R35 could not open his left-hand ring finger and 5th digit (pinky). R35 did not have a splint or brace on his left hand. During interview on 8/5/25 at 2:54 p.m., R35 stated he could not move his left hand much and wanted help with that. R35 could not bend his left pointer finger and could not straighten his left ring finger and stated he had this prior to coming to the facility. During interview on 8/5/25 at 1:08 p.m., nursing assistant (NA)-A stated they used a care plan and followed what was on the Kardex in order to know what cares a resident required and stated if a resident required ROM, it would be on their care plan and if a resident refused, they let the nurse know and refusals were documented in the computer. NA-A stated most of the time, R35 did not refuse cares and stated she did not see R35 had any ROM for his hands and stated ROM was on their care sheet. R35 pulled out a care sheet and stated R35 was not on her group but could ask the nurse. During interview on 8/5/25 at 1:14 p.m., NA-F stated they looked at their care plan to know who had ROM and further stated pictures showed what to do up to patient tolerance for ROM. NA-F verified R35 did not have ROM instruction in his room and was not located inside or outside R35’s closet. NA-F stated he just set down his care sheet and did not have the care sheet. During interview on 8/5/25 at 1:27 p.m., OT-B ROM was largely based on diagnosis at evaluation and if a resident had impaired muscle function would require passive or active ROM. (passive ROM is when someone else moves the limb, active ROM is when the patient moves the limb) and further stated residents who had a stroke could have ROM to possibly regain function. OT-B stated both PT and OT completed ROM, but if it was for the upper body, OT completed ROM and PT completed the lower body ROM. OT-B stated last time he saw R35 was in May 2025, for a wheelchair issue and in October to November 2024 saw R35 and stated he was very nice and was not resistant to therapy and was willing to participate and did not recall R35 having any contractures and stated R35 had paralytic syndrome, cerebrovascular disease and discitis and did not see anything about upper body ROM in the notes. OT-B viewed R35’s notes and stated he had not seen a need for ROM for R35’s upper extremities. OT-B further stated instructions for therapy would be posted in a resident’s room. During interview on 8/5/25 at 2:31 p.m., physical therapist (PT)-A stated OT handled upper body ROM and sometimes if PT saw a resident, would incorporate upper body in their plans. PT-A stated residents who required ROM included those with a diagnosis of hemiplegia and some residents came in with baseline contractures and would work on preventing the contractures from getting worse. PT-A further stated contractures were painful and viewed therapy notes and verified R35 did not have any PROM but had PRAFO boots and thought R35 had a home exercise program for his legs and verified R35 did not have any documentation for upper body ROM and verified there was no home exercise program for R35’s upper body and did not know if R35 had contractures to his upper body adding their last evaluations didn’t identify upper body contractures. During interview on 8/5/25 at 2:58 p.m., NA-E stated he knew what cares a resident required based on the care plan and further stated R35 never refused cares and added if a resident refused, they documented in the chart and the nurses documented refusals. NA-E stated had not seen a hand brace for R35 and stated they used them to make sure a resident’s hand didn’t close. During interview on 8/5/25 at 3:09 p.m., licensed practical nurse (LPN)-D stated she knew what cares a resident required by looking at the care plan and refusals were documented in progress notes. LPN-D stated therapy instructs staff how to complete ROM and either the nurses or the aides complete ROM, if the nurse completes ROM, it shows up on the medication administration record (MAR) and treatment administration record (TAR) and further stated there is an order for ROM if nursing completes ROM. LPN-D stated she did not think R35 was on a therapy program. LPN-D viewed R35’s orders and verified there were no orders for a ROM program and further, reviewed R35’s care plan and verified R35’s care plan indicated to follow PT and OT for mobility but lacked any instruction and verified there was no ROM care plan in R35’s chart. LPN-D stated R35 was alert and oriented and stated R35 was so contracted. LPN-D stated all the care plan indicated was to follow instructions and that it was from 2022 and did not know where the instructions were. LPN-D further stated R35 had a contracture on his left hand that was present when LPN-D started working at the facility and added R35 may need something for his hand and had not seen a brace for R35 and added normally they put a brace on to keep the hand from closing. During interview on 8/5/25 at 3:30 p.m., LPN-B stated she supervised the floor and further ROM exercises would be on a care guide and the nurses make sure aides perform the ROM, and the ROM was on a nursing order. LPN-B stated if a resident had a contracture, she expected a resident to have something in place such as home exercises because they want to maintain functioning and if a program was recommended and the resident refused, it was documented in a progress note. LPN-B stated R35 had paralysis on one side and stated R35 had a contracture on the left hand and viewed the care sheet and verified there was no direction for ROM for R35’s extremities on the care sheet. LPN-B viewed R35’s care plan and verified the care plan lacked ROM interventions. LPN-B further stated R35’s risks for contractures included having discitis, paralytic syndrome, hemiplegia and chronic pain and expected R35 have a cushion to prevent his hand from closing. LPN-B viewed nursing assistants Task forms and verified the NA’s did not have ROM on a Task for documenting. During interview on 8/7/25 at 10:55 a.m., the director of nursing stated therapy completed screening but was not sure how frequently. Further, the DON stated contractures were documented in the care plan and the physicians should have documentation in their notes as well as treatment orders. If a resident refuses treatment orders, it was documented in a progress note. The DON stated she thought R35 had a home program. The DON further stated they hadn’t had ROM programs at the facility and completed a sweep and provided ROM programs if residents had a contracture to maintain and improve abilities and further stated they put exercises in residents’ rooms in the closets or by the bed if a resident approved. The DON stated she recognized they were working out the kinks. R35’s physician’s orders form saved 8/7/25, at 8:03 a.m., was later updated to include the following orders: 8/6/25, ROM: thumb: 1. Flexion and extension (thumb bending and straightening, 2. Abduction and adduction see detailed instructions in resident closet or restorative binder. 8/6/25, ROM fingers 1) flexion and extension (finger bending and straightening), 2) abduction and adduction finger spreading, see detailed instructions in resident closet or restorative binder. 8/6/25, home exercise program daily seated in chair, kick, straighten operated leg and try to hold it for 3 seconds. Repeat 20 times, 1 to 2 times per day. 8/6/25, home exercise program daily seated in chair 8 leg out to the side, sitting straight, move legs slowly apart, then together again. Do one leg at a time. Repeat 20 times, one to two times a day. 8/6/25, home exercise program daily seated in the chair pillow squeeze, place one pillow under and one between knees. Squeeze knees together while straightening them by pushing down into the pillow, hold for 5 seconds. Repeat 20 times one to two times a day. 8/6/25, home exercise program daily, seated in chair, march, bring knee up toward chest, repeat with the other leg to complete the set. Repeat 20 times one to two times a day. 8/6/25, home exercise program daily supine, slide foot up, bend knee and pull heel toward buttocks. Hold three seconds. Return and repeat with the other knee to complete the set. Repeat 20 times once daily. 8/6/25, home exercise program daily supine straight leg raise, bend one leg, raise other leg 6 to 8 inches with knee locked. Exhale and tighten thigh muscles while raising the leg. Repeat using the other leg. Repeat 20 times once daily. 8/6/25, home exercise program daily supine push knee into the bed, slowly tighten muscles on thigh of straight leg while counting out loud to 10. Repeat 20 times once daily. 8/6/25, home exercise program daily supine butt squeezes squeeze buttocks muscles as tightly as possible while counting out loud to 10. Repeat 20 times once daily. 8/6/25, home exercise program daily to bilateral lower extremities supine leg out to the side slide one leg out to the side. Keep the kneecap pointing toward the ceiling and gently bring leg back to the pillow and repeat with the other leg to complete the set. Repeat the set 20 times, once daily. A PDF document signed by OT-B on 8/7/25, was later provided by the facility on 8/7/25, at 1:19 p.m., that indicated R35 was previously evaluated for wheelchair placement and positioning in the fall of 2022 and the fall of 2025 and had resting contractures at both evaluations, but had no complaints of pain with functional ROM and refused a ROM program or splinting and was not appropriate for splinting as reversal of his contractures was unlikely and would not contribute for increased activity of daily living (ADL) performance.

Based on observation, interview, and record review, the facility failed to ensure a scheduled pain medication was available as ordered for 1 of 1 resident (R102) reviewed for pain. Findings include:R102's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required partial to moderate assistance with toileting hygiene, supervision with upper and lower body dressing and set up assist with personal hygiene. Further, R102's active diagnoses included: amputation, diabetes mellitus, acquired absence of left leg below the knee, and cutaneous abscess of limb. Additionally, R102 had scheduled pain medication, as needed pain medications, did not receive non medication interventions, had occasional pain during the last 5 days, that occasionally affected sleep, interfered with therapy activities, day to day activities and had a numerical rating of a 4 out of 10 on a 0 to 10 pain scale. R102 had a surgical wound and required surgical wound care and took opioid medications.R102's pain care area assessment 7/13/25, indicated pain would be addressed in the care plan to avoid complications and minimize risks. Further, medications and treatments were in accordance with the physician or nurse practitioner (NP) order and the floor nurse was to update the provider on any changes in pain complaints as needed and staff were directed to observe resident for non-verbal signs of pain with examples given of facial grimacing or guarding.R102's care plan dated 11/11/24, indicated R102 had an alteration in comfort due to recent left below the knee amputation (BKA) and interventions indicated completing a pain assessment per protocol, providing non medicinal forms of pain such as positioning, rest, massage, providing pain medication as ordered by the physician, documenting on the effectiveness of the pain medication, encouraging resident to verbalize discomfort, monitor for verbal and nonverbal indicators of discomfort, and further resident would be interviewed to determine acceptable level of pain control and contact the provider when pain level was not acceptable. R102's care plan dated 8/6/25, indicated R102 had an alteration in skin integrity due to left lower extremity BKA and interventions included R102 preferred to do his own dressing on his own pace due to pain, NPWT (negative pressure wound therapy, a treatment that uses controlled suction to promote healing in slow healing or non-healing wounds): Suction -125 on left BKA.R102's Pain Evaluation form dated 7/7/25 at 10:56 a.m., indicated R102 had occasional pain in the last 5 days that occasionally affected sleep, therapy activities, day to day activities and rated his worst pain over the last 5 days as a 4 on a 0-10-point scale. R102 stated pain was mild. Further, R102 was on a Butrans transdermal patch (a long-acting opioid) weekly 10 mcg/hr (micrograms/hour) every Tuesday, along with methocarbamol (a muscle relaxant) 500 milligrams (MG) three times, pregabalin (a medication to treat nerve pain) 100 mg three times a day and a Lidocaine patch 4% (a medication to treat pain) once daily. Additionally, R102 received oxycodone (an opioid) 10 mg every three hours as needed and acetaminophen (Tylenol) 1000 mg every 8 hours as needed. The evaluation indicated R102's pain was controlled with scheduled and PRN (as needed) pain medication and the pain regimen was effective. No other pain evaluation forms were completed after 7/7/25. R102's Physician's Orders form indicated the following orders related to pain:2/12/24, non-pharmacological pain interventions: 0=no intervention, 1=ice, 2=heated blankets, 3=massage, 4=repositioning, 5=music, 6=essential oils, 7=food and drink, 8=relaxation breathing.7/1/25, Lidocaine external patch 4% apply to BKA left lower extremity topically one time a day for pain 12 hours on and 12 hours free and remove per schedule.7/30/25, Acetaminophen (Tylenol) 1000 mg by mouth three times a day for pain.6/30/25, Methocarbamol (a muscle relaxant brand name Robaxin) oral tablet, give 500 mg by mouth three times a day for pain.7/25/25, hold from 7/25/25 to 7/26/25 and discontinue on 8/6/25 at 11:40 a.m., Pregabalin oral capsule 150 mg give 150 mg by mouth three times a day for pain related to complete traumatic amputation of left lower leg.8/6/25, Pregabalin oral capsule 150 mg by mouth three times a day for pain.-Oxycodone (opioid)7/1/25, and discontinued on 7/18/25, oxycodone 10 mg tablet, give 10 mg by mouth every 3 hours as needed for severe pain. 7/18/25, and discontinued on 7/25/25, oxycodone 5 mg tablet, give 10 mg by mouth every 3 hours as needed for pain, do not use 10 mg tablet, give two tablets a maximum of 5 doses per day (50mg/day).7/25/25, and discontinued on 7/30/25, oxycodone 5 mg tablets, give 10 mg by mouth every 3 hours as needed for pain a maximum of 5 doses per day (50 mg/day).7/30/25, and discontinued on 8/6/25 at 11:42 a.m., oxycodone 5 mg tablets, give 15 mg every 4 hours as needed for pain for a maximum of 3 doses per day (45mg/day).8/6/25, Oxycodone 5 mg tablets, give 15 mg every 4 hours as needed for pain. -Butrans7/1/25, and discontinued on 7/18/25, Butrans transdermal patch weekly 10 mcg/hr apply 1 patch transdermally one time a day every Tuesday for pain and remove per schedule. 7/22/25, and discontinued on 7/25/25, Butrans transdermal patch weekly 15 mcg/hr apply 1 patch transdermally one time a day every Tuesday for pain and remove per schedule.7/29/25, and discontinued on 8/5/25 at 9:16 a.m., Butrans transdermal patch weekly 15 mcg/hr apply 1 patch transdermally one time a day every Tuesday for pain and remove per schedule. 8/6/25, and discontinued on 8/6/25 at 11:40 a.m., Butrans transdermal patch weekly 15 mcg/hr apply 1 patch transdermally one time a day every Wednesday for pain and remove per schedule.8/13/25, Butrans transdermal patch weekly 15 mcg/hr apply 1 patch transdermally one time a day every Wednesday for pain and remove per schedule.R102's medication administration record (MAR) and treatment administration record (TAR) dated July 2025 indicated R102 utilized as needed oxycodone as follows:7/1/25, and discontinued on 7/18/25, oxycodone 10 mg tablet, give 10 mg by mouth every 3 hours as needed for severe pain. R102 utilized 40 doses.7/18/25, and discontinued on 7/25/25, oxycodone 5 mg tablet, give 10 mg by mouth every 3 hours as needed for pain, do not use 10 mg tablet, give two tablets a maximum of 5 doses per day (50mg/day). R102 utilized 14 doses.7/25/25, and discontinued on 7/30/25, oxycodone 5 mg tablets, give 10 mg by mouth every 3 hours as needed for pain a maximum of 5 doses per day (50 mg/day). R102 utilized 10 doses.7/30/25, and discontinued on 8/6/25 at 11:42 a.m., oxycodone 5 mg tablets, give 15 mg every 4 hours as needed for pain for a maximum of 3 doses per day (45mg/day). R102 utilized 3 doses.R102's MAR and TAR dated August 2025 indicated R102 was to have a new Butrans transdermal patch applied on 8/5/25 at 8:00 a.m., and a 9 was documented on the MAR for 8:00 a.m. indicating Other/See Nurse Notes. R102's progress notes dated 8/5/25 at 9:15 a.m., indicated R102's Butrans patch was unavailable, and the nurse manager called the pharmacy to get the patch delivered and the pharmacy stated they would deliver on their run that evening. Further the note indicated the order would be rescheduled for the following a.m. shift. R102's provider encounter note dated 7/31/25, indicated R102 had a pain management team involved due to difficult to control pain at the BKA site and R102 reported severe leg pain. R102's nursing home visit note dated 8/6/25, at 1:52 p.m., indicated R102's chief complaint was left BKA site pain. R102 was in the hall and a phone interpreter was used during the visit. R102 reported having pain every morning and the pain decreases about 12:00 p.m. The note indicated R102's oxycodone was increased at the last visit and R102 could feel a difference and reported feeling stable on his current pain regimen. R102 had mild to moderate pain in his left leg. R102's oxycodone 5 mg tablets 3 tablets three times a day were renewed along with the Butrans 15 mcg 1 patch every week and was filled on 8/6/25.During interview and observation on 8/4/25 at 5:34 p.m., R102 stated he had pain at night when viewing pain on his communication sheets. During interview and observation on 8/5/25 at 8:39 a.m., registered nursing (RN)-C prepared R102's medications, except for R102's Butrans 15 mcg/hour patch and stated the medication was on order and was not in the medication cart after looking for the patch. Licensed practical nurse (LPN)-E asked RN-C if she checked the other medication cart and LPN-E checked the medication cart and stated they didn't have it, and it should be there. LPN-E stated they would call the pharmacy and ask for an immediate order and added the patch was applied every 7 days. LPN-E stated the medication should be at the facility but might be on back order and added sometimes the pharmacy delivers and they switch the patch to p.m.'s or if there is no order, call the pain provider to write a new order and send the prescription. LPN-E stated the patch was not a medication they had in stock and did not have an emergency kit with the medication either. During interview on 8/5/25 at 8:50 a.m., RN-C stated R102 last had the Butrans patch administered on 7/29/25, on his right shoulder and added the pharmacy usually provided one or two patches at a time. The narcotic book indicated there were 0 patches left on 7/15/25. On 7/22/25, R102 had 2 patches on hand, and one was used and R102 had one left. Then on 7/29/25, R102 had 1 patch left and after the patch was administered, had no patches remaining.During interview on 8/5/25 at 9:07 a.m., when asked how R102 was, R102 shook his head no and pointed to his leg amputation site and made a fist opening and closing his fist. During interview on 8/6/25 at 9:05 a.m., R102 was grabbing at his amputation site and when asked how he was stated, no good. During interview with R102 and the interpreter on 8/6/25 at 9:12 a.m., R102 stated he had a lot of pain and pain medications helped but when the effects passed pain built up again and stated he was more uncomfortable when his dressing was changed. During interview on 8/7/25 at 11:10 a.m., the director of nursing stated medication orders were faxed to the pharmacy and the medications were sent to the facility twice daily. Some medications are on back order or prior authorization is needed. If a medication is not available, they ask the pharmacy to send the medication on the next run. The DON further stated Butrans was a medication used to treat pain and stated if a patch was due to be changed, the patch should be available in the medication cart and stated when staff apply the last patch, they need to contact the provider so they don't run out and further stated she knew medications weren't always available on the cart and has seen this happen. The DON further stated R102 had an amputation, had severe pain and literally cried with pain and were supposed to premedicate for the NPWT and the Butrans was more of a steady medication. The DON stated R102 had pain when rubbing the amputation site and viewed R102's MAR and verified the Butrans wasn't administered as ordered on 8/5/25, and stated she expected the patch to be administered when it was ordered. A policy on medication ordering and pain management was requested. During interview on 8/7/25 at 11:26 a.m., the administrative tech at Polaris pharmacy (AT)-F stated they received a prescription on 8/6/25, and sent four patches. Additionally, two patches were sent on 8/5/25, and prior to that, a script was sent on 7/18/25, for two patches that went out on 7/18/25, and stated the Butrans wasn't requested again until 8/5/25, and added a script was sent on 7/25/25, and may have been too soon to send additional patches. During interview on 8/7/25 at 11:32 a.m., Polaris pharmacist, (P)-G stated Butrans was a once weekly patch applied every week and the medication was slowly released depending on the dose every hour for chronic pain and was used when other pain medications don't work, or don't get good relief with other tablets. Further, P-G stated patients who don't receive the patch as ordered may experience pain.A progress note was later added dated 8/7/25 at 2:22 p.m., that indicated the provider was updated and was ok with rescheduling R102's Butrans patch to Wednesday a.m. shift and R102's pain would be controlled with PRN pain medication and R102's PRN pain medication dose was recently increased to accommodate the pain control.A policy, Pain Management Protocol, dated 3/23/23, indicated residents with pain or at risk for pain, have an effective pain management plan in place. The provider will order appropriate medication interventions to address individuals' pain. The policy further indicated, if the prescribed medications are not available or there is a delay in obtaining the medication, the provider will be notified, and alternative medications or interventions will be obtained to meet the resident's pain management needs. Resident and or the resident representative will be updated.

Based on interview, and document review, the facility failed to ensure ongoing communication and collaboration with dialysis services for 1 of 1 resident (R138) who had a critically low hemoglobin. Findings include:See also F684: R138's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have behaviors or reject care, had a wheelchair for mobility, required substantial assistance with dressing, toileting hygiene, and personal hygiene, had anemia (low hemoglobin or HGB), end-stage renal disease (ESRD), a coagulation defect (a bleeding disorder affecting the blood's ability to clot), and thrombocytopenia (a condition of a low platelet count in the blood which can lead to increased bleeding and bruising). Further, R138 was on dialysis. R138's Physician's Orders form indicated the following orders:7/16/25, dialysis every Monday, Wednesday, and Friday. 8/5/25, lab CBC (complete blood count which includes an HGB), CMP, Mg, PTH, CRP, INR (a blood test that indicates how well the blood can clot), Phosphorus on 8/5/25. R138's hospital discharge orders dated 7/27/25, indicated a CBC, INR, and CMP was recommended on 7/30/25.R138's care plan dated 7/14/25, indicated R138 was at risk for complications related to dialysis and interventions included to call the physician if any changes in the dialysis port line, fistula to left forearm, excess bleeding, notify dialysis of any concerns, send communication folder to dialysis with each run. R138's labs collected on 8/5/25 at 6:05 p.m., with a fax time stamp at the top of the form dated 8/5/25 at 8:53 p.m., indicated the following:HGB 6.7 (LL) and the normal reference range was 13.5 to 17.5 g/dl (grams per deciliter). Platelets (platelets are essential for blood clotting) 78 (L) and the normal reference range was 150 to 450 x 10(9)L. A legend at the bottom of the lab form indicated an (LL) was a critically low lab value and an (L) value was a low lab value. Further, the lab result form contained an illegible signature.R138's labs collected on 8/5/25 at 6:55 p.m., with a fax time stamp at the top of the form dated 8/5/25 at 9:33 p.m., indicated the following:INR: 3.2 (H) with a reference range of 0.9 to 1.1. The legend at the bottom of the lab form indicated an (H) was a high level. Further, the lab result form contained an illegible signature.R138's nurse practitioner (NP)-E notes dated 8/4/25 at 2:25 p.m., indicated on 7/29/25, R138 had chronic, stable anemia of chronic disease and required multiple transfusions during hospitalization with no signs of bleeding. The note further indicated to check HGB as soon as possible (lab can't come until tomorrow), and discussed low HGB during dialysis can cause aches due to blood pull off and if abdominal pain is severe before work up can be completed by lab, can discuss hospitalization for uncontrolled pain and suspected symptomatic anemia. Additionally, the note indicated R138 received 2 units of packed red blood cells the week of 7/20 and R138's HGB at the time of discharge was 7.8. NP-E indicated R138 was visibly uncomfortable due to lower abdominal pain and was concerned about symptomatic anemia and R138's code status was a full code and was unclear what R138's baseline HGB was but, the note indicated R138's HGB was stable at 7 to 8 now.R138's hospital history and physical note dated 8/6/25, indicated R138 presented with abdominal pain with abdominal wall cellulitis, possible cholecystitis, and chronic normocytic anemia with a HGB of 7.2 and further indicated the HGB was stable from baseline of 7-8 g/dl range. R138's progress notes dated 7/21/25 at 10:46 p.m., indicated R138 was transferred to the hospital with a HGB of 6.3. R138's progress notes were reviewed from 8/5/25, and lacked evidence dialysis staff or the provider were notified of R138's critically low HGB. During interview on 8/6/25 at 12:46 p.m., nursing assistant (NA)-H stated R138's wheelchair came back from dialysis, but he thought R138 went to the hospital because the chair came back but R138 did not. During interview on 8/6/25 at 12:51 p.m., with the dialysis registered nurse (RN)-D stated they sent R138 to the hospital from dialysis due to confusion following dialysis and due to an issue with R138's skin on his abdomen and stated she had not been informed by the facility of any declining health and had not received a report from the facility. RN-D stated per dialysis policy, if a HGB is 7 or below, the patient needs to go to the emergency room for a blood transfusion and further stated she did not receive a report on R138's HGB and stated the facility should have called the provider. During interview on 8/6/25 at 1:58 p.m., RN-E stated the lab calls to inform of a critical lab and then staff are supposed to call the provider right away. If a lab is not critical staff fax the provider. Further, RN-E stated if they receive a lab it was documented in the electronic medical record (EMR). RN-E viewed R138's labs and verified R138's HGB was low and stated LL meant the HGB was low and added maybe the lab was low from the previous lab. RN-E verified a lab value of LL indicated it was critically low and opened NP-E's note dated 8/4/25, that indicated R138's HGB was 7.8 on 7/26/25, and verified R138's HGB on 8/5/25, was 6.7 and stated she had to check the progress notes. RN-E verified the progress notes lacked evidence the physician was called and stated a HGB of 6.7 was a critical lab and stated the nurse should have called the provider. During interview on 8/6/25 at 2:32 p.m., LPN-E stated she had not heard the results of R138's labs from 8/5/25. LPN-E stated staff observe the lab results and call the provider right away when a lab was critical versus faxing and was documented in a progress note and stated the HGB result should have been called to the provider already. LPN-E asked RN-E if RN-E was informed of the critical lab and RN-E stated she had not been informed and LPN-E stated staff had not been informed because there was no progress note.During interview on 8/6/25 at 2:35 p.m., with the director of nursing (DON) and LPN-E, LPN-E verified RN-F signed R138's lab form. The DON stated the NP should have been notified immediately and would have expected dialysis be updated as well. During interview on 8/6/25 at 2:39 p.m., RN-F stated he worked on the evening of 8/5/25, and viewed R138's lab results, however, did not call the provider. During interview on 8/7/25 at 8:58 a.m., RN-D stated dialysis sent R138 to the hospital at approximately 11:45 a.m., on 8/6/25 and further stated dialysis absolutely needs to be informed of a critically low HGB because when a resident is on treatment for dialysis, 250 milliliters (ML) of blood is not in their body at any given time because it is going through an artificial kidney and they cannot treat people when their HGB is low because their HGB can drop lower and can be a big reason to send someone to the emergency room. Their HGB needs to be higher than 7 because they are taking blood out of a person's body to clean it. RN-D further stated dialysis was not aware of R138's critically low HGB and further stated dialysis also draws labs, but the labs are not seen right away.During interview on 8/7/25 at 10:43 a.m., the DON stated R138's baseline HGB on follow up notes were 7 to 7.2 and further stated RN-F was suspended and added the lab always called when there was a critical lab and RN-F did not receive a call and assumed everything was ok, however the DON expected if a nurse put a signature on a lab form, they had to review it and still expected if a nurse placed their name on something they had to look at what the report indicated and further stated they conducted house-wide education and added, the lab didn't do their part, but that didn't excuse the nurse from doing their part. The DON further stated dialysis obtained labs, but the facility should have given the dialysis staff a heads up. Updates from the facility to the dialysis center on 8/6/25, were requested on 8/7/25 at 1:30 p.m., however no additional information was provided. A policy, Dialysis, dated 5/2003, indicated residents will receive safe administration of hemodialysis, in a certified dialysis facility from qualified staff, the facility staff and the dialysis center will have ongoing communication and collaboration regarding dialysis care and services. The facility will collaborate with the dialysis unit to create an individualized emergency protocol based upon the resident's dialysis access device and other care needs. The facility will complete emergency procedures, as indicated, per dialysis protocol and recommendations i.e. clamping a cut catheter, applying pressure to an access site, and or calling dialysis unit/nephrologist, primary provider, or 911. Communication shared between the facility and dialysis provider can include, but is not limited to, the resident's response to the dialysis treatment, medications administered, labs drawn and their results, the resident's end weight, changes in condition or mood, and evaluation of the access site.

Based on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were available for 1 of 1 resident (R3) reviewed for activities. Findings include:R3's annual Minimum Data Set (MDS) dated [DATE], indicated R3 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). Preferences for routine and activities was not assessed. R3's MDS indicated R3 had zero minutes of recreational therapy (to include recreational and music therapy) in the lookback period. R3's diagnoses include hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction affecting right dominant side, dementia, contracture of muscle, aphasia (conditioning affecting speech) and depression. R3's care plan (CP) dated 7/8/25, indicated R3 spoke Vietnamese, Cantonese, and some English. In his free time, he enjoys watching TV-especially Chinese dramas, listening to Vietnamese music, and watching movies. The CP further indicated, Resident has a smart TV so he can watch TV and listen to music in his language. This is his favorite thing to do. R3's physician order dated 12/13/24, indicated, Non-pharmacologic interventions offered to relieve pain: 1. Music 2. Redirection 3. Reposition.Document which # intervention was used.In addition, R3's order dated 12/13/24, indicated, Ensure resident is in the dining room for lunch and dinner. R3's Activity/Leisure Time task report dated 7/1/25 through 7/31/25, indicated the following: -TV in room/group-11 times-Looking out the window/music/time spent in room-independent-9 times R3's Activity/Leisure Time task report dated 8/1/25 through 8/5/25, indicated the following:-TV in room/group on 8/2, 8/4, and 8/5. -Looking out the window/music/time spent in room-independent on 8/4. During observation on 8/4/25 at 1:36 p.m., R3 was in room in Broda-type wheelchair in middle of the room facing the wall opposite his TV. The TV had a purple screen indicating, we are having difficulty connecting. R3 was not facing the window. During interview 8/4/25 at 4:24 p.m., family member (FM)-A stated expectation for staff to take R3 out to the common area 2-3 hours each day. FM-A also stated R3 liked to be next to the window so he could look outside and that R3 also enjoyed watching TV or listening to Vietnamese music in his room. During observation on 8/5/25 at 8:29 a.m., R3 lying in bed awake by window. TV was on a dresser at the foot of the bed. The TV was on with the purple screen still displaying, we are having difficulty connecting on the screen. During observation on 8/5/25 at 1:21 p.m., R3 sitting up in wheelchair in room awake in the middle of the room. The room was quiet and the TV still showing the no connection message. During observation on 8/5/25 at 1:37 p.m., an activity with a movie, music and nail care in the common area on the first floor. R3 was not in attendance. During observation on 8/5/25 at 3:03 p.m., R3 was lying in bed awake. The room was quiet, and the TV still displayed the no connection message. During observation on 8/5/25 at 3:16 p.m., licensed practical nurse (LPN)-B was in R3's room assisting with reposition. Replaced called and left the room. LPN-B did not address the TV or lack of music. During observation on 8/6/25 at 7:23 a.m., R3 was lying in bed awake with the TV on still displaying the no connection message. Nursing Assistant (NA)-C performed cares on R3's roommate and left the room. NA-C did not address the TV or lack of music. During observation on 8/6/25 at 8:38 a.m., LPN-B, NA-B and NA-C in to perform morning cares and get R3 up for a shower. R3's window blinds were closed for privacy during cares. R3 moaned during cares and transfer. During observation on 8/6/25 at 9:14 a.m., R3 was wheeled back to his room after the shower, dressed in a new gown and transferred back to bed by NA-B and NA-C. R3's window blinds were still closed and the TV displaying the same message. During observation on 8/6/25 at 9:36 a.m., LPN-A in R3's room to administer medications via G-tube (gastronomy tube). LPN-A placed medications and other supplies on top of the dresser where the TV sat. R3 moaned several times during medication administration. LPN-A left the room and did not address the no connection message on the TV, lack of music, or the closed blinds. During observation on 8/6/25 at 10:37 a.m., LPN-A in R3's room to apply face lotion, neck brace and palm protector. R3 awake and groaning. LPN-A left the room and did not address the no connection message on the TV, lack of music, or the closed blinds. During observation on 8/7/25 at 8:16 a.m., R3 lying in bed in room awake. R3's blinds were still closed and the TV still displaying the no connection message. During observation and interview on 8/7/25 at 8:21 a.m., NA-A stated R3 should be out of his room for lunch and when in his room he enjoyed looking out the window, watching TV and listening to music in his own language. NA-A into R3's room and confirmed the TV was not tuned to any show or music and the blinds were closed. During interview on 8/7/25 at 8:26 a.m., registered nurse (RN)-A stated R3 should be out of his room in the morning and back to lie down after lunch. RN-A stated R3 enjoyed phone calls with his family and watching TV. RN-A further stated R3 liked to look outside and that his blinds should be open when cares not being performed. During interview on 8/7/25 at 8:31 a.m. LPN-B stated would expect R3's TV to be working properly and if not would expect staff to notify maintenance via a workorder. LPN-B further stated R3 enjoyed looking outside and his blinds should be open when not receiving cares. During interview on 8/7/25 at 8:49 a.m., therapeutic recreation director (TRD) stated R3 was taken to a music activity twice a month and to church once a month. TRD further stated R3 enjoyed TV in his own language and looking outside when in his room. TRD stated expectation for staff to close his blinds during cares and open them when completed. During interview on 8/7/25 at 9:23 a.m., maintenance assistant (M)-A stated staff were supposed to enter a workorder in their TELS system when something was not working properly. M-A stated not being notified of an issue or receiving a workorder for R3's TV until this morning. During interview on 8/7/25 at 9:48 a.m., director of nursing (DON) stated would they had recently rearranged R3's room so he could better see outside and his TV since those were two activities he really enjoyed. DON stated would expect staff to submit a workorder if R3's TV was not working and that his blinds should be open in between cares. DON stated recently spoke to FM-A who requested R3 be able to look outside and watch TV. Facility Therapeutic Recreation/Activities policy requested but not provided. Email received 8/7/25 at 10:11 a.m., indicated, For Therapeutic rec policy, we do not have a specific policy, we follow the guidelines.

Based on observation, interview, and record review the facility failed to implement the baseline care plan developed for 1 of 3 residents (R2, R3 and R4) reviewed. The care plans indicated the residents had cognitive concerns and were to have one-to-one staff care and 15-minute checks. R2 had a fall within hours of admitting to the facility. Upon observation R3 and R4 were not receiving one-to-one cares or 15 minutes checks. Findings include: R2's baseline care plan dated 5/20/25 indicated safety monitoring would be implemented as needed to ensure residents safety, (i.e.) 15-minute safety checks and 1:1 staff to resident ratio. R2's nursing progress note dated 5/20/25 at 2:39 p.m. indicated R2 was arrived at the facility at 2:00 p.m. on a stretcher with one emergency medical systems (EMS) person. R2 was [AGE] years old with a primary diagnosis of glioblastoma (aggressive brain cancer) with recent craniotomy revision (a section of the skull bone is removed to expose the brain for surgery), sepsis (infection of the blood) and diabetic wound with a history of bacteria (bacteria found in the blood stream). He was a fully code (CPR was to be performed). R2 had a PICC (peripherally inserted central catheter) line on his right arm. R2 was at the facility for rehab, physical therapy (PT) and occupational therapy (OT). R2's note did not indicate any safety checks to be performed on R2. R2's admission Minimum Data Set (MDS) dated [DATE] was not completed as R2 was admitted to the facility on [DATE] and discharged on 5/21/25. Upon interview on 5/30/25 at 3:25 p.m. registered nurse (RN)-B stated he worked the night shift on 5/20/25. He stated R2 was not a 1:1 or receiving 15-minute safety checks because the facility could not manage that on the night shift as they only staff one nurse and one nursing assistant (NA). Upon interview on 6/2/25 at 10:11 a.m. RN-A reviewed R2's care plan and stated the care plan should not have stated 1:1 care for R2. His care plan was meant to be 15-minute checks. The 15 minutes safety are informal checks completed by all the staff, for example looking in the room, answering call lights, assisting with toileting, or giving medications. R3's baseline care plan dated 5/31/25 indicated safety monitoring would be implemented as needed to ensure residents safety, (i.e.) 15-minute safety checks and 1:1 staff to resident ratio. R3's nursing progress notes dated 5/31/25 at 9:00 p.m. indicated R3 admitted from the hospital at 7:43 p.m. on a stretcher by two EMS staff. R3 had a history of left femoral neck fracture, total hip arthroplasty with WBAT (weight bearing as tolerated, Type II diabetes, depression, generalized anxiety. R3 was alert and oriented and continent of bowel and bladder. The note did not indicate any 1:1 care or 15-minute safety checks. R3's MDS dated [DATE] was not completed since R3 had admitted on [DATE]. Upon interview on 6/2/25 at 10:51 a.m. R3 stated she was weak when she stood and has a brain injury therefor since she had not been assessed by therapy, she should have had 15-minute safety checks. Since her admission staff only entered her room when they brought her meds or meals and when she pressed the call light. She stated she did not recall her care were supposed to be. R4's baseline care plan dated 5/24/25 indicated safety monitoring would be implemented as needed to ensure residents safety, (i.e.) 15-minute safety checks and 1:1 staff to resident ratio. R4's nursing progress notes dated 5/24/25 at 2:53 p.m. indicated R4 was admitted to the facility at 2:30 p.m. with two EMS personnels from the hospital. R4 was admitted to the facility due to multiple falls and was at the facility for PT. Per R4's hospital notes R4 was impulsive and did not use his call light. R4 was alert and oriented to himself. The notes did not indicate 1:1 care or 15-minute safety checks. Upon interview on 6/2/25 at 11:08 a.m. R4 stated he was not certain what was supposed to be doing for him. He stated staff came into his room [ROOM NUMBER]-3 times a day to bring him food and medications. Upon continuous observation on 6/2/25 from 11:08 a.m. to 12:33 p.m. R3 and R4 both had their doors closed. At 11:39 a.m. the director of nursing (DON) and the social worker (SW) entered R3's room. The DON exited her room at 11:42 and the SW exited at 11:50 a.m. At 12:25 p.m. R3 walked out of her room with her walker as the food cart was coming down the hall. She turned around and went back into her room. R3's meal was delivered to her room at 12:33 p.m. No staff entered R4's room during the observation period. His meal was delivered at 12:40 p.m. R3 and R4 were not receiving 1:1 care or 15-minute safety checks. Upon interview on 6/2/25 at 12:16 p.m. nursing assistant (NA)-A stated the transitional care unit which housed R2, R3, and R4 did not have any residents with 1:1 care 15-minute checks. He stated the only time had a worked with 15-minute safety checks was when residents were combative with each other, otherwise safety checks were every two hours. The checks were the when the NA's rounded the unit, provided visualization of the residents, repositioned the residents or check and changed incontinent briefs. He stated he had not had a 1:1 resident in years at the facility. Upon interview on 6/2/25 at 1:18 p.m. the Social Worker stated she was not certain how 1:1 care or 15-minute checks got on the care plans. Upon interview on 6/2/25 at 1:30 p.m. RN-C stated the unit did not have any 1:1 care or 15-minute safety checks. Upon care plan review, she stated she was not aware the care plans indicated 1:1- or 15-minute checks. If the care plan indicated specific checks, then the facility is required to do what the plan indicated. In addition, it should indicate 1:1 or 15-minute checks, not both. The initial care plan needed to be patient centered and accurate so staff can do their job properly. Upon interview on 6/2/25 at 1:59 p.m. the Administrator stated when the facility staff create a 48-hour care the 1:1 and 15-minute safety checks are an example to use. She stated the care plan was meant to offer safety checks as needed for new residents. She stated after the 48-hours it should be reviewed and removed if that is not what the facility doing. She did not expect the staff to follow the example on the baseline care plan however the care plan should indicate clear parameters for the safety checks needed. A facility policy titled Baseline Care Plan with a revision date of 8/2017 indicated the interdisciplinary team reviewed the healthcare practitioner's orders and implement a baseline care plan within 48 hours of admission to meet the resident's immediate base care needs, including things as; initial goals, physical orders, nursing orders, dietary orders, therapy services and social services as needed.

Based on interview and record review the facility failed to provide fundamental quality of care of professional standards of practice for 1 of 3 residents reviewed for quality of care. R2 had a fall, and the facility was unable to ensure neurological checks (a critical assessment to identify any potential damage to the brain and nervous system) had been completed. Findings include: R2's baseline care plan dated 5/20/25 indicated safety monitoring would be implemented as needed to ensure residents safety, (i.e.) 15-minute safety checks and 1:1 staff to resident ratio. R2's nursing progress note dated 5/20/25 at 2:39 p.m. indicated R2 arrived at the facility at 2:00 p.m. on a stretcher with one emergency medical systems (EMS) person. R2 was [AGE] years old with a primary diagnosis of glioblastoma (aggressive brain cancer) with recent craniotomy revision (a section of the skull bone is removed to expose the brain for surgery), sepsis (infection of the blood) and diabetic wound with a history of bacteria (bacteria found in the blood stream). He was a full code (CPR was to be performed). R2 had a PICC (peripherally inserted central catheter) line on his right arm. R2 was at the facility for rehab, physical therapy (PT) and occupational therapy (OT). R2's note did not indicate any safety checks to be performed on R2. R2's incident note dated 5/20/25 at 10:43 indicated R2 was found seated on the floor less than five minutes after two nursing assistants and the nurse offered to help him use the bathroom. R2 stated he was trying to stand up to use the bathroom. He denied pain, hitting his head and had no injury. R2's vital signs were; blood pressure 145/98 (normal 120/80), pulse 85 (normal 60-100), respirations 18 (normal 12-20), oxygen saturation was 96% on room air (normal 92% - 100%), pain 0/10 (0 being no pain and 10 being great pain). Under the heading hit head title on the document (initiate neuro-checks for head bump) indicated R2 did not hit his head. A voice mail was left for the on-call provider. The immediate action that took place was to lower the bed and re-educated R2 on using the call light and placed his telephone within reach. The note did not indicate what R2 was doing prior to the fall, where he fell from or what his immediate or follow-up neuro-checks indicated. R2's nursing note dated 5/21/25 at 10:10 a.m. indicated R2 was found seated on the floor of his room, when asked he stated, I was trying to go to the bathroom and fell. R2 denied hitting his head, no injury was noted at that time. Neuro check sheet was started. R2 was reeducated on using the call-light. The note was documented the morning following the fall and after he went to the hospital. R2's nursing note dated 5/21/25 indicated R2 was sent to the emergency department (ED) around 9:00 a.m. related to a fall. The Family called emergency medical services (EMS). R2's admission Minimum Data Set (MDS) dated [DATE] was not completed as R2 was admitted to the facility on [DATE] and discharged on 5/21/25. R2's electronic Medical Administration Record (EMAR) dated 5/21/25 at 6:00 a.m. indicated to complete neuro sheet as applicable for three days. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 6:00 a.m. indicated for staff to make a progress note post fall x72 hours, make sure to include any signs of symptoms of injury and effectiveness of new fall interventions every shift for 3 days. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 6:00 a.m. indicated post fall vital sign checks every shift for 24 hours. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 0700 indicated to monitor R2 for signs and symptoms of injury post fall x 72 hours. This was initiated 8 hours after R2's fall. R2's (EMAR) dated 5/21/25 did not indicate any neuro-checks to be completed after R2's fall. A written statement to the facility on 5/22/25 by RN-B indicated: Taking care of R2 was very exhausting R2 was demanding and time consuming. He was verbally aggressive, arrogant, loud, and condescending, talking down to staff during cares. You guys don't know what you are doing. FM-B was present all night and witnessed R2's ranting and even shouting at her. All R2 wanted to do all night was Eat! Eat! Eat! He was constantly demanding more food, one after another enabled by FM-B. FM-B came to the nurses desk for multiple things one after the other, asking for help including more food for R2. She asked for help with him to the bathroom, RN-B helped him to the bathroom when the NA was on a break and for some reason R2 was pretending he was not able to walk/stand. That night NA was in his room multiple times either doing cares, delivering food, or fixing R2's incontinent brief. Between RN-B and NA-A R2's needs and wants were addressed to the best of their ability. Trying to do vital signs on R2 and administer his IV antibiotics was time consuming because he wanted to do something else instead. RN-B's statement did not include the assessments he provided for R2's behavior and post fall. RN-B did not document R2's behaviors in the progress notes. Upon interview on 5/30/25 at 12:15 p.m. R2's family member (FM)-A stated she had not heard from R2 for a few hours on 5/20/25. At approximately 10:45 p.m. she called his room and did not receive an answer. She then called the reception area to ask for staff to check on R2. She was on the phone and registered nurse (RN)-A stated R2 was on the floor, and he was looking for staff to assist him to get him up with the mechanical lift. She stated she was worried because the staff were unable to provide information on how he fell to her over the phone. R2 was a fall risk due to his brain cancer and recent surgery, therefor he was to be closely monitored. FM-A called FM-B and asked her to go to the facility to see R2 and stay with him until the morning until the family could speak with the facility. FM-B got to the facility at approximately 12:30 a.m. FM-B was concerned about R2 as she noticed he appeared short of breath, confused, and combative. FM-B was told the facility conducts 15-minute neuro-checks for the first hour following a fall, 30 minutes for the next hour and then hourly for 24 hours. FM-B stated the staff were not completing half hour or hourly checks when she was there. FM-B had to go out and get staff at the desk when R2 needed assistance because the staff did not answer the call light. Another family member, FM-C, arrived at the facility on 5/21/25 at approximately 8:00 a.m. Upon interview on 5/30/25 at 1:31 p.m. RN-C the nurse manager stated she spoke with FM-C the morning after R2's fall. FM-C stated R2 was to be a 1:1 with his cares as he was in the hospital. RN-C stated she re-read the hospital discharges notes and did not find an order to indicate R2 was to be a 1:1 for cares. FM-C requested documentation of what cares were performed following R2's fall including his neuro-checks. FM-C was told the nurse on duty puts batch orders (the facility fall protocol) into the residents electronic chart, so the staff are sure to complete all the post fall assessments. RN-C stated the neuro-checks can be documented on a hard copy instead in the electronic chart. RN-C could not locate the neuro-checks at the time of the survey. The morning of 5/21/25 RN-C attempted to complete a risk assessment for R2 around 8:30 a.m. however the family would not allow her to and was wanting R2 to be sent to the hospital. The family called EMS. Upon interview on 5/30/25 at 3:10 p.m. RN-A stated he worked and completed R2's admission on [DATE]. He stated two nursing assistants had asked R2 if he wanted assistance to the bathroom moments before he found R2 on the floor. He was walking past R2's room and found him seated on the floor. He stated R2's wife was on the phone with him. RN-A told FM-A R2 was on the floor, and he was getting assistance and a mechanical lift. About 40 minutes after the fall, FM-C arrived at the facility and stayed the night with R2. RN-A stated he started a hard copy of a neuro-flow sheet and completed the first three neuro-checks. RN-A reported the fall and left the neuro-check sheet for RN-B, the incoming night nurse. Upon interview on 5/30/25 at 3:25 p.m. RN-B stated he worked the night shift on 5/20/25 and referred to it as a crazy night stating FM-C was in his face all night with questions about R2. He stated he came to work the following day and heard the family had complained that no staff were in R2's room all night. His response was he took R2 to the bathroom when the NA-A was busy. In addition, he hung R2's IV medication and completed his admission vital signs, which were every 4 four hours for the first 24 hours. When prompted about R2's fall RN-B stated the fall happened on the evening shift, so all the fall evaluations were completed at that time. He stated he could not recall if the neuro-checks were still ongoing into the night, if they were he completed them on a hard copy sheet. NA-A was not available for an interview during the survey. Upon interview on 6/2/25 at 8:49 a.m. FM-C arrived at the facility on 5/21/25 due to concerns RM-B called and informed her of. FM-C observed R2's mental status to be altered, increased confusion and anxiety along with grabbing his head. FM-C requested post fall documentation, especially concerned with R2's neuro-checks. The staff could not provide the neuro checks. FM-C was given copies of R2's vital signs taken 5/20/25 at 2:34 p.m., 5/20/25 at 8:01 p.m. (these were before the fall), 5/20/25 at 11:03 p.m. (this was right after the fall), 5/21/25 at 12:47 a.m. and 5/21/25 at 4:03 a.m. and R2's incident fall note from 5/20/25 at 10:43 p.m. FM-C was concerned about R2's neurological status. She called EMS around 9:00 a.m. Upon interview on 6/2/25 at 1:59 p.m. the Administrator expected staff to follow the facility protocol for falls. She was not certain what documentation was completed post-fall for R2. An email request dated 6/2/25 at 3:16 p.m. sent to the Administrator requesting R2's neuro-checks. None were provided. A policy regarding neuro-checks was requested however none was provided. A facility policy titled falls with a revision date of 2/20/25 indicated: Fall occurs: a. When a resident has fallen, or is found on the floor, nursing staff will provide comfort, but not move the resident until evaluated for injury. b. The nursing staff will record vital signs (including orthostatic BP), when appropriate. c. If a bump to the head is suspected or confirmed complete neuro checks and update the provider timely. Nursing should utilize the neuro flow sheet per policy. d. If resident is noted to be on a blood thinning medication and sustains a fall there is significant risk of bleeding. This should be reported to the provider in a timely manner. e. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. If a fracture is suspected, do not move resident, but stay with resident and wait for instructions from medical provider or for emergency medical staff to arrive. e. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. f. Nursing staff will notify the resident's medical provider and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practitioner routinely (e.g., by fax, phone, or in-house communication book, the next office/visit day). g. Nursing staff will observe for delayed complications of a fall for (72) hours after an observed or suspected fall and will document findings in the medical record. h. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. i. Nursing staff will complete an incident review and analysis. 2. Defining Details of Falls: a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred, where it occurred and what the individual was trying to do at the time the fall occurred. 3. Identifying Causes of a Fall or Fall Risk: a. Nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. b. Staff will evaluate chains of events or circumstances preceding a recent fall, including: 1) Time of day of the fall; 2) What the resident was doing or attempting to do; 3) Whether the resident was standing, walking, reaching, or transferring from one position to another; 4) Whether the resident was among other persons or alone; 5) When was the last time the resident was repositioned or toileted; 6) Time of the last meal; 7) Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or 8) Whether there is a pattern of falls for this resident. c. The interdisciplinary team will review falls daily at morning meeting. d. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. e. As indicated, the attending physician may examine the resident or may initiate testing to try to identify causes. f., when possible, the attending physician or nursing staff will document the basis for identifying specific factors as the cause. g. If the cause of a fall is unclear, the fall has a significant medical cause such as a transient ischemic attack or an adverse drug reaction (ADR), or if the resident continues to fall despite attempted interventions, the nursing staff will discuss the situation with the attending physician or Medical Director. h. If causes of a fall cannot be readily identified and if the fall is accompanied by other signs and symptoms (e.g., confusion, lethargy, restlessness), the staff and physician will consider a possible underlying acute medical cause. Based on interview and record review the facility failed to provide fundamental quality of care of professional standards of practice for 1 of 3 residents reviewed for quality of care. R2 had a fall, and the facility was unable to provide documentation that neurological checks (a critical assessment to identify any potential damage to the brain and nervous system) had been completed. Findings include: R2's baseline care plan dated 5/20/25 indicated safety monitoring would be implemented as needed to ensure residents safety, (i.e.) 15-minute safety checks and 1:1 staff to resident ratio etc. R2's nursing progress note dated 5/20/25 at 2:39 p.m. indicated R2 arrived at the facility at 2:00 p.m. on a stretcher with one emergency medical systems (EMS) person. R2 was [AGE] years old with a primary diagnosis of glioblastoma (aggressive brain cancer) with recent craniotomy revision (a section of the skull bone is removed to expose the brain for surgery), sepsis (infection of the blood) and diabetic wound with a history of bacteria (bacteria found in the blood stream). He was a full code (CPR was to be performed). R2 had a PICC (peripherally inserted central catheter) line on his right arm. R2 was at the facility for rehab, physical therapy (PT) and occupational therapy (OT). R2's note did not indicate any safety checks to be performed on R2. R2's incident note dated 5/20/25 at 10:43 indicated R2 was found seated on the floor less than five minutes after two nursing assistants and the nurse offered to help him use the bathroom. R2 stated he was trying to stand up to use the bathroom. He denied pain, hitting his head and had no injury. R2's vital signs were; blood pressure 145/98 (normal 120/80), pulse 85 (normal 60-100), respirations 18 (normal 12-20), oxygen saturation was 96% on room air (normal 92% - 100%), pain 0/10 (0 being no pain and 10 being great pain). Under the heading hit head title on the document (initiate neuro-checks for head bump) indicated R2 did not hit his head. A voice mail was left for the on-call provider. The immediate action that took place was to lower the bed and re-educated R2 on using the call light and placed his telephone within reach. The note did not indicate what R2 was doing prior to the fall, where he fell from or what his immediate or follow-up neuro-checks indicated. R2's nursing note dated 5/21/25 at 10:10 a.m. indicated R2 was found seated on the floor of his room, when asked he stated, I was trying to go to the bathroom and fell. R2 denied hitting his head, no injury was noted at that time. Neuro check sheet was started. R2 was reeducated on using the call-light. The note was documented the morning following the fall and after he went to the hospital. R2's nursing note dated 5/21/25 indicated R2 was sent to the emergency department (ED) around 9:00 a.m. related to a fall. The Family called emergency medical services (EMS). R2's admission Minimum Data Set (MDS) dated [DATE] was not completed as R2 was admitted to the facility on [DATE] and discharged on 5/21/25. R2's electronic Medical Administration Record (EMAR) dated 5/21/25 at 0600 indicated to complete neuro sheet as applicable for three days. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 0600 indicated for staff to make a progress note post fall x72 hours, make sure to include any signs of symptoms of injury and effectiveness of new fall interventions every shift for 3 days. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 0600 indicated post fall vital sign checks every shift for 24 hours. This was initiated 7 hours after R2's fall. R2's (EMAR) dated 5/21/25 at 0700 indicated to monitor R2 for signs and symptoms of injury post fall x 72 hours. This was initiated 8 hours after R2's fall. R2's (EMAR) dated 5/21/25 did not indicate any neuro-checks to be completed after R2's fall. A written statement to the facility on 5/22/25 by RN-B indicated: Taking care of R2 was very exhausting R2 was demanding and time consuming. He was verbally aggressive, arrogant, loud and condescending, talking down to staff during cares. You guys don't know what you are doing. FM-B was present all night and witnessed R2's ranting and even shouting at her. All R2 wanted to do all night was Eat! Eat! Eat! He was constantly demanding more food, one after another enabled by FM-B. FM-B came to the nurses desk multiple things one after the other, asking for helpe including more food for R2. She asked for help with him to the bathroom, RN-B helped him to the bathroom when the NA was on a break and for some reason R2 was pretending he was not able to walk/stand. That night NA was in his room multiple times either doing cares, delivering food or fixing R2's incontinent brief. Between RN-B and NA-A R2's needs and wants were addressed to the best of their ability. Trying to do vital signs on R2 and administer his IV antibiotics was time consuming because he wanted to dosomething else instead. RN-B's statement did not include the assessments he provided for R2's behavior and post fall. RN-B did not document R2's behaviors in the progress notes. Upon interview on 5/30/25 at 12:15 p.m. R2's family member (FM)-A stated she had not heard from R2 for a few hours on 5/250/25. At approximately 10:45 p.m. she called his room and did not receive an answer. She then called the reception area to ask for staff to check on R2. She was on the phone and registered nurse (RN)-A stated R2 was on the floor, and he was looking for staff to assist him to get him up with the mechanical lift. She stated she was worried because the staff were unable to provide information on how he fell to her over the phone. R2 was a fall risk due to his brain cancer and recent surgery, therefor he was to be closely monitored. FM-A called FM-B and asked her to go to the facility to see R2 and stay with him until the morning until the family could speak with the facility. FM-B got to the facility at approximately 12:30 p.m. FM-B was concerned about R2 as she noticed he appeared short of breath, confused, and combative. FM-B was told the facility conducts 15-minute neuro-checks for the first hour following a fall, 30 minutes for the next hour and then hourly for 24 hours. FM-B stated the staff were not completing half hour or hourly checks when she was there. FM-B had to go out and get staff at the desk when R2 needed assistance because the staff did not answer the call light. FM-C arrived at the facility on 5/21/25 at approximately 8:00 a.m. (see her interview below). Upon interview on 5/30/25 at 1:31 p.m. RN-C the nurse manager stated she spoke with FM-C the morning after R2's fall. FM-C stated R2 was to be a 1:1 with his cares as he was in the hospital. RN-C stated she re-read the hospital discharges notes and did not find an order to indicate R2 was to be a 1:1 for cares. FM-C requested documentation of what cares were performed following R2's fall including his neuro-checks. FM-C was told the nurse on duty puts batch orders (the facility fall protocol) into the residents electronic chart, so the staff are sure to complete all the post fall assessments. RN-C stated the neuro-checks can be documented on a hard copy instead in the electronic chart. RN-C could not locate the neuro-checks at the time of the survey. The morning of 5/21/25 RN-C attempted to complete a risk assessment for R2 around 8:30 a.m. however the family would not allow her to and was wanting R2 to be sent to the hospital. The family called EMS. Upon interview on 5/30/25 at 3:10 p.m. RN-A stated he worked and completed R2's admission on [DATE]. He stated two nursing assistants had asked R2 if he wanted assistance to the bathroom moments before he found R2 on the floor. He was walking past R2's room and found him seated on the floor. He stated R2's wife was on the phone with him. RN-A told FM-A R2 was on the floor, and he was getting assistance and a mechanical lift. About 40 minutes after the fall, FM-B arrived at the facility and stayed the night with R2. RN-A stated he started a hard copy of a neuro-flow sheet and completed the first three neuro-checks. RN-A reported the fall and left the neuro-check sheet for RN-B, the incoming night nurse. Upon interview on 5/30/25 at 3:25 p.m. RN-B stated he worked the night shift on 5/20 and referred to it as a crazy night stating FM-B was in his face all night with questions about R2. He stated he came to work the following day and heard the family had complained that no staff were in R2's room all night. His response was he took R2 to the bathroom when the NA-A was busy. In addition, he hung R2's IV medication and completed his admission vital signs, which were every 4 four hours for the first 24 hours. When prompted about R2's fall RN-B stated the fall happened on the evening shift, so all the fall evaluations were completed at that time. He stated he could not recall if the neuro-checks were still ongoing into the night, if they were he completed them on a hard copy sheet. NA-A was not available for an interview during the survey. Upon interview on 6/2/25 at 8:49 a.m. FM-C arrived at the facility on 5/21/25 due to concernss RM-B called and informed her of. FM-C observed R2's mental status to be altered, increased confusion and anxiety along with grabbing his head. FM-C requested post fall documentation, especially concerned with R2's neuro-checks. The staff could not provide the neuro checks. FM-C was given copies of R2's vital signs taken 5/20/25 at 2:34 p.m., 5/20/25 at 8:01 p.m. (these were before the fall), 5/20/25 at 11:03 p.m. (this was right after the fall), 5/21/25 at 12:47 a.m. and 5/21/25 at 4:03 a.m. and R2's incident fall note from 5/20/25 at 10:43 p.m. FM-C was concerned about R2's neurological status. She called EMS around 9:00 a.m. Upon interview on 6/2/25 at 1:59 p.m. the Administrator expected staff to follow the facility protocol for falls. She was not certain what documentation was completed post-fall for R2. An email request dated 6/2/25 at 3:16 p.m. sent to the Administrator requesting R2's neuro-checks. None were provided. A policy regarding neuro-checks was requested however none was provided. A facility policy titled falls with a revision date of 2/20/25 indicated: Fall occurs: a. When a resident has fallen, or is found on the floor, nursing staff will provide comfort, but not move the resident until evaluated for injury. b. The nursing staff will record vital signs (including orthostatic BP), when appropriate. c. If a bump to the head is suspected or confirmed complete neuro checks and update the provider timely. Nursing should utilize the neuro flow sheet per policy. d. If resident is noted to be on a blood thinning medication and sustains a fall there is significant risk of bleeding. This should be reported to the provider in a timely manner. e. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. If a fracture is suspected, do not move resident, but stay with resident and wait for instructions from medical provider or for emergency medical staff to arrive. e. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. f. Nursing staff will notify the resident's medical provider and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practitioner routinely (e.g., by fax, phone, or in-house communication book, the next office/visit day). g. Nursing staff will observe for delayed complications of a fall for (72) hours after an observed or suspected fall and will document findings in the medical record. h. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. i. Nursing staff will complete an incident review and analysis. 2. Defining Details of Falls: a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred, where it occurred and what the individual was trying to do at the time the fall occurred. 3. Identifying Causes of a Fall or Fall Risk: a. Nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. b. Staff will evaluate chains of events or circumstances preceding a recent fall, including: 1) Time of day of the fall; 2) What the resident was doing or attempting to do; 3) Whether the resident was standing, walking, reaching, or transferring from one position to another; 4) Whether the resident was among other persons or alone; 5) When was the last time the resident was repositioned or toileted; 6) Time of the last meal; 7) Whether any environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way); and/or 8) Whether there is a pattern of falls for this resident. c. The interdisciplinary team will review falls daily at morning meeting. d. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. e. As indicated, the attending physician may examine the resident or may initiate testing to try to identify causes. f., when possible, the attending physician or nursing staff will document the basis for identifying specific factors as the cause. g. If the cause of a fall is unclear, the fall has a significant medical cause such as a transient ischemic attack or an adverse drug reaction (ADR), or if the resident continues to fall despite attempted interventions, the nursing staff will discuss the situation with the attending physician or Medical Director. h. If causes of a fall cannot be readily identified and if the fall is accompanied by other signs and symptoms (e.g., confusion, lethargy, restlessness), the staff and physician will consider a possible underlying acute medical cause.

Based on interview and document review, the facility failed to ensure the comprehensive care plan indicated the presence of a ventriculoperitoneal (VP) shunt and include signs and symptoms of VP shunt malfunction for 1 of 3 residents (R1) reviewed for comprehensive care plans. Findings include: A VP shunt is defined as a plastic tube that drains extra fluid from the brain into the stomach. A VP shunt may become blocked and can cause excess fluid in the brain which is a neurosurgical emergency. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively impaired and was mostly independent with activities of daily living. R1's face sheet dated 4/17/25, included diagnoses of dementia, psychotic disturbance, nontraumatic intracranial hemorrhage, restlessness and agitation and, mechanical complication of ventricular intracranial shunt. R1's care plan printed 4/17/25, indicated R1 had a traumatic brain injury and was at risk for alteration in skin integrity related to wandering into other resident's rooms and bumping into doorways. The care plan lacked indication that R1 had a VP shunt, or interventions related to shunt malfunction. R1's physician order dated 1/20/25, indicated to monitor drainage from area on the right back of the scalp. Document any signs or symptoms of infection and notify the doctor. The order did not clarify the open area on the scalp was where the VP shunt was placed. R1's physician order dated 3/6/25, indicated to cleanse the area on the right temple with wound cleanser and pat dry. Apply calcium alginate with silver to wound bed and cover with foam dressing, daily and as needed. The order did not clarify the open area on the scalp was where the VP shunt was placed. On 4/17/25 at 12:19 p.m., licensed practical nurse (LPN)-A was interviewed and stated when R1 arrived, he had a small open area. R1 would constantly pick at it and remove the bandage so the area opened more and began to show signs of infection. There were no interventions in his care plan related to his VP shunt. On 4/17/25 at 1:11 p.m., LPN-B who was R1's care coordinator was interviewed and stated she was not sure if the care plan mentioned the VP shunt or not. LPN-B stated when R1 was transferred to the facility, staff were not initially aware he had a VP shunt. On 4/17/25 at 1:45 p.m., the director of nursing (DON) was interviewed. DON stated there should have been a care plan for the VP shunt, there was an existing process for adding VP shunt management to the care plan in the facility's care planning process. On 4/17/25 at 2:39 p.m., the administrator was interviewed and stated she would expect a resident to have a section in their care plan about shunts if they have a shunt. The administrator stated there were wound care orders for the shunt but did not clarify the wound was related to the shunt. Administrator verified that it would be difficult for a nurse to respond appropriately to a shunt malfunction without a care plan for malfunction signs, symptoms and interventions. Facility Care Planning policy last revised 11/2024, directed the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and document review, the facility failed to provide care in a manner that promoted dignity for 2 of 3 residents (R1, R6) reviewed for dignity concerns. Findings include: R1 R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and was frequently incontinent of bowel and required assistance with bathing. R1's diagnoses list printed 2/21/25, included diagnoses of melena (passage of black, tarry stools), and bipolar disorder. R1's care plan dated 1/31/25, indicated R1 required assistance with activities of daily living (ADLs) related to persistent diarrhea and identified staff were to assist R1 with personal cares including washing hands, cleaning self, and using the toilet. During an interview on 2/21/25 at 11:44 a.m., family member (FM)-A stated R1 left the facility against medical advice when FM-A visited and found R1 with stool dripping down his leg in the dining room, on his hands, and no sheets on R1's bed. FM-A stated R1 would not like to have stool on his hands and body, and no sheets on his bed. On 2/21/25 at 12:49 p.m., during document review, two photographs sent by FM-A, taken on 2/16/25, demonstrated R1 had stool on his hand and was lying on a bed with no bed sheets. During an interview on 2/21/25 at 4:46 p.m., nursing assistant (NA)-A stated R1 should not have been in the dining room with stool on his hands, and R1 would have been embarrassed to have stool on his hands for others to see. During an interview on 2/21/25 at 5:09 p.m., registered nurse (RN)-A stated other residents would not like to see stool on R1's hands in the dining room. R6 R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. R6's diagnoses list printed 2/24/25, indicated unspecified psychosis, morbid obesity, and bipolar disorder. R6's care plan dated 9/22/24, indicated R6 had an alteration in psychosocial well-being and staff would try to meet her needs. During an interview and observation on 2/24/25 at 9:52 a.m., R6 was not in her room. The bed lacked a bed sheet. NA-B stated R6 would not like to lie in her bed without a sheet and would be upset staff had not made her bed. During an interview on 2/24/25 at 10:47 a.m., R6 stated she slept on her bed with no bed sheet, she did not like it and was angry about it. During an interview on 2/24/25 at 10:55 a.m. social worker (SW)-A stated every resident should have a made bed if it was their preference and should have sheets on their beds. During an interview on 2/24/25 at 11:44 a.m., the administrator stated the facility had enough sheets for the beds and residents should have sheets on the their beds if it was their preference. Administrator indicated the residents would not like to sleep on beds with no sheets. The administrator stated the facility did not have a policy related to dignity. During an interview on 2/24/25 at 12:24 p.m., the director of nursing (DON) stated R1 would try to clean himself and he was embarrassed by the stool on himself. The DON further stated residents should have a sheet on their beds, and sleeping on the bed without a sheet would be uncomfortable. The DON stated her expectation was all residents would have a sheet on their bed for comfort and hygiene if that was their preference. Review of facility policy titled The Residents Rights dated 01/2024, indicated it was the practice of the facility to uphold the rights of all residents.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R1) remained nothing per oral (NPO), receiving nutrition via tube feeding per his hospital discharge orders. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had Parkinson's, hemiplegia and was severely cognitively impaired. In addition R1's MDS indicated he had no behaviors, had impairment in upper and lower extremities, no or unknown for weight loss or weight gain and received feeding via tube feeding and also had a mechanically altered diet, and 51% or more alternative route and 501 cubic centimeters (CC) or more per day by IV (intravenous) or tube feeding, which R1 received tube feeding. R1's Care Plan dated 2/04/25, indicated R1 had Parkinson's and was at risk for malnutrition and dehydration due to dysphagia (swallowing disorder), and received tube feedings per physician order, staff to check placement of tube feeding, residents head of bed to be elevated 30-40 degrees during feeding and thirty minutes after tube feedings, monitor resident every shift for signs and symptoms of aspiration. R1 received enteral nutrition via PEG (Percutaneous endoscope gastrostomy) (a tube is passed into a patient's stomach through the abdominal wall) with nursing staff managing and mechanically altered diet due to dysphagia benefiting from puree with honey thicken liquids. R1's past hospitalization s indicated the following: 1) Discharge Summary (DC) orders dated 12/13/24, indicated R1 was admitted on [DATE] through 12/13/24, for aspiration pneumonia and to take amoxicillin 10.9 milliliters (ml) by mouth two times a day for 4 days. 2) D/C Summary dated 1/01/25, indicated R1 was admitted from 12/27/24 through 1/01/25, for sepsis due to pneumonia, acute respiratory failure. The D/C summary further indicated R1 had chronic tube feeding, Parkinson's disease, stroke, and risk of aspiration pneumonia on-going and was readmitted on [DATE] with sepsis. R1's Interagency Assessment and Orders dated 1/01/25 indicated R1's diet was to be NPO (nothing by mouth). And to have continuous Tube feeding prescription four cans of Iso-source 1.5 formula per day given through the PEG tube set at 65 ml/hr. per day 7:00 p.m. to 10:00 a.m. water flushes 150 ml every 4 hours. In addition to orders for Occupational Therapy, Physical Therapy and Speech Therapy. Review of the facility documentation indicated R1 received food/oral liquids even though R1 was supposed to be NPO on 1/01/25 through 1/27/25, R1 received oral intake of foods with percentages eaten on the following dates: -1/02/25 76% - 100% -1/3/2025 0 - 25% -1/4/2025 26% - 50% -1/5/2025 08:00 a.m. 51% - 75% -1/5/2025 12:00 p.m. 51% - 75% -1/07/25 51-75% -1/09/25 20-51% -1/10/25 51-75% -1/11/25 75-100% -1/13/25 25-50% -1/14/25 75 to 100% -1/15/25 75 to 100% -1/16/25 0-25% -1/17/25 51 -75% -1/18/25 0-25% -1/22/25 0 to 25% -1/25/25 0-25% -1/26/25 0-25% in the a.m. and 75-100% in the evening -1/27/25/25 0-25% in the a.m. and 0-25% in the evening. A Hospital Discharge Summary (DC) indicated a admitted [DATE] and discharge date of [DATE], R1's primary problem of right lower lobe pneumonia. R1 currently resided at a long-term care facility. R1 had sepsis pneumonia due to aspiration (unclear origin) and was to be NPO with tube feedings managed per registered dietician (RD). Staff were to to continue elevation of head of bed (HOB) greater than 30 degrees at all times and administer Vantin (antibiotic) 200 mg via tube feed twice daily. During observation on 2/04/25, licensed practical nurse (LPN)-A was observed to hook up R1's tube feeding and provide physician ordered water flush. R1 was observed to be in bed with his HOB greater than 30 degrees. During interview on 2/05/25, at 10:00 a.m. LPN-A stated R1 has been eating food in the dining room with staff assistance until the discharge from the hospital on 1/31/25, when he was placed on NPO. LPN-A was unaware R1 was supposed to be NPO after his discharge on 1/01/25. During observation on 2/05/25, at 10:10 a.m. R1 was observed to be lying in bed with his HOB elevated greater than 30 degrees. During interview on 2/05/25, at 10:21 a.m. registered nurse (RN)-A stated she was not aware of R1's diet changed to NPO 1/01/25 and referred me to the facilities speech language pathologist (SLP). During interview on 2/05/25, at 10:30 a.m., the speech-language pathologist (SLP)-A stated she was unaware R1 was placed on NPO after his 1/01/25, hospitalization . SLP-A stated it would make sense he was placed on 1/01/25, since R1 was hospitalized twice for aspiration pneumonia. She would not have approved R1 to be eating unless R1 had a swallow study in a hospital since he was unable to fully participate in a bedside swallow study. During interview on 2/05/25, at 10:56 a.m. with R1's nurse practioner (NP), she noted somewhere it was lost that R1 was supposed to be NPO after his hospitalization return on 1/01/25. Looking at the discharge orders, R1 should have been NPO and received PT/PT and ST evaluations. R1 was a Full Code and was at a high risk for aspiration with the tube feeding and even with oral intake. It would be really hard to know if he aspirated from food or the tube feeding, however, staff should not be feeding him oral foods without a swallow study evaluation. During interview on 2/05/25, at 11:13 a.m., hospital registered dietician (RD)-B stated she was unaware R1 had been receiving food by mouth after his discharge on 1/01/25. RD-B spoke with the facilities RD-A and was never informed he was eating along with getting his tube feedings. During interview on 2/05/25, at 11:41 a.m. the director of nursing (DON) stated after reviewing R1's discharge orders on 1/01/25, it was noticed staff did not sign off on the diet orders of NPO. The DON stated there is not a policy for checking the orders, and noted the facility had an ineffective process and they needed to change processes. Facility policy Therapeutic Diets revised October 2017, indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care. No policy was provided related to reconciliation of physician orders by the end of the survey.

Based on observation, interview and document review, the facility failed to ensure physician ordered weights were implemented as ordered for 2 of 3 residents (R3 and R4), reviewed for nutrition. Findings include: R3's care plan identified a focus dated 5/30/19, of alteration in nutrition .malnutrition related to history of inadequate oral intakes related to variable oral intakes as evidenced by underweight status .intervention dated 5/28/19, directed staff to have dietary consult as needed for weight gain/loss or other problems noted. An additional intervention dated 6/15/22, directed staff to obtain and record weights at least monthly, and more often as indicated by physician orders. R3's Care Area Assessment (CAA) dated 11/16/23, identified R3 had a potential for nutritional risk due to reduced micronutrient needs as evidenced by hemodialysis .therapeutic diet related to diabetes and End Stage Renal Disease (ESRD), with hemodialysis. R4 had a history of inadequate oral intakes related to variable oral intake, refusals to eat/be fed by staff as evidenced underweight status. No fluid restrictions at this time due to thickened liquids diet. Modified diet related to dysphagia (swallowing difficulties) as evidenced by pureed diet with honey liquids. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderately impaired cognition and diagnoses of ESRD (end stage renal disease), dependence on renal dialysis, diabetes, stroke, malnutrition, and aphasia (loss of ability to swallow). Further identified R3 received dialysis and had a mechanically altered and therapeutic diet. R3's physician order summary dated 10/1/24, include an order for R3 to have daily weights related to dialysis one time every day. R3's Medication Administration Record (MAR) dated October 2024, identified R3 had weights on the following days: 10/2/24: 117 pounds 10/4/24: 118 pounds 10/7/24: 122.5 pounds 10/9/24: 121.5 pounds 10/11/24: 120.3 pounds R3's MAR dated October 2024 did not identify weights on any other days from 10/1/24 to 10/21/24. R3's weight recorded under the vital signs tab included the following: -10/11/24 at 6:03 a.m., identified a weight of 120.3 pounds -10/11/24 at 1:40 p.m., identified a weight of 102 pounds -10/13/24 at 11:50 a.m., identified a weight of 103.5 pounds -10/14/24 at 5:11 a.m., identified a weight of 103.5 pounds -10/16/24 at 6:07 a.m., identified a weight of 100 pounds R3's progress notes were reviewed and did not identify if the physician was contacted for R3's missed physician ordered weights for further direction nor did the record include an assessment that accounted for weight gains/weight loss. R3's DaVita Dialysis pre and post weights dated 10/2/24 to 10/21/24 that were not in the record and obtained from the dialysis clinic, identified the following: 10/2/24: pre weight: 123.5 pounds; post weight: 124.1 pounds 10/4/24: pre weight: 126.5 pounds; post weight: 124.1 pounds 10/7/24: pre weight: 124.8 pounds; post weight: 120.2 pounds 10/9/24: pre weight: 119.7 pounds; post weight: 115.3 pounds 10/11/24: pre weight: 116.8 pounds; post weight: 117.5 pounds 10/14/24: pre weight: 122.1 pounds; post weight: 116.2 pounds 10/16/24: pre weight: 118.9 pounds; post weight: 115.3 pounds 10/18/24: pre weight: 117.9 pounds; post weight: 115.1 pounds 10/21/24: pre weight: 115.1 pounds; post weight: 114.2 pounds During an interview on 10/22/24 at 11:40 a.m., nurse manager (NM)-A indicated R3 had a current MD order to obtain daily weights due to dialysis. NM-A stated the last recorded weight for R3 was on 10/16/24 and was 100 pounds. NM-A was unable to articulate why daily weights were not being done and indicated the physician had not been notified. Further NM-A was unable to articulate how R3 on 10/11/24, went from 120.3 pounds to 102 pounds in one day. During an interview on 10/22/24 at 11:52 a.m., nursing assistant (NA)-A stated for residents with daily weights we would obtain a weight prior to the resident eating breakfast and let the nurse know the weight so they could document it. NA-A indicated R3 was on daily weights, and she was made aware of the list of residents who require daily weights by the sheet of paper with a list of residents that was taped to the nurses desk. NA-A stated NA-B would be responsible for R3 and indicated she did not get R3's weight this morning. During an interview on 10/22/24 at 12:09 p.m., NA-B stated she was responsible for the care. NA-B was not aware that R3 was a daily weight and stated the nurse usually lets her know and had not done that. This surveyor showed NA-B the list of daily weights taped to the nurses desk and NA-B verified R3's name was on there. NA-B stated typically with daily weights we would want to get a weight in the morning before the resident ate breakfast and verified R3 ate at 8:00 a.m. when she fed him and had not gotten his weight. During an interview on 10/22/24 at 12:23 p.m., licensed practical nurse (LPN)-A indicated R3 was a daily weight due to being on dialysis and he had not yet received R3's weight today. LPN-A stated he would expect the weight to be done prior to breakfast for accuracy. LPN-A verified on 10/11/24 at 6:00 a.m., R3 was 120.2 pounds, then at 1:00 p.m., R3 was 102 pounds, and stated R3 should have been reweighed. LPN stated R3's weights have been lower ever since. LPN-A indicated he did not notify the doctor of the daily weights not being done or of the weight changes, stated he didn't realize it until just now. During an interview on 10/22/24 at 12:24 p.m., NA-D stated daily weights should be completed in the morning before a resident has eaten breakfast and verified R3 was a daily weight and would know that by looking at the sheet that is taped to the desk. NA-D assisted NA-B with getting R3's weight with the full body mechanical lift, R3 weight was 106 pounds. During an observation and interview on 10/22/24 at 1:08 p.m., NA-B brought R3's lunch tray to his room and began to assist R3 with eating. R3 would open his mouth opening and swallow the food quickly. NA-B stated R3's appetite had been poor prior to his hospitalization a couple weeks ago, we struggled to get him to eat. At 1:17 p.m., NA-B stated R3 ate like this during breakfast earlier and stated he must be hungry today. R4 R4's significant change MDS dated [DATE], identified R4 had diagnoses including traumatic brain injury and malnutrition. R4 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss regimen. R4's CAA dated 9/13/24, identified R4 had an alteration in nutrition of malnutrition related to altered mental status as evidenced by inadequate oral intakes, requiring cues and encouragement at meals to consume adequate oral intake, and weight loss post hospitalization with a hospital weight of 233 pounds and previous weight of 255 pounds. R4's care plan identified a focus dated 8/13/24 of alteration in nutrition: Malnutrition related to altered mental status as evidenced by inadequate oral intakes, requires cues and encouragement at meals to consume adequate oral intake and weight loss post hospitalization . Does not initiate task of eating. Requires assist as needed if does not initiate task . Weight loss progressive and significant over 30, 90, and 180 days related to inadequate oral intakes. Remeron [psychiatric medication] use initiated 9/18/24 and side effect of increased appetite would be therapeutic. Referred to interventional radiology for G-tube [feeding tube] placement related to ongoing poor oral intakes and malnutrition, however resident recently reporting does not desire feeding tube. Intervention dated 8/13/24, identified to monitor, record, and report to the doctor signs and symptoms of malnutrition as needed including emaciation, muscle wasting, and significant weight loss. An additional intervention dated 8/13/24, directed staff to obtain weight per policy/order. R4's Clinical Nutrition Evaluation V-5 completed by dietician (D)-A dated 9/10/24, noted R4 had significant weight loss and included a recommendation for weekly weights due to malnutrition. R4's provider note dated 10/2/24, indicated R4 had not eaten for approximately one week with very little oral intake with discussion of a G-tube placement. Orders included weekly weights starting now. R4's provider note dated 10/17/24, included plan and orders of follow up visit for poor appetite and decline in condition . last weight available for review was from 10/3/24 . please ensure weekly weights are taken and recorded in [EHR system]. Diagnosis, assessment, and plan included malnutrition: little to no appetite, requires frequent reminders from staff to eat. Has not eaten in 1+ week, and was sparsely eating for weeks before that. History included weights have gone down from the 260s down to 223. R4's TAR dated October 2024 included multiple physician orders for weights: weekly weight every evening shift every Thursday with start date 9/19/24 and end date 10/13/24; weekly weight one time a day every Thursday for monitoring with start date 10/3/24 and end date 10/17/24; weekly weight one time a day every Thursday for monitoring with start date 10/24/24. R4's TAR for October 2024 included scheduled administrations for physician ordered weekly weights on 10/3/24, 10/10/24, and 10/17/24 with corresponding documentation of: 10/3/24: 223.8 pounds 10/10/24: X listed as weight and notation to see corresponding nurse note which indicated the weekly weight was done. 10/17/24: Blank, documentation not completed R4's electronic health record (EHR) included a vital sign section with the following weights recorded in October 2024: 10/3/24 at 2:08 p.m.: 223.8 pounds 10/10/24 at 8:00 a.m.: 220.2 pounds R4's TAR, and vital signs did not include weights on any other days from 10/1/24 to 10/22/24. During an interview on 10/22/24 at 3:24 p.m., NA-C stated residents with weekly weights were weighed on their shower days. NA-C noted aides used a shower sheet that listed what day showers and weights were to be done and also used a group sheet that identified what day of the week residents had weekly weights. NA-C noted the shower sheet indicated R4 was to be weighed on Thursday mornings and the group sheet indicated R4 was to be weighed on Wednesdays. NA-C did not know why they were different. During an interview on 10/22/24 at 3:36 p.m., registered nurse (RN)-A stated weights were done weekly on shower day or more frequently per provider orders. RN-A noted weights showed up on the MAR or TAR on the days they were due and were completed by aides or nurses. During an interview on 10/22/24 at 3:45 p.m., NM-B stated she knew R4 had orders for weekly weights. NM-B verified the direction for aides to weigh R4 was wrong on the group sheet and did not match the order for R4 to be weighed on Thursdays. NM-B stated it was important for R4 to be weighed because it was recommended by the dietician, he had stopped eating as much as before, and he had lost weight. NM-B noted it would be concerning if he was not weighed as directed because staff needed to track his weights because he was not eating. NM-B verified R4 was seen by a provider on 10/17/24 and visit orders included ensuring weekly weights were taken and entered in the EHR. NM-B verified there was no record of R4's weight on 10/17/24 as ordered, and stated her expectation was that he would be weighed weekly and should have been weighed on 10/17/24. NM-B noted R4's last recorded weight was on 10/10/24 which was 12 days prior. NM-B stated R4's care was not provided in accordance with provider orders and R4's plan of care. NM-B could not say why R4 had not been weighed since 10/10/24 and did not know why he was not weighed on 10/17/24. During a phone interview on 10/22/24 at 3:20 p.m., D-A stated R3 was on daily weights to monitor for fluid shift in between dialysis sessions that he received three times a week. D-A also indicated R4 was at risk for weight loss and has had frequent hospitalization s. R4 had been declining and we tried several interventions to maintain his weight. D-A verified the weights were not being performed per MD orders for R3 and R4 and should have been. D-A indicated it was important to follow the care plan and provider orders. D-A stated she could implement the orders but at this particular facility their process was to have the physician order the frequency of weights for the residents. During an interview on 10/22/24 at 3:44 p.m., director of nursing (DON) indicated provider ordered weights should be followed along with the care plan and were not followed for R3 and R4. DON indicated the weights the staff were getting were not accurate due to a failure in using the right equipment, we are currently in the process of getting everyone educated. DON further indicated the physician ordered weights should be implemented as ordered and if they are missed a provider should be notified for follow up. Facility policy, Weight Policy, dated 5/1/24, identified it is the policy of Monarch Healthcare Management to obtain accurate weights and provide monitoring to ensure each resident's nutrition parameters are maintained within acceptable parameters to prevent avoidable decline in nutritional status, unless their clinical condition demonstrates that this is not possible. Policy Interpretation and Implementation 1. All residents are weighed by nursing staff upon admission and at least monthly thereafter. All weights obtained will be entered into the resident's medical record. 2. This weight protocol shall also be implemented for resident returns or re-admissions from the hospital when they have been out of the building for over 24 hours. This protocol shall not apply for therapeutic leaves of absence. 3. Weights are to be taken utilizing consistent technique, e.g. at the same time of day, using the same scale, wearing, or not wearing prostheses or orthotics, etc. whenever possible. 4. At the discretion of the interdisciplinary team and/or physician, residents at high risk may be continued on more frequent weight monitoring. Signs that a resident may be deemed high risk may include but are not limited to changes in food intake, refusal to eat, average food intake levels falling below 50%, Residents on hemodialysis, residents with open wounds, residents with use of enteral or parenteral nutrition, heart failure, etc. 5. For residents with unintended weight loss, the facility or provider may initiate interventions which can include a. Addition of high calorie/nutrient fortifiers to food (i.e., protein powder, addition of whole milk, butter, extra gravy, sauces, mayo, half and half or whipped cream). b. Offering additional food snacks between meals, based on the resident's specific needs and preferences c. Increasing the resident's portions at meals d. Liberalizing the resident's diet. Interviewing the resident to ensure their preferred foods are being added to meals and snacks f. Nutritional Supplements g. Supplements may be scheduled between meals or with medication pass h. Referral to therapy or other disciplines i. Collaboration with family or friends to encourage intakes j. Medication review 8. Resident-specific interventions shall be recorded in the resident's comprehensive care plan. 9. The resident's physician and/or responsible party shall be notified of weight changes at the discretion of the interdisciplinary team. 10. The registered dietitian (RD) and/or registered dietetic technician (DTR) shall review residents who trigger for significant weight gain or loss. Significant is defined as a person with 5% weight change over 30days, 7.5% weight change over 90 days, or 10% weight change over 180days. 11. The interdisciplinary team and/or facility designee shall review weights for significant weight changes and will be discussed to determine individualized care plan interventions and documented in the electronic medical record. 12. Residents on hospice may experience unavoidable weight loss. Weighing and weight monitoring may not be warranted for individuals at the end of life who may be receiving comfort measures only or are on hospice care. Requested MD order policy and not received. 49338

Based on observation, interview, and document review, the facility failed to ensure residents on a secure memory unit were free from harm for 2 of 2 residents (R82 and R17) reviewed for resident-to-resident abuse. This resulted in actual harm when R17 was struck in the face by R82 causing a subconjunctival hemorrhage of the left eye (broken blood vessels in the eye) requiring emergency medical attention. Findings include: According to the state agency (SA) Incident Report, dated 6/9/24, identified a facility's reported allegation of physical abuse involving R17 and R82. The report outlined R17 reported he was struck by R82 in the eye with the incident occurring in R17's room. R17 had a laceration on his left eye and transported to the hospital for evaluation. R82 R82's quarterly Minimum Data Set (MDS) assessment, dated 5/15/24, identified R82 had dementia, post-traumatic stress disorder (a psychiatric disorder that may occur after experiencing or witnessing a traumatic event), restlessness, agitation, and severe impaired cognition. Furthermore, R82 demonstrated able to walk in room and unit independently, no hallucinations or delusions. No physical or verbal behaviors . R82 noted to wander daily and reject cares one to three days in the last 7 day look-back period for MDS. R82's care plan, identified R82 moved into facility on 8/5/21 and resides on locked memory care unit. R82's care plan included, -R82 at risk for alterations in behavior related to trauma, including PTSD(post-traumatic stress disorder) from time spent in Vietnam war with a goal resident will develop coping skills to address stated trauma . Interventions included: redirect resident to a different activity to help self sooth and when resident is getting agitated and engages in screaming, redirecting him from other residents is of value for safety. - R82 had a history of aggressive behavior including verbal and/or physical altercations with other residents, The goal was to prevent reoccurrence and keep other resident safe . -R82's has alteration in socialization related to difficulty engaging due to diagnosis of dementia and related cognitive deficits. Resident appears to enjoy visiting with staff and other resident around him. Resident would benefit from socializing with others during group activities. Resident also enjoys music groups and independently listening to music in his room. -R82 has alteration in behavior related to diagnosis of dementia. Resident often wanders and enters other residents' rooms , The goal related resident will respond to intervention by staff to calm and redirect . R82 does have periods of increased confusion and agitation will typically increase in the afternoon. At times, resident is difficulty to redirect .history of wandering . has history of physical altercations with other residents. Goal of resident will respond to interventions by staff to calm and redirect with a revision date of 4/19/24. Interventions included: Staff reported more wandering and anxiety in the night. Implement an exercise program where staff walk with him in the hallway for 5-10 minutes in the evenings to help release excess energy and anxiety with initiation date of 5/6/24. -R82 Care plan included an alteration in psychosocial wellbeing related to diagnosis of Dementia. Resident is pleasant at baseline, preferring to be around others for most of the day, liking to converse with others, though often conversation is hard to follow. Resident has periods of increased agitation or restless, will start walking around the unit quickly and asking others to help him get to his car. R82's treatment administration record (TAR) for 5/1/24 and 6/13/24 had the following order for staff to monitor and document altercations if the following behaviors were identified: picking at skin, restlessness, agitation, hitting, increase in complains, biting, kicking, spitting, cussing, racial slurs, elopement, staling, delusions, hallucinations, psychosis, aggression, refusing care. The records indicate staff checked the box R82 had behaviors every shift for the month of May and June except one shift. R82 had a history of behaviors prior to most recent incident involving R17 as indicated in R82 progress notes: -2/1/24 at 2:19 p.m.: exiting seeking .another resident keeps talking to resident .causing resident to become increasingly agitated. -3/7/24 at 1:21 p.m.: emotional and exit seeking -3/13/24 at 11:52 a.m.: agitated, pacing and shouting at others -3/13/24 at 9:42 p.m.: agitated -4/7/24 at 5:19 p.m.: was exit seeking and agitated. -5/3/24 at 6:31 a.m.: aggressive with staff with cares, resident not able to calm down, he started chasing other res [resident] cursing and yelling . difficult to calm down. -5/3/24 at 7:50 a.m.: physical altercation with another resident. R82 was transferred to the hospital for further evaluation as was bleeding from right eye. -5/4/24 at 7:23 a.m.: exhibited escalating behaviors including grabbing a fire extinguisher from wall, attempting to hit staff with it, and was unable to be redirected. All other resident doors needed to be shut for safety. R82 attempted to fight another resident. -5/4/24 at 9:59 p.m.: aggressive during cares and attempted to elbow a nursing assistant. -5/9/24 at 11:52 a.m.: exit seeking. -5/18/24 at 4:03 p.m.: exit seeking. -6/1/24 at 9:44 p.m.: pacing the hallways, going back and forth between all the doors looking for how to get out. -6/4/24 at 7:17 a.m.: refused cares despite multiple attempts. -6/7/24 at 3:29 p.m.: attempted to strike a nursing assistant with the shower hose during care. -6/9/24 at 7:37 p.m., reported by R17 that R82 entered R17's room and struck him in the eye, R82 unable to explain. Although R82's TAR indicated behaviors charted daily by staff, the progress notes lacked daily documentation of what altercations R82 were exhibiting and what interventions were implemented. R82's nursing assistant care sheet, included R82 was independent with ambulation and transfers. History of res [resident] to res [resident] and whom altercations occurred with. R17 R17's care plan identified: -R17 is a vulnerable adult while residing in a skilled nursing facility and is at risk for decreased cognitive and physical ability related to diagnosis included dementia . The goal related resident will remain free from abuse and/or neglect . -R17 is at risk for alteration in psychosocial well-being related diagnosis of dementia while residing on a secure memory care unit. At baseline. Resident is pleasant to others, though often keeps to himself. Resident does like to watch TV in the common area with others. He likes to watch the other resident . Accused another resident of hitting him in the chin, no injury noted, and this was unwitnessed. Resident gets upset when other residents wander into his room . Stop sign on the doorway of his room to help prevent other resident form entering his room with a date initiated of 1/22/24 with a revision added after altercation on 6/12/24, [R17] often takes the stop sign off his door and he will put it in his drawers or closet. During an observation and interview on 6/10/24 at 2:03 p.m., R17's left eye was black and blue and the white of his eye was bright red. R17 indicated he was punched by another resident which caused his black and blue eye. R17 denied pain at this time. There was no stop sign observed to be on R17's door when entering. During follow up observation on 6/11/24 at 1:22 p.m., there was no stop sign observed to be hanging on R17's door. During breakfast on 6/12/24 at 8:17 a.m., R17 stated, he was hit in the eye by another resident. On 6/12/24 at 8:31 a.m., during an observation, it was noted there was no stop sign on R17's door. R17's quarterly MDS assessment, dated 5/7/24, identified R17 had dementia, schizophrenia, slurred speech, and severe cognitive impairment. MDS indicated R17 used wheelchair for mobility and dependent on staff for transferring to and from wheelchair. R17 noted to have verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others both of which occurred one to three days. R17's nursing assistant care sheet, identified R17 was HOH [hard of hearing] has a pocket talker to aide with HOH, R17 was Assist of 1 with transfers. He often self-transfers. Stop sign on his door to prevent others from entering. R17's progress notes included the following: 2/1/24 at 2:22 p.m. R82 had been wandering around the dining room and hallways exiting seeking and R17 continues to talk to R82 stating thinks like I'll knock you out, and I'll through you out the window. R17 has some speech that is hard to understand and R82 is becoming agitated with R17. Writer asked R17 not to talk to R82 and give him space. R17 continues to move seats in the dining room and go near R82 and make statements causing more and more agitation to R82. Staff will redirect as necessary. 6/9/24 at 7:33 p.m., writer went to resident room at around 8:20 a.m., to check with him and remind him to come out for breakfast. Noted resident left eye reddened. Per resident, someone came to his room and punched him to his eye. Resident was asked to come out with writer and identify the person who had punched him. He came out and went straight to dining area where he pointed at a resident R82. Resident has impaired speech, he was heard mumbling and pointed at R82 he punched me, he did it. sent to hospital for further evaluation. 6/9/24 at 10:23 p.m., patient returned from emergency department, no new orders, or treatments. R17's emergency department note, dated 6/9/24, indicated R17 was seen following an assault. R17 reported some pain in left eye and a little more difficult to see out of the left eye but is still able to see. CT scans indicated no evidence of acute hemorrhage, or skull fracture and no orbital, facial bone, or mandibular fracture. R17 discharge diagnosis subconjunctival hemorrhage of left eye. R17's record lacked interventions to prevent additional verbal or physical altercations. During an interview on 6/12/24 at 10:32 a.m., licensed practical nurse (LPN)-E verified working with R82 and R17 for over a year. LPN-E indicated received report R82 hit R17 . LPN-E reported no other incidents (verbal or physical altercations) between R17 and R82. LPN-E stated R17 should have a stop sign on his door but he takes it off all the time. LPN-E indicated the stop sign was to stop other residents from entering his room. On 6/12/24 at 10:39 a.m., nursing assistant (NA)-M verified working with R82 and R17 for over a year. NA-M indicated they worked the morning of 6/9/24. NA-M stated they were in the dining room when R82 walked up to them and hit NA-M in the arm stating, do you need another? NA-M stated they encouraged R82 to sit in the dining room, and it was shortly after R17 reported R82 hit him in the face. NA-M stated they do not know of any other incidents (verbal or physical altercations) between the two residents but adds we have been trying to follow him around since this happened. NA-M verified R17 should have a stop sign on his door and does not have it on there. NA-M was able to find the stop sign which was found in R17's drawer. On 6/12/24 at 10:54 a.m., NA-B verified they are familiar with R17 and R82 and have worked with them for over a year. NA-B stated they knew about the physical altercation between R17 and R82. NA-B stated R82 has been more aggressive recently and difficult to get things done. NA-B stated, we just re-approach a lot and offer a lot of reassurance. NA-B stated there have been no other incidents (verbal or physical altercations) between R17 and R82. On 06/12/24 at 2:22 p.m., LPN-D verified they update the care plans. LPN-D reviewed the chart and verified the verbal altercation with R17 and R82 on 2/1/24. LPN-D verified the care plan had not been updated. LPN-D stated R17 was having an increase in behaviors due to having a gradual dose reduction on a medication, a urinary tract infection and then kidney stones. LPN-D verified this was not on his care plan. LPN-D indicated R17 and R82 are seated at separate tables in the dining room, R17 has a stop sign on his door, put in extra behavioral monitoring, the unit is small so we can watch people closely, and make sure staff are aware of the situation so we can continue to watch and see problems. LPN-D further indicated it's not like it's a daily occurrence referring to R17 and R82. LPN-D verified R17 or R82's care plans had not been updated following the 2/1/24 verbal altercation. On 6/13/24 at 12:04 p.m., administrative administrator (AA) and administrator verified they were familiar with R17 and R82 and recent incidents. AA indicated on 2/1/24 there was an argument between R17 and R82. The interventions to follow were staff asked R17 not to talk to R82, R82 was seen by Associated Clinic of Psychology (ACP) on 2/5/24 and a (Patient Health Questionnaire-9) PH-Q9 completed on 2/6/24 with no disturbances. AA and administrator agreed there were no similar incidents. AA stated she was on-call on 6/9/24 and received a call from the supervisor regarding the physical altercation. AA verified she filed the state agency report. AA explained what had been done immediately following the physical altercation. AA verified R17's care plan had been updated on 6/12/24 following the incident. When asked what had been added since the verbal altercation to R17's care plan to prevent another altercation, AA stated I don't know, I need to look thoroughly. AA verified R82's care plan had been updated on 6/12/24 regarding a new medication for behaviors. AA stated she needed to look at R82's care plan more to verify if it had been updated to reflect 2/1/24 incident. On 6/12/24 at 12:30 p.m., administrator stated, I did not have a chance to look into IDT [interdisciplinary team] notes yet. Administrator indicated I think there was education to staff on the floor following each of the incidence. An in-service training record for all staff, dated 2/15/24, indicated the abuse policy, review that facility must report abuse to the state within 2 hours, and when to notify nursing home administrator and notification of director of nursing guideline. Two items are highlighted on each: serious injuries such as a fracture and resident to resident altercations. The abuse prohibition / vulnerable adult policy was attached. No further documentation was provided on any education provided to staff regarding these incidents. Furthermore, no documentation was provided on how to ensure other resident safety with a resident with known and multiple aggressive behaviors. Documents provided by facility after survey exit, on 6/17/24, included R17 and R82's care plan with highlighted areas, ACP notes for R17 and R82, timeline of events following 2/1/24 and 6/9/24 incidents and R82 medication changes were reviewed. The additional documentation lacked evidence on how the facility ensured through specific interventions, staff education, or care planned interventions to ensure the safety of R17 from physical abuse from R82 who had known history and increasing aggressive behaviors. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy, review date 3/24, was provided. The document indicated the purpose is to protect resident against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse. Furthermore, under the prevention section, The Interdisciplinary Care Plan Team reviews residents requiring behavioral interventions at least quarterly and/or during Target Behavior meeting to develop individual behavior plans.

Based on observation, interview and document review, the facility failed to promote a dignified environment for 3 or 4 residents (108, R2, R49) reviewed for resident rights. Findings include: R108's quarterly Minimum Data Set (MDS) assessment, dated 5/14/24, indicated R108 had severe cognitive impairment and required partial to moderate assistance with activities of daily living (except eating) and ambulation in the unit hallways. During observation on 6/12/24 at 7:00 a.m., R108 and seven other residents were seated out in the dining room. Four of the residents had coffee in front of them and four had empty juice and coffee cups sitting in front of them. No interaction was observed between staff and residents as staff was still getting residents up for the day. During an interview and observation on 6/12/24 at 7:31 a.m., clinical coordinator and licensed practical nurse (LPN)-D stated breakfast was not served until around 8:30 most days, which was a long time for these residents to wait. During observation on 6/12/24 at 8:03 a.m., residents were still sitting in the dining area, a total of sixteen residents now, four residents with empty juice and coffee cups in front of them. One resident observed sitting at a table alone, with her forehead resting on the table. During observation on 6/12/24 at 8:10 a.m., there were eighteen residents out in the dining room, juice and coffee at the tables but no food at this time. Outside of the dining room was an empty sitting area with a television, one recliner, one love seat, one side chair and multiple dining room chairs and space for wheelchairs. During an interview on 6/12/24 at 8:12 a.m., certified nursing assistant (CNA)-J stated the process he followed was to get the residents who needed the most care up first and bring them out to sit in the dining room followed by residents who could ambulate on their own. CNA-J stated this order of getting residents up was for convenience to ensure they had enough time to get up all residents up before breakfast. During an interview and observation on 6/12/24 at 8:22 a.m., R108 stated she was still waiting on breakfast (was observed in the dining room since 7:00 a.m.), stating I am hungry, hopefully soon. The residents in the dining room were becoming restless and loud as they were still waiting for breakfast, with residents who were ambulatory getting up and leaving the dining room area. During observation on 6/12/24 at 8:27 a.m., R108 was yelling out, I am hungry! from her seat at the table in the dining room. During observation on 6/12/24 at 8:35 a.m., a metal cart with breakfast trays was brought into the dining room and the first residents were served their breakfast. Residents at the same table were not served at the same, with 4 tables having one resident eating and the others at the table without food. Residents who required assistance with eating were served before residents who could feed themselves. All residents were served their food by 8:42 a.m. During an interview on 6/12/24 at 2:05 p.m., clinical coordinator and LPN-D stated each CNA had their own process for how and when they would get the residents up each morning. LPN-D stated breakfast used to come up earlier, around 7:30 a.m. - 7:45 a.m., which worked out better for the residents, stating the staff try to entertain the residents as best they can while waiting for breakfast. LPN-D stated it gets hard to keep the residents calm in the dining room, stating you can feel the energy change in the room as time goes on and it felt like we [staff] are just waiting for something to happen. LPN-D stated bringing the residents out to the TV room while waiting for breakfast was not something they had tried before but could try to reduce the institutionalized feel of the breakfast meal. During an interview on 6/13/24 at 1:51 p.m., the director of nursing (DON) stated they had just hired a new dietary manager and were working on food times and mealtimes, stating mealtimes used to be earlier. The DON stated the expectation would be to keep the residents engaged while waiting for breakfast either in their room or out in the main TV area. Clothing Labels R108's quarterly Minimum Data Set (MDS) assessment, dated 5/14/24, indicated R108 had severe cognitive impairment and partial to moderate assistance with activities of daily living (except eating) and ambulation in the unit hallways. During observation on 6/10/24 at 4:04 p.m., R108 was sitting in the main dining area, wearing blue slippers with her first and last name visible on the top of her slippers. During observation on 6/11/24 at 2:41 p.m., R108 was sitting in the main dining area, wearing blue slippers with her first and last name visible on the top of her slippers. During observation on 6/12/24 at 7:26 a.m., R108 was sitting in the main dining area, wearing blue slippers with her first and last name visible on the top of her slippers. R2 was also sitting at a table with her first and last name visible on the outside of her slippers. During an interview on 6/12/24 at 2:05 p.m., clinical coordinator and LPN-D stated she was aware clothing labels being visible on the outside of clothing was a dignity concern for residents, confirming the label should not be visible on R2's or R108's slippers. During an interview on 6/13/24 at 8:27 a.m., laundry aide (LA)-A stated the process for labeling clothing, including slippers and socks, was to label clothing on the inside of clothing for the safety of the residents. During an interview on 6/13/24 at 1:51 p.m., the director of nursing (DON) confirmed the expectation for labeling clothing was to place all labels on the inside of clothing. 49034 R49's quarterly MDS dated [DATE], indicated R49 had moderate cognitive impairment and was diagnosed with kidney disease, depression, and a stroke with aphasia (a disorder affecting speech). The MDS indicated R49 was able to independently wheel 50 feet, required set-up help for eating, and was dependent on staff for transfers. R49's care plan dated 4/8/24, indicated R49 enjoyed watching television, visiting the courtyard, and socializing with peers. The care plan indicated staff would assist R49 with activities as needed and encourage and invite R49 to said activities. During an interview on 6/10/24 at 2:29 p.m., family member (FM)-B stated R49 had a stroke and had resulting difficulties with speech but R49 still knew what he wanted and was able to communicate through nodding to yes or no questions. FM-B stated when he came to visit, he would often find R49 sitting in the dining room with no activities going on or a television playing. FM-B stated it bothered him R49 was left there with nothing to do as he knew R49 would not like this. FM-B stated R49 was always an independent person and didn't necessarily like other group activities but had always liked to watch television. During an observation on 6/13/24 at 8:24 a.m., R49 was observed sitting at a dining table on the far-right side of the dining room facing the wall. During an observation on 6/13/24 at 8:42 a.m., R49 was observed sitting at a dining table eating breakfast. During an observation on 6/13/24 at 9:06 a.m., R49 was observed sitting at a dining table by himself eating breakfast. During an observation and interview on 6/13/24 at 9:19 a.m., R49 was observed sitting at a dining table by himself and when asked if he was done eating, R49 nodded his head yes. During an observation on 6/13/24 at 9:31 a.m., R49 was observed sitting at a dining table by himself. During an observation on 6/13/24 at 9:49 a.m., R49 was observed sitting at a dining table by himself facing the wall on the right side of the dining room. Three other residents were observed sitting around a table facing and watching television on the left side of the dining room (behind R49). When R49 was asked if he would like to watch television, he nodded his head yes. When asked if anyone had offered to bring him over to the television, he shook his head no. During an observation and interview on 6/13/24 at 9:51 a.m., housekeeper (H)-A was observed sweeping up food debris from the dining room floor. H-A stated she had seen R49 and other residents sitting in the dining room with no entertainment for a long period after meals and this had led to residents becoming visibly upset to the point of crying in the past. During an observation on 6/13/24 at 10:07 a.m., R49 was observed sitting at a dining table by himself facing the wall on the right side of the dining room. R49 was observed attempting to push himself away from the table but the right wheel appeared locked so the wheelchair turned to the right but appeared unable to move farther. R49 was then observed to put his head in his hand and look down towards his lap. During an observation on 06/13/24 10:23 AM, RN-E, the nurse manager for the unit, was observed to approach and quickly converse with R49 and was then observed to leave the dining room. During an observation on 6/13/24 at 10:43 a.m., activity staff (A)-B was observed to approach R49 and ask if he wanted to sit by the tv, he nodded yes, and she pushed him in his wheelchair and sat him with the other residents watching television. During an interview on 6/13/24 at 10:48 a.m., RN-E stated she did not think anyone had offered to assist R49 to the other side of the dining room to watch television with the other residents until the occurrence at 10:43 a.m. RN-E stated she would have expected floor staff to offer R49 assistance to the other side of the dining room to watch tv or take him back to his room. During an interview on 6/13/24 at 1:47 p.m., the DON stated she would have expected floor staff to assess what R49's preferences were after a meal, such as returning to his room or participating in other activities. The DON stated she would not want R49 stuck sitting alone at his table with nothing to do as it could lead to feelings of sadness. Facility policy on dignity was requested and not received.

Based on interview and document review, the facility failed to routinely assess skin conditions and implement interventions for 1 of 1 residents (R1) reviewed for quality of care. This resulted in actual harm to R1 who admitted to the facility following surgical repair of abdomen due to cancer, did not receive wound care for nine days, and was re-hospitalized due to severe sepsis. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated R1 was cognitively intact had diagnoses of cancer, diabetes mellitus, major surgery involving gastrointestinal tract involving abdominal contents with surgical wound care. The MDS further indicated R1 does not reject care, required supervision with activities of daily living (ADLs), occasionally incontinent of urine, frequently incontinent of bowel, received parental intravenous feeding, and a mechanically altered diet. R1's Care Plan dated 2/21/24, indicated R1 had generalized weakness due to recent surgical removal of pancreas related to malignant neoplasm of extrahepatic bile duct, intrahepatic bile duct carcinoma and fistula of the intestines. The care plan indicated R1 had alteration in skin integrity due to ostomy in place with window to provide wound care and directed staff to monitor skin integrity daily during cares, and treatment to open areas per order with weekly measurements and assessment of wound. R1's signed physician orders dated 1/25/24, indicated wound or incision care for skilled nursing facility: Please change wound pouch once weekly or more frequently as needed if it is leaking, etc. Remove old Kerlix packing and exchange for new dry Kerlix packing twice daily or more as needed. If pouch is leaking, remove pouch and clean skin. If comfortable, can attempt to reapply pouch: cleanse and dry skin thoroughly. Apply Cavilon Advanced to all intact skin around wound and allow to dry. Apply barrier ring along bottom half of wound edge. Cut pouch slightly larger than wound, enter around wound and apply consistent pressure to encourage adherence. If unable to get pouch to adhere or uncomfortable changing can initiate normal saline moistened Kerlix packing, cover with ABD and secure with Medipore tape. Change BID (twice daily) and PRN (as needed) for saturation. Cover with ABD (abdominal pad) then abdominal binder. R1's Treatment Administration Record (TAR) 2/1/24 through 2/13/24 , directed staff to do the following: Wound or Incision Care: Once weekly and PRN for leaking. Remove old Kerlix packing and exchange for a new dry Kerlix packing BID or more PRN. If pouch is leaking, remove pouch and cleanse skin. Can attempt to reapply pouch Cleanse and dry skin thoroughly. Apply Cavlion advanced to all intact skin around wound, allow to dry. Apply barrier ring along bottom half of wound edge. Cut pouch slightly larger then wound, enter around wound and apply consistent pressure to encourage adherence every evening shift every Thursday. The treatment sheet indicated all days were marked with a X except Thursday February 1st and February 8th 2024. Review of the TAR from 2/1/24 through 2/13/24 indicated the following: 2/01/24- indicated the treatment was completed with a initials 2/08/24- indicated initials by a nurse representing the treatment was completed. R1's Wound Care Pancreatic Surgery Follow up Progress Note Dated 2/09/24, indicated: The patient's hospital course was complicated . She had Colorectal surgery and wound ostomy assisted with wound cares and the patient currently has an ostomy pouch with dressing changes twice daily. Discharge Summary dated 2/21/24 at 11:14, indicated R1 was admitted on [DATE], for severe sepsis secondary to colocutaneous fistula and cellulitis (Subcutaneously fistulas are abnormal communications between the colon and the abdominal skin. Cellulitis is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). During interview on 2/28/24 at 7:45 a.m., registered nurse (RN) case manager from [NAME] Hospital stated she spoke with the physician assistant (PA)-A from surgical unit who informed her R1 was admitted to the hospital on 2/13/24, with severe sepsis probably due to lack of wound care and stated the PA-A informed her she changed R1's dressing on 2/09/24, and on the same day she was admitted to the hospital with sepsis (2/13/24). RN added, during the exchange PA-A informed her the dressing should have been changed twice daily but was not. During interview on 2/28/24 at 10:52 a.m., heath unit coordinator (HUC)-A stated she transcribed the orders and missed the second order for the dressing to be changed twice daily. In addition, the HUC-A stated after she transcribes the orders onto point click care (PCC) two other nurses are to check the orders in addition to the nurse manager which did not occur. During interview on 2/28/24 at 3:03 p.m., registered nurse (RN)-B stated he had only worked with R1 once but had never seen her wound. When surveyor questioned RN-B if it was his initials on the dressing change dated 2/8/24 (Thursday), he stated again that he had never seen R1's wound and that the NP was in the building and must have treated her would so he signed off on it. During RN-B's interview HUC-A overheard the discussion and denied the NP saw R1 on 2/8/24 as she was not on NP's schedule that day. RN-B verified according to the TAR the only time the dressing was changed at the facility was on 2/01/24. R1's medical record lacked evidence of a NP visit on 2/8/24. During interview on 2/28/24 at 3:22 p.m., R1 stated the facility only changed her dressing once a week, and that is why she ended up in the hospital with sepsis. R1 stated she kept asking the staff to change her dressing and they told her they would but never came back to change it. R1 added that she knew it needed to be changed twice daily because that is what the hospital did. During interview on 2/29/24 at 10:05 a.m., surgical physician assistant (PA)-A stated R1 she was admitted to the skilled nursing facility on 1/31/24 and was supposed to have her dressing changed twice daily and as far as they know her dressing was changed only twice since her hospitalization on [DATE] with a discharge back to the facility on [DATE]. The PA-A stated R1 was seen at the clinic on 2/9/24 and her wound looked okay and then on 2/13/24, they were shocked to see she had the same dressing on since the 2/09/24 appointment and her wounds had cellulitis on the top of the wound with purulent drainage. The PA-A stated the lack of dressing changes definitely contributed to her sepsis and with stool coming out of the fistula she was surprised R1 did not get sick sooner. During interview on 2/29/24 at 1:36 p.m., the facility RN case manager (interim assistant director of nursing)(RN-C) stated she had worked with R1 once on 2/22/24, upon her return from the hospital. RN-C described the process for transcribing new orders, stating the HUC would transcribe the orders, then the nurse checks the orders to ensure accuracy and then a second nurse confirms the order and lastly the nurse manager is to finalize the orders. All individuals in this process should sign off. In reference to R1's initial orders on 1/31/24 upon admission, RN-C stated the check should have been completed and she would need to located the paperwork with the initials and send that to the surveyor. As of 3/04/24 (2 days following exit), no paperwork had been received by the facility. On 2/29/24 at 2:00 p.m., RN-C provided the facility's wound measurements which identified the following: -On 1/31/24, R1 had a superior surgical wound measured area -13 centimeters (cm), length 5.63 cm, width 3.03 cm and deepest point 2.2 cm. The facilities next measurement was not until 2/22/24 at 11:49 a.m., which identified the following after R1 was hospitalized from 2/13/24 to 2/21/24: -on 2/21/24 R1 had a superior surgical wound measured area - 3.23 cm, length 7.95 cm, width 1.25 cm and deepest point 2 cm. The measurements showed a increased improvement to R1's wound since hospitalization . During interview on 2/29/24 at 11:00 a.m., the facility administrator stated the director of nursing had been out now for a few weeks and the assistant of director of nursing (ADON) had just quit. The administrator stated they have recently hired a new ADON and are hoping things will get better. Administrator acknowledged the orders were not followed. Skin Wound Management Policy revised 2/2024, indicated a weekly skin inspection will be completed by a licensed staff. When a significant alteration in skin integrity is noted the following actions will be taken: Notify Provider/Treatment Ordered, Notify resident representative, complete education with resident/resident representative including risk nd benefits, initiate skin and wound evaluation.

Based on observation, interview, and document review the facility failed to comprehensively assess for appropriate level of supervision for safety in the community for 1 of 3 residents (R1) who had cognitive impairment and a history falls in the community unsupervised. The facility failures resulted in an immediate jeopardy (IJ) when R1 was assaulted and suffered facial injuries while out in the community. The immediate jeopardy began on [DATE], when R1 left the facility without staff awareness, was found by law enforcement 9.3 miles away with facial injuries and transferred to hospital. The immediate jeopardy was identified on [DATE], and the administrator was notified on [DATE], at 4:14 p.m. The immediate jeopardy was removed on [DATE], at 4:02 p.m. but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal that is not immediate jeopardy. Findings include: R1's Admission record included diagnosis of alcoholic cirrhosis of liver with ascites (build up of fluid in the belly), alcohol dependence in remission, anxiety disorder, repeated falls, and altered mental status unspecified. R1's significant change Minimum Data Set (MDS) dated [DATE], noted R1 was cognitively intact. R1 was independent with activities of daily living (ADL)'s. R1 required setup help only with eating, personal hygiene, and bathing. R1 was always steady with walker. R1's Elopement Risk Evaluation dated [DATE], at 10:18 p.m. indicated R1 was not at risk for elopement. R1's fall care plan initiated on [DATE], included R1 was at risk for falls with a history of not complying with leave of absence (LOA) policy. Falls/being pushed by someone-which has resulted in skin tears, bruises, and pain. Corresponding interventions dated [DATE], included R1 is not required to have an escort with him for all outings. R1's cognition care plan dated [DATE], identified R1 was at risk for alteration in cognition due to diagnoses of altered mental status and alcohol abuse; Associated Clinic of Psychology (ACP) resident continued to present with a level of memory loss that would suggest a dementia syndrome. Corresponding intervention was to provide and maintain a consistent environment. R1's record did not include a comprehensive assessment that addressed R1's vulnerabilities and safety needs in the community. R1's Release of Responsibility for Leave of Absence form, indicated R1 had signed himself out 8 times between [DATE] through [DATE]. The form included: date out, time out, signature of person accepting responsibility, destination contact person phone number, date of return and estimated time of return. Not all of R1's entries on the form were completed and/or legible, including the date, time out, date/time returned. The Destination section included only a phone number. Additionally, R1's progress notes did not include entries when R1 had signed himself out of the facility or that he had notified staff when he left the faciity on the recorded dates. R1's progress note dated [DATE], included R1 left on LOA at 4:45 with his walker, did sign out, said he's going to his mom's house and will be back at 6:00 p.m. Further indicated staff asked R1 if someone was picking him up, R1 responded, yes. Review of the LOA form identified R1 signed out however, the date was not clearly written and looked like [DATE]. R1's progress note dated [DATE], at 8:35 p.m. authored by a registered nurse included At around [SIC] the writer received a call [did not identify who called] that the resident was seen walking along Texas Avenue. I went and met him seated on the side of the road. I asked him where he was going and he said, I was waiting for my ride of which has not come and I decided to [NAME] cub foods and buy some fruits. The writer assisted him into the vehicle and brought him back without any issue. Nursing to continue to monitor Review of the LOA log that appeared to identify [DATE] did not include a time of when R1 returned to the facility. R1's progress note dated [DATE], at 2:03 p.m. indicated physical therapy (PT) and occupational therapy (OT) both reported a decline in resident's participation. R1 was rated moderate to high risk for falls. R1 was currently an assist of one staff/supervision with his walker but had been seen carrying his walker instead of walking with it. Also, non-compliant with using his call light for assistants. R1 scored a ,d+[DATE] on the St. Louis University Mental Status (SLUMS) Alzheimer screening suggesting a mild neurocognitive disorder (decreased mental function, but able to stay independent and do daily tasks). R1's progress note dated [DATE], at 1:36 p.m. indicated R1 had an appointment, and a community escort service would pick up R1. Nurse manager stated resident was ok to go unescorted if he has door to door services. R1's progress note dated [DATE], 10:30 p.m. indicated resident came to desk and reported he had a fall outside in the courtyard, he stated he tried to jump over the flower beds and was instructed to stay on the sidewalk. R1's Elopement Risk Evaluation dated [DATE], at 10:18 p.m. identified R1 was not a risk for elopement. No other elopement assessments were completed after that date also there was no indication of the SLUMS assessment completed on [DATE], identifying he had mild neurocognitive disorder. R1's progress note dated [DATE], 10:49 p.m. indicated R1 went out for paracentesis (procedure to remove extra fluid from the belly) and decided to go to Taco Bell. The transportation driver went to pick R1 up from the appointment, but he was not there and was not receiving his calls. At around 5:00 p.m. he was brought back to the facility by the health unit coordinator (HUC.) R1 stated he fell and that was why he was soiled all over. R1 was to be accompanied to all upcoming appointments for his safety. Physician order dated [DATE] included resident to go with a responsible party to his paracentesis appointments going forward. R1's physician progress note dated [DATE], nurse practitioner (NP) indicated R1 falls frequently likely related to hepatic encephalopathy (complication of cirrhosis of the liver that causes mental and physical symptoms), he reported that he was inconsistently taking his lactulose (medication that lowers ammonia in the blood). R1's physician progress note dated [DATE], indicated R1 sodium had slowly improved but he continued to be non-compliant with fluid restrictions, impaired decision-making as shown in his fluid noncompliance despite extensive education as well as frequent excursions from the building with frequent falls. Last week was found to have Ativan (medication used to treat anxiety) at bedside filled by an outside provider. Assessment indicated R1 appeared to have severe impaired decision-making. Despite education on topics such as fluid restrictions he continues to disregard advise and puts himself in critical danger. He also has frequent falls, fell off a retaining wall last week, days later he took himself to Taco Bell after his paracentesis and had another fall, was found incontinent with soiled pants, and returned to the facility. Provider ordered patient not to leave for his paracentesis without an escort. R1's progress note dated [DATE], at 5:48 p.m. indicated R1 approached health unit coordinator (HUC) and stated Hey guess what? I don't have to have an escort anymore. I talked to the bosses up front, and they said it's probably been long enough and nothing bad has happened, so they will just ask therapy to make sure. And I can wrap around the block alone too since I haven't tried to run off. The note indicated R1 did not know who he talked to or what they looked like. HUC spoke with admin personnel who informed R1 had not been cleared by therapy to go out alone. R1's progress note dated [DATE], 7:02 p.m. included Writer called patient [R1] to know his whereabouts after he was noted to take off the grounds. He stated that he went to help his friend to change a flat tire. He stated he will be back soon. He was reminded of the need to sign out LOA whenever he leaves the building. The facility LOA log dated [DATE], did not identify R1 signed himself out. Further R1's record did not identify when R1 returned to the facility and/or if R1 was assessed for injuries or other changes upon his return. R1's ACP visit note dated [DATE], 3:57 p.m. indicated R1 scored ,d+[DATE] on SLUMS Alzheimer screening which indicated ,d+[DATE] was dementia. R1 appeared to be functioning adequately within the secure setting and continued to present with memory loss. He was most likely dependent in all ADLs at this time. R1 would most likely benefit from power of attorney (POA) or guardianship if not already in place. He was struggling cognitively and most likely not presenting with the capacity to make good decisions. He appeared to want to do well but struggled to follow through. R1's physician note dated [DATE], included R1's mentation is a bit foggier today, having very mild word finding difficulty (Struggling with more complex words like Hernia, Butrans patch). More lethargic than normal. Physician gave order to send R1 to the emergency department (ED) for imaging to rule out abdominal Hernia strangulation/incarceration. R1's hospital notes dated [DATE] indicated R1 was admitted to the hospital on [DATE] for abdominal pain and distention. R1 was discharged back to the facility on [DATE], at 1:19 p.m. however, a couple of hours later R1 was returned to the hospital by emergency medical services (EMS) after he had been found down with a temperature of 102.7 degrees Fahrenheit and incontinent of urine. R1 was subsequently readmitted to the hospital on [DATE], with diagnosis that included heat stroke, fever, and syncope, he was discharged back to the facility on [DATE]. R1's progress note dated [DATE], indicated R1 was readmitted from the hospital at 2:00 p.m. R1 stated the driver dropped him at the front entrance but could not remember the name of the company or vehicle that transported him. R1's progress note dated [DATE], at 10:16 p.m. R1 readmitted earlier today. At around 6:00 p.m. R1's family member (FM)-A called the facility and asked if R1 had arrived safely from the hospital. FM-A was told R1 was in the facility and had last been seen around 5:30 p.m. walking down the hall. At 8:30 p.m. FM-A called again and informed the facility that R1 had called her and told her he was in Bloomington and wanted FM-A to pick him up. FM-A stated soon after that call she was unable to reach R1. A search within the facility and surrounding areas was conducted and R1 could not be located. R1 had not signed the LOA book or informed staff he was leaving. Police were called and a missing vulnerable adult report filed. Police were given FM-A's phone number as she was the last person to speak to R1. At 10:00 p.m. police called the facility to report they had located R1 in Edina and were sending him to the hospital for an evaluation as he had blood on his shirt. St. Louis Park Police Department report dated [DATE], at 9:40 p.m. indicated a missing person report was filed and officer had been dispatched to the facility. Officer reported she had talked to staff and been informed that R1 was a vulnerable adult and was missing from the facility. Officer stated facility informed her that they had recently talked to FM-A who advised them R1 was in Bloomington. FM-A also informed officer, R1 had kidney failure, which often caused him mental health issue and R1 had just been discharged back to the facility that morning. While officer was talking to FM-A R1 again called FM-A and stated he was in Edina at a car wash. FM-A called Edina police department, they located R1, he had been covered in blood, and they would be taking him to the hospital. R1's emergency department notes dated [DATE]-[DATE] indicated R1 presented to the ED for a fall evaluation following a missing person report. R1 told hospital staff he got back to the nursing home last night but then he wanted to go out to get some nicotine and soda. He took an Uber to convenience store. Then at the convenience store, he could not get his phone to work right to get another Uber. R1 reported to the police he had been assaulted; he was pushed from behind and fell forward into railing causing an injury to his face/mouth. He did not lose conscious. R1 reported pain to his upper lip. Physical exam identified an abrasion to the upper lip and chin contusion. Notes indicated because R1 was not the best historian, physician ordered imaging for the head/neck, which were negative for acute brain bleed and concussion. R1 was discharged from the hospital back to the facility on [DATE]. R1's progress note dated [DATE],a t 2:51 a.m. indicated R1 would be returning to the facility with no new orders. Further review of the notes did not identify what time R1 was readmitted to the facility. However, note dated [DATE], at 3:31 p.m. indicated he met with his mental health provider. R1's record reviewed between [DATE] to [DATE], identified R1 on [DATE] resident had an unwitnessed fall, was shaking uncontrollably, and was readmitted to the hospital. On [DATE] R1 returned to the facility on [DATE] at 1:34 p.m. however, note at 6:05 p.m. indicated R1 had a fall with head strike and was sent back to the hospital. R1 subsequently died on [DATE]. During an interview on [DATE], at 2:00 p.m. RN-A stated he had worked with R1 several times and had worked the night of [DATE]. RN-A had seen R1 after dinner walking in the hallway. Ten minutes later R1's FM-A called and informed her R1 had returned from the hospital and had just seen him. Later at almost 8:00 p.m., FM-A had called again saying R1 had just called her and was lost somewhere. RN-A told FM-A he was not aware of R1 leaving the building. RN-A checked the LOA book and with other staff members and found out R1 had not signed out nor informed any staff he was leaving. RN-A had the staff search the building, he drove around the neighborhood, and was not able to find R1. Around 8:00 p.m. to 9:00 p.m. RN-A called [DATE] to file a missing person's report. RN-A reported to the police the details he had been given from FM-A and her phone number. The police later called back to the facility informing they had located R1 and he was taken to the hospital because he was bleeding. RN-A indicated after he returned from the hospital there were no treatment or care plan changes. R1's ACP visit notes dated [DATE], 3:32 p.m. indicated R1 was lethargic but cooperative with the interview. R1 struggled to identify what had happened but talked about being pushed in the local community. He remembered walking and walking for a long time but that was all he could remember. R1 scored ,d+[DATE] on his SLUMS presenting with deficits in short-term memory and comprehension. This level of cognitive impairment would suggest dementia. Ruling out dementia will be of value to help guide treatment interventions and placement. R1 most likely needed more help than he believed in staying on top of his medical appointments. R1 continued to present with dysfunctional behavior without insight. R1's SLP Evaluation and Plan of Treatment dated [DATE] indicated reason for referral to SLP to assess patients' cognition to determine if he requires guardianship per social work. Patient has had a history of unsafe LOA's. R1's Brief Cognitive Assessment Tool (BCAT) was ,d+[DATE] indicating mild dementia, ADL deficit, typically requires residential support services, clear objective evidence of memory and other cognitive declines. Prior therapy indicated patient was noncompliant with treatment and refused therapy (,d+[DATE]-,d+[DATE]). During an interview on [DATE], at 9:10 a.m. assistant director of nursing (ADON) stated R1 had one fall on [DATE] after going to his paracentesis appointment. After the appointment, he had walked to McDonalds and slipped in the mud. He then called the facility to request a ride back. Following the incident, the team discussed R1's elopement risks, looked at his BIMS (brief interview for mental status) score on [DATE] that listed him as cognitively intact, and his [DATE] PT discharge summary that stated he was able to walk unlimited distance. Administration made the decision after R1's [DATE] fall that he could go out independently. On [DATE], at 1:08 p.m. an unsuccessful call was placed to nursing assistant (NA)-B. A message was left with no return call. On [DATE], at 1:11 p.m. an unsuccessful call was placed to NA-C. A message was left with no return call. On [DATE], at 1:11 p.m. NA-D stated she did not remember R1 nor if any residents had been missing from the facility. On [DATE], at 1:15 p.m. an unsuccessful call was placed to NA-E. A message was left with no return call. On [DATE], at 1:15 p.m. an unsuccessful call was placed to NA-F. A message was left with no return call. During an interview on [DATE], at 2:00 p.m. RN-A stated he was not aware if R1 had ever signed himself out on the log form without his knowledge or if R1 had left the facility without his knowledge. RN-A thought R1 was safe to be in the community unsupervised because he would say where he was going, what he was doing, and when he would return. RN-A stated he had not completed a community safety assessment and he was not aware of formal process that determined a resident's ability to be independent in the community. During an interview on [DATE], at 1:42 p.m. RN-B stated elopement risk evaluations were completed on all residents. If a resident was a high risk for elopement a wander-guard safety device was placed on the resident that alerted staff when the resident left the facility. RN-B explained if the resident was confused, or they had frequent falls it would not be appropriate to allow the resident to leave the facility unsupervised. RN-B indicated he frequently worked with R1 and thought despite R1's waxing and waning cognition he was safe to leave the facility without supervision. RN-B indicated if a resident needed an escort there would a note in their record under the special instructions that would instruct if an escort was required. RN-B could not recall if R1 had special instructions. Residents who are able to leave the facility unsupervised are given risks and benefits and were supposed to sign out on the LOA form. If the resident did not sign out, RN-B would report it to the supervisor. During an interview on [DATE], at 2:31 p.m. RN-C stated she worked with R1. RN-C stated R1 was pretty independent, he needed help with little things. RN-C did not recall R1 being confused but had started getting weaker and more forgetful, however was not sure when. RN-C recalled R1 getting lost after an appointment. RN-C thought maybe after that happened, he required an escort when he went out for appointments but was not aware if he could sign himself out of the facility. During an interview on [DATE], at 10:37 a.m. social worker (SW) stated therapy usually would do an assessment for resident safety in the community. SW was not sure who was responsible for putting the information into Point Click Care (PCC-electronic health record) under the resident's profile. The interdisciplinary team (IDT) which consisted of nursing, therapy, social workers and administration, discussed the residents and would make the decision if someone can go out on LOA or leave independently. SW was not aware of a formal assessment and hoped the HUC had a list of residents who needed escorts for supervision to appointments in the community. During an interview on [DATE], at 1:22 p.m. health unit coordinator (HUC) stated she looked at the special instructions in PCC on the resident's chart, if there were no instructions then resident is good to go independently. HUC stated she uses her common sense if she feels she needs to send an escort or not, if a resident seems confused or if she wonders about them, she will check with nurse managers, therapy, or social workers. HUC stated R1 would have community escort service or family go with him to all appointments after [DATE], however was not aware if R1 could leave the facility unsupervised for LOA's not associated with appointments. During an interview on [DATE], at 3:13 p.m. occupational therapy (OT)-A stated upon every resident admission OT would complete a SLUMS assessment. OT was unable to recall R1's admission SLUMS score. The OT-A progress note dated [DATE] indicated staff was unable to hold R1's attention to task when attempted to complete SLUMS cognition screening. OT-A stated the SLUMS assessment helps to identify if a resident would be safe in the community, helps the nurses determine how to provide care, and how much supervision is needed. R1 was discharged from OT on [DATE], with a history of refusals. OT-A reported R1's last Montreal Cognitive Administration and scoring (MOCA) completed by speech language pathologist (SLP) was ,d+[DATE] with 26 or above considered normal. A score of 21 suggests mild Alzheimer's disease this had been completed at the start of therapy dated [DATE]. OT-A stated based on the information he could locate in the computer for R1 it would not have been recommended that he be able to leave the facility independently. During an interview on [DATE], at 3:43 p.m. assistant director of nursing (ADON) stated the facility did not have a formal system in place to make the decision of residents going into the community independently or with escorts. ADON stated the IDT would discuss the residents in morning meetings and decide who was able to be independent and or needed escorts to appointments, who was requesting LOA's ect. ADON stated the IDT made the decisions, but the nurse managers thoughts carried the most weight in the decisions because they worked most with the residents. ADON indicated there was documentation of the IDT's decision making related to R1's ability to leave the facility without supervision. During an interview on [DATE], at 8:17 a.m. with NP stated she believed R1 would be safe to be independent in the facility but would not consider him safe to go into the community independently. NP stated she was not involved in the decision making of him being able to leave the community. NP stated she believed the order she made on [DATE] made it clear R1 needed an escort to his appointments. She would not feel safe with him to be alone in the community. During an interview on [DATE], at 10:18 a.m. administrator stated IDT reviewed residents in morning meetings and discuss residents and the appointments. Administrator stated the facility does not have a formal assessment to decide if a resident is safe to go out independently on appointments or LOA's. Administrator stated she did recognize the facility needed a better way to determine if a resident is safe to leave independently or not. Based on her understanding R1 was ok to leave independently on [DATE] and because of that did not feel it was a reportable elopement. Administrator could not articulate how they made the determination that R1 was safe to leave independently. A facility policy titled Elopement Policy, revised ,d+[DATE], indicated Monarch Healthcare Management is committed to provide a safe environment for all residents. Assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. The immediate jeopardy that began on [DATE], was removed on [DATE] and was verified through observation, interview and document review, when the facility implemented the following interventions: -created and established community safety assessment for all residents -provided education related to the Leave of absence (LOA) orders and process specifically related to resident's going alone in the community to nursing, social services, therapy, and IDT/leadership on or before the start of their next shift -Created a plan for DON or designee to conduct audits on all new admissions, changes in conditions, and/or falls in the community for residents on independent LOA's

Based on interview and document review the facility failed to ensure residents were free and protected from ongoing verbal, physical abuse, and deprivation of goods by nursing assistant (NA)-A for 11 of 13 residents (R1, R2, R3, R4, R5, R9, R10, R11, R12, R13, R14) who identified abuse by NA-A and were dependent on staff for daily living needs. The facility's failures resulted in an immediate jeopardy (IJ). The IJ began on 5/12/23 when NA-A returned to work after an allegation of sexual and physical abuse. This resulted in ongoing resident complaints of aggressive rough handling, deprivation of services, and ongoing resident expressions of fear, demoralization, humiliation, shame, and degradation. The immediate jeopardy was identified on 6/2/23 and the administrator, assistant administrator, and the director of nursing (DON), was informed of the IJ on 6/2/23 at 9:37 a.m. The immediate jeopardy was removed on 6/2/23 at 4:27 p.m., but noncompliance remained at the lower scope and severity of level 2 E- pattern which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: Review of the facility reported incident dated 5/12/23, indicated employee (later identified as nursing assistant (NA)-A) and a resident (later identified as R1) was masturbating in R1's room, grabbing R1's ankles causing pain, and threatening to cause harm with a gun. The facility internal investigation for allegations submitted to the state agency (SA) on 5/18/23, identified NA-A was suspended immediately pending investigation and the allegations were unsubstantiated. Interventions included, R1 would see Associated Clinic of Psychology (ACP), the facility would attempt to keep NA-A off R1's unit, not work with her for as long as possible and only in the event of a staffing crisis. The facility's investigation did not identify NA-A was interviewed nor other staff interviewed regarding the allegations. NA-A's personnel file included a form titled Notice of Suspension Pending Investigation dated 5/12/23, that identified NA-A was suspended on 5/12/23 at 11:53 a.m. related to allegation of physical and sexual abuse. Further indicated, on 5/12/23 at 2:48 p.m., two hours and 55 minutes later, the facility had unsubstantiated the allegation, and NA-A's suspension was rescinded. The form was signed by NA-A, director of nursing (DON), human resource (HR) director, and administrator. In review of the facility's investigative file and NA-A personnel file did not identify any education was provided after the 5/12/23 allegations were made, NA-A returned to work the same day. NA-A's employees file contained the following documents titled teachable moments with relatable instances of reported concerns that did identify what had occurred; the file lacked details and/or investigation or education provided. -Document dated 10/6/17, indicated NA-A was suspended pending investigation of allegation related to joking that made a resident feel threatened. -Document dated 12/13/19, indicated NA-A had allegations of assault and refusal of cares resulting in education provided by facility as well as support of associated clinic of psychology (ACP). -ACP note dated 12/13/19, indicated NA-A was provided individualized education on dealing with resident with behaviors. Education including supporting and validating the resident and offering alternative approaches and responses to negative resident behaviors. NA-A provided personalized sample of appropriate statements to use in difficult situations. -Document dated 3/10/20, indicated NA-A had a reportable event and was investigated and unsubstantiated due to resident mental illness. During interview on 5/30/23 at 5:30 p.m., administrator stated she started with the facility on 3/13/23. Administrator indicated the facility completed a thorough investigation was completed and R1's allegations were not substantiated. NA-A was removed from R1's care team unless there was a staffing crisis. The facility could not guarantee he would never work with R1. Administrator indicated the investigation did not identify any other concerns about NA-A from other residents that were interviewed. Administrator stated she was not aware, and there was no indication of other resident abuse allegations currently that involved NA-A and/or other staff. Administrator indicated that full investigation was in file. R1's current face sheet identified R1's diagnoses included schizoaffective disorder-bipolar type, and obesity. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment, did not have sign/symptoms of delirium, and did not have behaviors. The MDS further indicated R1 required extensive assistance of two staff for transfers, toileting, dressing. R1 was always incontinent of bowel and bladder. R1's care plan dated 9/24/21, indicated R1 was at risk for abuse and or neglect. Interventions directed staff to be aware of statements or signs/symptoms of abuse. If they are present, update physician, director of nursing, and administrator immediately. Monitor for signs of emotional distress or mood/behavior changes and notify associated clinic of psychology (ACP) therapist of any allegations of abuse and/or neglect that involves resident. The ACP therapist will follow up with resident as needed. Safety monitoring will be implemented as needed to ensure residents safety (i.e. 15 min checks, 1:1, etc.) Staff will continue to follow the facility vulnerable adult & abuse reporting policy. The local Ombudsman, Adult Protection, Police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. During interview on 5/31/23 at 10:05 a.m., R1 was able to verbally recall NA-A by name and provided details of allegation she reported on 5/12/23. R1 was visibly upset during the interview as she described details, she looked down when speaking not making eye contact, clenched her jaw, displayed facial grimaces, and was wringing her hands or fidgeting. R1 described NA-A's behaviors as mocking, degrading, mean, stern, and yelled when he got angry. R1 stated NA-A would sometimes refuse to provide her personal cares. At times when NA-A had to provide cares, he would be physically aggressive and/or would mock her ability to care for herself. R1 explained she could not complete her own peri care, when she asked NA-A for help he would say things like you do it yourself, I am not going to do that. R1 reported NA-A had grabbed her left hand and ankle to pull her over onto her stomach in a quick motion that caused her to be in pain, when she asked NA-A what he was doing, NA-A responded in a sarcastic tone you know what I am doing. R1 stated she had recently informed NA-A of a family members funeral and NA-A responded by making insensitive sarcastic jokes about her attending. NA-A's joking comments were very degrading and made her feel ashamed. R1 indicated she has reported her concerns to the facility but felt the facility was not doing anything because NA-A's treatment and behavior towards her was ongoing. R1 stated she did not want NA-A to take care of her; she not only feared him taking care of her but also scared he would not provide cares. R1 stated since NA-A continued to care for her, she did not want to keep reporting her concerns in fear of further retaliation, and it would make things worse for her. R1 explained she tries to protect herself by staying in her room or leave the facility to avoid NA-A. During an interview on 6/2/23, at 10:40 a.m. family member (FM)-A stated she has been to the facility. FM-A explained had been a video camera in R1's room and had witnessed staff being rough with cares and verbally curt. FM-A indicated the camera kept getting unplugged. FM-A stated she did not report to administration, she was afraid R1 would be retaliated against by facility staff. FM-A reported this past Mother's Day she had come to the facility to give R1 a framed picture as a gift. Staff yelled at FM-A and made her feel as though she was a burden to the staff, although was unable to recall the names of staff members. FM-A indicated the video was not available for review. During interview on 5/30/23 at 4:38 p.m. NA-A stated he has had residents complain to him that he spoke meanly, but it was just the way he speaks. He has also had residents complain to him he was too rough when he provided care and when that happened, he would just apologize to the resident. NA-A stated he said things to residents in a joking manner that have been taken out of context, however, did not identify how his joking could be interpreted to some residents as offensive and demeaning. NA-A explained he was aware R1 had made allegations he grabbed her and threw her into bed with her clothes on. NA-A indicated he could not physically lift R1 on his own, so that allegation was not true. The day that R1 made the allegations (5/12/23), he was not placed on administrative leave, he gave a statement to administration, did not work with R1 directly, and was moved from R1's unit to another unit. NA-A further explained if R1 would be in the dining room and wanted food heated or wanted water, he could assist with those tasks. NA-A stated he did not receive any education/training. NA-A reported historically there have been residents that filed reports alleging he abused them but through the investigation it was determined to be untrue. NA-A stated he was not sure why residents kept on alleging he was abusing them. During a subsequent interview with NA-A on 6/2/23 at 8:07 a.m., NA-A gave an example of his joking around with residents would be; he would walk up to a resident and say, what's up man, he has a girlfriend call him all the time, is your girlfriend calling you, why doesn't she call you anymore. Ohhh does she not talk to you anymore NA-A indicated that because of R1's delusions you never know where she is going to stand when you are joking with her. NA-A indicated what R1 hears sticks, she keeps thinking about it. During interview on 6/1/23 at 7:11 a.m., licensed practical nurse (LPN)-A indicated NA-A jokes a lot and at times it may be too much, pushing the point of humor. LPN-A stated NA-A's jokes were not appropriate because they could be demeaning or offensive. One example is when NA-A went into the dining room, abruptly hit his palm on the table and say, okay residents I am here, which could frighten residents or be taken the wrong way. LPN-A has personally provided education/counseling to NA-A. NA-A seemed to understand the discussion in the moment, however, had not noticed any on-going changes. LPN-A did not document education/counseling provided to NA-A. LPN-A indicated she would report allegations of verbal abuse, however did not report NA-A's demanding and offensive jokes to administration or other team members. LPN-A indicated all staff were aware R1 repetitively made and reported allegations against NA-A and aware of the allegation R1 made on 5/12/23. LPN-A indicated R1 was not reliable; NA-A could not possibly pick up R1 and throw her as per the allegation. When R1 made that allegation to LPN-A, LPN-A told R1 oh you know he didn't do that. During an interview on 6/2/23, at 8:23 a.m. DON stated NA-A has a big personality, he would get excited and loud, and at times could be hard to understand. DON stated she was not able to give an example of NA-A's humor and had not worked with him or seen many of his interactions with the residents. DON stated she was aware of two reports against NA-A; the administrator and assistant administrator investigated them. DON indicated the administrator directed to have NA-A avoid R1, DON was not able to provide details of the facility's investigation. During an interview on 6/1/23, at 8:31 a.m. with RN-E nurse manager for 2nd floor stated he had done a verbal coaching with NA-A in February (2023) related to report of call lights not being answered and for not providing incontinence cares to residents or following up with the call lights. RN-E was aware of the investigation related to R1 and NA-A being suspended pending the investigation. RN-E stated he has never talked to R1 or her family about any care concerns. R2's current face sheet identified R2 had diagnoses that included morbid obesity and schizoaffective disorder, bipolar type. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment, did not have signs/symptoms of delirium, and did not have behaviors. R2 required extensive to total assistance from two staff for transfers, toileting, and dressing and was frequently incontinent of bowel and bladder. R2's care plan dated 4/22/21, indicated R2 was risk for alterations in behavior related to being a veteran in active combat during the Vietnam war. Behaviors included yelling, being jumpy, nightmares/night terrors, and depressive like symptoms. R2's care plan dated 11/10/22, identified a goal for R2 to remain free from abuse and/or neglect. Interventions included be aware of statements or signs/symptoms of abuse and update the physician, DON, and administrator immediately. During an interview on 5/31/23 at 8:13 a.m. R2 stated when NA-A worked it took a few hours to all day to get changed after having an incontinent accident. NA-A usually started his shift between 2:00 p.m. and 2:30 p.m., he (R2) would put on his call light for help, NA-A would come into his room and shut off the call light without providing care. That was a common practice of NA-A's. R2 indicated he took bowel medications and was sometimes incontinent of bowel that had a really foul odor that could not go unnoticed; NA-A still would shut off the call light and not clean him up. Instead, NA-A would respond by rudely and abrasively telling R2 I don't have time for you or this mess right now, we have other patients to take care of! R2 stated this made him feel embarrassed and ashamed for having accidents and sitting in urine and feces caused pain and sores on his butt. One time after R2 was told by NA-A he did not have time, R2 saw NA-A go sit down at a table in the dining room from 3:30 p.m. to 4:00 p.m. There was another time, when R2 was assisted to bed by NA-A, NA-A told R2 You get in that bed, you stay in that bed!. R2 indicated when asking for NA-A's help with personal cares NA-A would get sassy thinking he was funny, or it was a show of power over him. R2 thought NA-A's actions were willful and hurtful. R2 stated he has requested for NA-A to not provide him care anymore because of NA-A behaviors that made him feel worthless and undignified, however NA-A still provided care. R2 indicated he filed a grievance and reported it to the social worker, but no one has followed up with him and seemingly nothing done to correct R2's concerns. During a subsequent interview on 6/2/23, at 1:27 p.m. R2 stated when NA-A completed incontinent cares a while ago, he had scrubbed his scrotum so hard to the point of R2 had to say stop, it did cause a sore spot that got better. R2 stated his experiences with NA-A have made him feel withdrawn I just don't care anymore, I just want to quit dealing with being treated this way. R2 stated he wanted to move to another facility because of how NA-A treated him and the pain NA-A caused when he provided care to him. Facility grievance dated 4/6/23, indicated R2 turned on call light at 1:30 p.m. NA-A came into room at 2:00 p.m. NA-A turned off the call light and left the room. It was not until 6:30 P.M. that night when he received assistance to change his incontinence pad. The form did not identify any actions taken, there was no indication the grievance was investigated or resolved. During interview on 6/2/23 at 8:49 a.m., FM-B stated she has had to call the facility to have staff provide incontinence care to R2 on multiple occasions. She was upset regarding the lack of care R2 received and has tried to report concerns to different facility staff. FM-B indicated that she has reported concerns several times to the DON and felt she was being ignored. When she reports concerns it was a temporary fix, as in someone will go up to the floor to address it at that time, but there has been no permanent solution or resolution of ongoing issues. FM-B explained she lived out of state, because of the unaddressed concerns she needed to purchase a video phone. FM-B has witnessed via video call on different occasions (could not recall dates), waiting for hours at a time to be changed after incontinent episodes.FM-B was unable to provide video. FM-B heard NA-A say to R2 If I change you, you know you have to stay in bed. Some days R2 was not able to get out of bed even if he asked staff and R2 would tell her after he was cleaned, he still smelled of feces. FM-B indicated she thought R2 was being bullied in the facility and should not need to beg to go to the bathroom or get out of bed and receive basic needs. FM-B stated R2 has told her he had depressed feelings and sadness regarding his care at the facility. FM-B reported she has noticed R2 was more and more withdrawn since admitting to the facility. He did not engage in the typical things because of the lack of opportunity to have been provided basic activities such as sitting on a toilet. During an interview on 6/1/23 at 2:46 p.m. RN-A indicated he worked on the overnight shift with NA-A. RN-A indicated that nurses should know and be involved in the grievance process. RN-A stated he was not aware of any grievances filed by R2. RN-A reviewed R2's grievance dated 4/6/23, he acknowledged it was not completed and stated something should have been done to resolve it. RN-A indicated since there was an allegation of neglect, it was a reportable incident to the State Agency. During an interview on 5/31/23 at 11:08, DON indicated an awareness R2 would prefer NA-A did not provide cares. Typically if a resident did not want to work with a certain staff, the resident would be interviewed to find out the reason why. Sometime customer service education needed to be provided to the staff member. DON stated the facility could not guarantee the staff member would not work with the resident or the resident would not see the staff member. R3's current face sheet identified R3 had diagnoses of morbid obesity, bipolar disorder, moderate intellectual disabilities. R3's quarterly MDS dated [DATE], R3's cognition was not assessed. Prior MDS dated [DATE], identified R3 did not have cognitive impairment. The MDS dated [DATE], indicated R3 did not have sign/symptoms of delirium and did not have behaviors. R3 required extensive to total assist of two staff for transfers, toileting, and dressing tasks and R3 was always incontinent of bowel and bladder. R3's vulnerable adult care plan dated 4/22/21, identified R3 was vulnerable due to residing in long term care facility with diagnosis of bipolar disorder that increases resident vulnerability. Interventions included minimize risk for abuse to remain safe and be treated with respect. R3's communication care plan intervention directed staff to provide resident adequate time to communicate needs and process information. During an interview on 5/30/23 at 5:09 p.m., R3 stated he had concerns with his care and had been hit in the mouth by a staff member. R3 would not say which staff member. R3 stated NA-A has yelled at him and he would get frustrated when providing cares because he (R3) was slow; getting yelled at made him feel bad. R3 explained he was scared to talk about it and did not tell anyone about the incident. During a subsequent interview on 6/1/23, R3 further disclosed it was NA-A who hit him in the mouth when he was on a different unit. R3 liked to have his teeth brushed however, NA-A would not brush his teeth. NA-A has refused to give him water because then he (R3) would need to go to the bathroom. NA-A treated him roughly when providing cares, he has yelled and raised his voice, and NA-A has told him he does not have time for him. R3 stated he was sad, angry, and uncomfortable living in the facility. R3 has told his family about these situations but has not told anyone at the facility because he was scared of retaliation. FM-D was contacted but did not respond R3's family member was contacted but did no respond. R4's current face sheet identified an admitted [DATE], and included diagnoses of Schizophrenia, morbid obesity, anxiety disorder, urge incontinence and insomnia. R4's annual MDS dated [DATE], identified R4 did not have cognitive impairment, no signs/symptoms of delirium and did not have behaviors. R4 required extensive assist of one staff for bed mobility, transfers and dressing and was always incontinent with bowel and bladder. R4's mood/behavior care plan dated 6/8/12, indicated R4 had behaviors of yelling during cares and swearing when frustrated, irritated, or anxious and had difficulty regulating emotions. Vulnerable adult care plan intervention dated 8/26/21, directed for staff to avoid the use of sarcastic humor. Incontinence care plan interventions included, R4 needs to return to her unit by 12-1 a.m. to get ready for bed (dated 10/21/14.), Met with resident to discuss incontinence voiding on floor in common areas on 1st floor reviewed plan to decrease and prevent voiding on floors (dated 7/20/20). 1. toilet before going to first floor. 2. Return to floor every two hours to toilet during day/evening 3. XL pull up brief; this has helped with independence and ease of toileting for resident. Toilet upon arising, after meals and before bedtime (dated 7/21/20). During an interview on 5/31/23, at 12:58 p.m. R4 stated staff were nasty to residents sometimes. NA-A was mean to her and has physically pushed her back into her wheelchair when she was attempting to stand up. R4 explained when she has told NA-A he was mean to her, he responded by telling her she was lying. When she (R4) asked NA-A for help he would tell her, No. NA-A has accused her (R4) of deliberately having incontinent episodes, he would call me lazy and make me feel bad. R4 stated some of her friends really like NA-A, they would take his side. R4's friends have warned her she would have consequences like not getting her makeup put on or not go to the country store if she continued to have incontinent episodes. R4 reported she has seen NA-A being rough with other residents in the facility. Several months ago, NA-A told her (R4) he was not going to change her and she had to wait for the next shift to be changed; R4 became upset and called NA-A a name, then told NA-B. NA-B then told the overnight charge nurse RN-A who then blamed R4, RN-A told R4 it was my fault I did not get changed because I stayed up until 2:00 a.m. so they did not change me. R4 stated she was called a liar by RN-A so she became angry and replied, thanks a lot. RN-A replied you're welcome. R4 stated she became so flustered she dropped a book, she asked RN-A to help to pick it up, RN-A said no When R4 asked another resident to help pick the book up, RN-A told the resident not to help R4. I [R4] told him [RN-A] I hated him and he responded by saying good. RN-A then said, hey [R4] you're supposed to be in bed, get in bed. R4 stated she had not reported the incident to anyone else aside from NA-B and RN-A because she was afraid things would only get worse R4 reported at night she did get afraid because staff would tell her to not turn the call light on because they were too busy for her. The staff always complained to her they have to clean her up after she has accidents. Review of R4's medical records and facility incident reports dated 3/1/23-6/1/23, did not identify the allegations or documentation related to R4's reported concerns to NA-B and RN-A. During an interview on 6/1/23 at 9:33 a.m. LPN-A stated it would not surprise her if NA-A told a resident not to lie after a resident reported concerns because that was how NA-A talked to residents. LPN-A witnessed NA-A say to R4 he could not help, or he would not help. LPN-A indicated NA-A was dishonest. One morning she saw R4's call light on, NA-A entered the room, turned it off, and came back out. NA-A told her that R4 did not need anything, she was sleeping. LPN-A stated she immediately went to R4's room and found R4 wide awake and R4 stating Darn him! LPN-A explained R4 would often go tell the health unit coordinator (HUC) no one was helping her; the HUC would have to call the nurse's station to get help for R4. During an interview on 6/1/23, at 8:31 a.m. RN-E indicated R4 was very particular about how she looks, but has not heard any concerns related to NA-A refusing to help R4. RN-E stated R4's care plan showed she should be encouraged to toilet every 2 to 3 hours at night and as needed without her putting her call light on. If R4 reported call light concerns at night, the facility would try to solve the problem internally, and would ask the overnight supervisor to do an audit. RN-E stated he did not work overnights so it would not be him doing the audits and he was unaware who would complete the audits if they were needed RN-E stated if someone had a complaint about an overnight supervisor that complaint would come to him. RN-E stated that if R4 stated no one was checking on her at night she was alert and oriented she would know if someone checked on her or not. RN-E stated he was not aware of any other complaints related to NA-A. During an interview on 6/1/23, at 11:38 a.m. with HUC stated she has talked to R4 almost every day. HUC stated R4 has said NA-A told R4 I am too slow and tell me, Move it, Move it. R4 has told HUC, NA-A has refused to provide care and told her I shouldn't have gone in my diaper, I shouldn't be too lazy, I should take myself to toilet, she shouldn't have to go to the bathroom because she had just gone not too long ago, he's [NA-A] is too busy and other people to take care of. HUC stated R4 has never reported physical abuse abuse, only verbal. HUC explained R4 would get really down on herself because of the things NA-A has said to her. R4 would say things like, I know I am too slow. HUC stated she had reported her concerns about NA-A to the assistant administrator about a month ago. During an interview on 6/1/23 at 9:33 a.m. with LPN-A indicated she has worked when HUC has called after R4 reported complaints to the HUC she was not getting assistance from NA-A. LPN-A stated recently she came to work in the morning and R4 was still awake in her chair stating she had been sitting up all night. LPN-A asked R4 why she had not asked staff to lay down, R4 reported she did not ask them to lay her down because she didn't want to make them mad. R4 was afraid to get others made and would not name any names because her friends like NA-A. LPN-A stated the night staff that would have included NA-A and RN-A have told her if R4 did not ask them they did not offer to lay her down. LPN-A stated R4's care plan indicated that the staff are to ask R4 to toilet every 2-3 hours and offer to lay her down. LPN-A stated R4 told her no one was asking her and she was afraid to get others mad. R4 would not name any names out of fear of upsetting her friends and retaliation of staff. LPN-A indicated even though R4 had sat up in her chair without being toileted according to the care plan and R4 reported she was fearful of staff, she did not report it administration. During an interview on 6/1/23 at 2:46 p.m. RN-A indicated he worked on the overnight shift with NA-A. RN-A denied having any awareness of NA's loud tone, aggressiveness, and refusing cares. Further denied awareness of any residents complaints about NA-A and/or residents not being provided with incontinence care. RN-A stated I am surprised of complaints at all at night! RN-A indicated that nurses should know and be involved in the grievance process. RN-A stated he was not aware of any grievances filed by R2. RN-A reviewed R2's grievance dated 4/6/23, he acknowledged it was not completed and stated something should have been done to resolve it. RN-A indicated since there was an allegation of neglect, it was a reportable incident. During an interview on 6/2/23, at 8:23 a.m. DON stated she was unaware of any allegations of abuse related to R4 but stated she can be obsessive, to the extent one male staff member requested a different work location. R4 had a hard time regulating her emotions and would have explosions. DON stated R4 also had a history of inappropriate incontinence in public areas and can be reluctant with cares. R5's current face sheet identified R5 had diagnoses that included hemiplegia, hemiparesis following cerebral infarction (stroke) affecting dominant side, major depressive disorder with severe psychotic symptoms, psychotic disorder with delusions due to known physiological condition R5's Quarterly MDS dated [DATE], identified R5 did not have cognitive impairment, did not have signs/symptoms of delirium or behaviors. R5 required extensive assistance of one staff for bed mobility, transfers, dressing, hygiene, toilet use and was always incontinent with bowel and bladder. R5's care plan dated 3/23/21, identified R5 was at risk for abuse and or neglect as resident resides in a LCT facility. R5 is at risk for cognitive and physical decline related to her diagnosis of adjustment disorder with delusions due to known condition and major depressive disorder with psychotic symptoms including catatonic disorder. Interventions included be aware of statements or signs or symptoms of abuse. If present, update physician, DON and administrator immediately. R5's care plan further indicated R5 was under a psychiatric commitment order related to history of suicidal ideation, refusal of cares and physical aggression to staff. An intervention directed staff to notify ACP therapist and mental health therapist (MHT) of any allegations of abuse and or neglect that involves the resident and ACP therapist will follow up with resident as needed (start date 12/14/21). Review of R5's progress notes dated 3/1/23-6/1/23, did not identify any reported allegations of abuse/neglect. During an interview on 6/1/23, at 12:16 p.m. R5 stated NA-A is not my favorite. When R5 was asked why? R5 responded, It's the whole thing! Changing me, turning me over; he is rough, it just hurts! R5 stated she had told someone but could not remember who. R5 explained she did not like NA-A coming into her room and would just ignore him. R5 did not feel educating NA-A would do any good because he is naturally rough. R5 indicated NA-A had hurt her head; R5 demonstrated on herself striking herself in the head with her hand. During the interview when discussing NA-A with R5 she became increasingly visibly distraught; R5 was tearful, displayed facial grimacing, and wincing as she recalled details of her encounters with NA-A. R5 stated she was scared of NA-A tearful and stated she was fearful of NA-A. During this interview NA-E entered room, NA-E stated she has never witnessed R5 cry or grimace and is normally just flat or calm. During an interview on 6/2/23, at 1:21 p.m. FM-C stated she visited R5 between 5/25/23 and 5/30/23. During the visit, R5 looked really upset, kind of hurt, just shut down and would not express anything. FM-C stated she questioned R5 about her mood because it was out of character, she was not acting at all like herself; R5 did not say anything. FM-C stated they had brought R5 a lazy boy, a couple of weeks ago and came to visit R5 a couple of days after she had brought it and it was gone. When FM asked R5's nurse where her chair went, FM-C was told they didn't know and she could go look for it. During an interview on 6/1/23 at 9:33 a.m. LPN-A stated she was aware of residents who did not want NA-A to provide cares to them or want him in their rooms; R5 was one of those residents. LPN-A did not know why and was unable to determine why R5 did not want NA-A in her room. LPN-A has had to encourage R5 to allow NA-A to assist her in providing cares but had to promise R5 she would not leave her alone with NA-A. R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had diagnoses of muscle weakness and gait abnormalities. R9 had moderate cognitive impairment, [TRUNCATED]

Based on observation, interview, and document review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in actual harm to R3 when she was found to have an elevated sodium level during her stay and subsequently required hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On [DATE], at 5:26 p.m. hospital admission record indicated R3 was sent to the emergency room for abnormal labs. Resident was admitted to the hospital for severe dehydration, acute kidney injury (AKI), and acute [CONDITION(S)] were she required admission for treatment with intravenous fluids. R3's facility physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's PN indicated R3 was sent to the emergency room for evaluation of her hyperosmolality (condition in which the blood has a high concentration of salt (sodium), glucose, and other substances) and [CONDITION(S)]. R3's labs on [DATE], indicated R3 had: - a sodium level of 156 with normal range of 135 and 145 milliequivalents per liter (mEq/L) with high levels which can indicate dehydration. - a potassium level of 5.2 with normal range of 3.6 to 5.2 millimoles per liter (mmol/L) - a chloride level of 121 with a normal range of 96 to 106 milliequivalents per liter (mEq/L) with high levels of chloride may be a sign of dehydration - BUN (blood urea nitrogen) (BUN) test reveals important information about how well your kidneys are working was 50 with normal range (2.1 to 8.5 mmol/L ) - a creatinine of 1.42 with a normal range of (0.6 to 1.1 mg/dL) and high creatinine levels can mean kidney damage or dehydration. R3's nutrition care area assessment (CAA's) dated [DATE], indicated R3 had suffered an [CONDITION(S)] brain injury from seizures and a [CONDITION(S)] from pre-[CONDITION(S)] during pregnancy and delivery. R3 was not able to communicate and was totally dependent on staff for all of her activities of daily living (ADL) related to her [CONDITION(S)] (paralysis from the neck down, including the trunk, legs and arms). R3's CAA further indicated R3 had her nutrition and hydration needs met with tube feeding and water flushes. R3's Order Summary Report dated [DATE], indicated R3 had orders for: - On [DATE], flush with 30 ml's water before med administration, and flush with 15 ml's water in between each med, & finish with 30 ml's after medications every shift. - On [DATE], free water flushes 100 cc via G-TUBE (feeding tube) every 2 hours and per G-TUBE, free water of 1200 ml (milliliter) daily Facility Standing Orders undated, indicated if a resident had a tube feeding, to water flush feeding tube with 150 ml of water every 8 hour unless otherwise ordered. R3's care plan revised [DATE], revealed R3 had a potential for alterations in nutritional status related to dysphagia, [CONDITION(S)], and need for chronic enteral feeding. R3's care plan also directed facility staff to observe for signs and symptoms of dehydration, to give water flushes per order of 100 ml every two hours and to administer tube feeding and flushes per physician orders. R3's admission nutrition assessment dated [DATE], identified R3 had 100 percent of her food calorie and fluid intake by tube feeding. R3 was NPO (nothing by mouth) and had dysphagia (difficulty swallowing). R3's nutritional assessment further indicated R3 was on enteral feeding of [MEDICATION(S)] 1.5 which ran at 40 ml per hour for 24 hours continuous with flushes to continue at 100 ml's every two hours. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - On [DATE], R3 had a complete blood count and basic metabolic panel drawn. - On [DATE], R3 had a sodium level drawn. - On [DATE], R3's order directed staff to replace, initial and date bag, enteral tube feeding set, and graduate (containers are ideal for measuring intake or output) each shift. - On [DATE], R3's order directed staff to check for placement using air auscultation (listening to sounds from the stomach) method and residual feeding volume prior to administering medication. Crush each medication in 15 ml of warm purified or sterile water and administer each separately using gravity. Flush with 30 ml between each med every shift. - On [DATE], R3's order directed nursing to give 100 ml of water flush every 2 hours via pump. - On [DATE], through [DATE], R3's orders directed staff to give enteral feeding ordered for every shift and flush with 100 ml of water every 2 hours. - On [DATE] through [DATE], R3's orders directed staff to give enteral feeding ordered for every shift of [MEDICATION(S)] 1.5 40 ml per hour continuous; 1. Before administering medication, stop feeding for 30 minutes and flush the tube with at least 15 ml sterile water. Do not add medication directly to an enteral feeding formula. - On [DATE], R3's order directed staff to give R3 [MEDICATION(S)] 1.5 40 ml per hour continuous via kangaroo pump. - On [DATE] to [DATE], R3's order directed staff to give enteral feeding ordered every shift of [MEDICATION(S)] 1.5 40 ml/hr x 24 hrs continuous. - On [DATE] to [DATE], R3's order was to give R3 [MEDICATION(S)] 1.5 40 ml/hr for 24 hours continuous. - On [DATE] through [DATE], R3's order directed staff to give 100 ml's of free water flushes every two hours. - On [DATE] through [DATE], R3's order directed staff to give 100 ml's of free water flushes by g-tube every two hours for a total of 1200 ml's daily. - On [DATE], to [DATE], R3's order directed staff to flush with 30 ml's of water before medication administration,15 ml's in between each medication and 30 ml's after medication administration. - On [DATE], R3's orders directed staff to observe R3 for signs of dehydration every shift. - On [DATE], R3's orders directed staff to use a Kangaroo pump for water flushes and feedings. R3's order further directed staff to check pump settings every shift for functionality and ensure setting are correct for rate and amount. R3's orders lacked indication staff were to monitor or track R3's intake of water and label the water infusion bag with date, initials, and amounts. R3's admission PN dated [DATE], at 11:01 p.m. indicated R3 was readmitted back to the facility and had severe [CONDITION(S)]. R3's admission PN lacked indication of tube feeding orders or flushes. R3's nutrition note dated [DATE], indicated R3 had been readmitted from the hospital on [DATE], for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 remained nothing by mouth and continued with enteral feeding of [MEDICATION(S)] 1.5 running at 40 ml/hour at 24 hours continuous. Flushes continued at 100 ml every two hours. R3's nurse PN dated [DATE], at 12:33 p.m. indicated R3 had a critical laboratory value and results were faxed to physician's office with a follow up phone call. R3's physician (NP) progress note dated [DATE], at 2:07 p.m. indicated R3 was assessed by the physician and due to critical laboratory values and acute kidney injury R3 was sent to the hospital at 2:00 p.m. on same date. R3's admission nurse progress note (PN) dated [DATE], at 2:50 p.m. indicated R3 was readmitted into the facility after a hospitalization on [DATE], and her diet instruction included tube feeding lsosource 1.5 given at 40 ml/hr and flush with water 100 ml every 2 hrs. On [DATE], at 8:45 a.m. family member (FM)-C stated she was concerned for R3's well being and the care she received at the facility because R3 cannot communicate how she feels. FM-C further stated R3 was hospitalized because she did not receive her water for many days. On [DATE], at 9:11 a.m. medical doctor (MD)-A stated she saw R3 on [DATE] th due to her elevated sodium and creatinine levels. MD-A further stated R3's sodium level was very high at 156 which indicated [CONDITION(S)] and her hospital records discharge summary indicated R3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD-A further stated she was greatly concerned for R3 wellbeing because due to the dehydration and not receiving the water flushes as ordered she could have had a [CONDITION(S)], brain dysfunction, cardiac injury, or even death. MD-A stated her expectation for staff is to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MD-A stated the lack of water intake was the direct cause for R3 being admitted to the hospital with dehydration and was directly caused by not receiving her water flushes as ordered. She further stated if she didn't check R3's labs on [DATE], she could have died . On [DATE], at 9:45 a.m. dietitian stated R3 had dysphagia and received all feedings and hydration by mouth. Dietitian further stated R3 had orders for 40 ml of [MEDICATION(S)] formula continuous with 100 ml's of water flushes every two hours. Dietitian stated the pump settings for water infusion did not match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at 10:00 a.m. registered nurse (RN)-C stated she was notified by MD-A that R3's sodium level was elevated, and MD-A questioned whether R3 had received her water as ordered. RN-C stated she verified on the MAR, R3 had received water as ordered every two hours. RN-C further stated, when she assessed the Kangaroo pump settings, she discovered R3's pump settings were set to infuse water at 100 ml every 6 hours instead of 100 ml every two hours. On [DATE], at 10:16 a.m. RN-B stated R3's pump settings were entered wrong and were set to give R3 100 ml of water every six hours rather than the prescribed 100 ml every two hours. RN-B stated she did not check the settings for R3's pump during her shift. RN-B stated, I assumed it was correct since it was running. RN-B stated when a new tube feeding formula bag and water bag are hung, you can enter pause on the pump, so the setting does not need to be reentered. On [DATE], at 12:45 p.m. licensed practical nurse (LPN)-B stated she does not verify or document how much volume of water or formula is in the tube feeding bags at the beginning or end of her shift for the resident. LPN-B further stated she did not verify the setting on the Kangaroo pump when she changed the formula and water bag. On [DATE], at 11:19 a.m. director of nursing (DON) stated on [DATE] around 12:30 p.m., the facility discovered upon review of the resident's charts of who received tube feeding the facility discovered orders were inconsistent or some orders were missing for tube feeding. Additionally, DON stated the facility's procedure was for the health unit coordinator to enter the tube feeding order, the primary nurse would then check to ensure the order is accurate and the nurse manager on duty would provide that last check. She stated nursing staff required education on signs of dehydration, water flushes, the use of the Kangaroo pump and verifying physician orders. DON stated R3 received 400 ml of water each day instead of the 1200 ml she was ordered creating a deficit of 800 ml each day because the pump was set for 100 ml every six hours and the order was for 100 ml every two hours. On [DATE], at 1:15 p.m. DON stated nursing staff do not document infusion amounts. DON further stated we should document the fluid intake each shift from tube feedings because it could help provide a check and balance for how much fluid was being administered. The facility policy Enteral Tube Feeding via Continuous Pump dated ,d+[DATE], indicated guidelines for the use of a pump for enteral feedings. The policy directed staff to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and document review, the facility failed to ensure adequate supervision to prevent and identify an elopement for 1 of 3 residents (R1) reviewed for elopement. This resulted in an immediate jeopardy (IJ) when R1 left the faciity on [DATE], and walked to a hospital 2.2 miles from the facility. The facility was unaware of R1's absence for 6.5 hours. The facility immediately implemented corrective action so the deficient practice was issued at past noncompliance. The IJ that began on 3/31/22, was corrected on 4/1/22, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ on 4/11/22, at 4:50 p.m. The IJ was removed, and the deficient practice corrected on 4/1/22, prior to the start of the survey and was therefore past noncompliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and required supervision for mobility off the unit. R1 required a walker or wheelchair for mobility. R1's diagnoses included [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] (disorder affecting ability to communicate), malignant neoplasm of frontal lobe (cancerous tumor in the brain), repeated falls, history of stroke, and major depressive disorder. R1's elopement/wandering risk assessment (ERA) dated 3/4/22, indicated R1 had a history of one or more attempted elopements and had a wander guard (WG) placed per guardian's request. The ERA further indicated R1 propelled self in wheelchair around the building which included the first floor. R1's care plan (CP) dated 9/14/21, indicated R1 was at risk for impaired community safety r/t [related to] dx [diagnoses] of [CONDITION(S)] [stroke], Expressive Apagia [sic], [CONDITION(S)] D/O [disorder] and possible medical or recreational appointments in the community. Intervention included Responsible party will accompany on community appointments and outing. R1's CP further indicated R1 was at risk for elopement with interventions including, WG placement and staff will be aware of residents whereabouts in the building. R1's physician orders dated 7/21/20, directed staff to check for WG placement every shift and function every night shift. R1's March 2022 medication and treatment administration record (MAR/TAR) indicated R1's WG was checked for placement and functioning per physician order. R1's progress note dated 3/31/22, at 22:30 (10:30 p.m.) indicated, The nursing supervisor received a phone call from St. Louis Park Police stating that resident [R1] was currently at Methodist hospital. The staff did not send resident to the hospital, nor did family have resident sent to the hospital. Supervisor updated the ED [administrator] and DON immediately. [Administrator] came to facility and looked at facility cameras and noted that resident [R1] exited the facility at the ambulance entrance at approximately 1530 [3:30 p.m.] using his walker. Methodist hospital nursing staff did contact resident's family. A report has been made to MDH [Minnesota Department of Health] and investigation has begun. The facility investigative report dated 3/31/22, included interviews with nursing staff who indicated R1 had last been seen around 3:15 p.m. at the nurse's station asking for his medications. Licensed practical nurse (LPN)-A reported providing R1 with his 8:00 p.m. medications earlier than scheduled and that R1 was wearing a WG on his wrist. Nursing assistant (NA)-A reported delivering R1's dinner tray to his room and R1 was not there at that time. NA-A reported R1's absence was not unusual since R1 frequently went to the smoking patio. Review of the report made by the hospital social worker (SW)-A dated 3/31/22, indicated R1 was taken to the emergency department (ED) to be evaluated after being observed by hospital security wandering in the hospital vestibule. R1 was experiencing expressive [CONDITION(S)] and hospital staff were unable to identify him. SW-A was called for an interview on 4/11/22, and a message was left however SW-A did not return the phone call. Review of the report made by police officer (PO)-A dated 3/31/22, indicated PO-A was called to the hospital ED to assist staff in identifying R1. The report indicated R1 arrived at the ED on 3/31/22, at approximately 5:00 p.m. and was only able to state his first name and month and day of birth. The report indicated R1 was unable to communicate effectively answering most questions with 'I don't know'. PO-A reported contacting the facility at approximately 10:00 p.m. and speaking to LPN-A who admitted not knowing that R1 was not in the facility. PO-A was called for an interview on 4/11/22, and a message was left however PO-A did not return the phone call. When interviewed on 4/11/22, at 11:28 a.m. R1 stated he remembered leaving with the intention of going to the hospital. R1 could not recall from which door he exited the facility. R1 stated he did not hear any alarms when he exited the door and that he walked with his walker the entire way to the hospital. When interviewed on 4/11/22, at 12:26 p.m. administrator stated R1 was seen on camera footage leaving through the ambulance door on 3/31/22, at 3:30 p.m. R1 wore a black jacket with a hood and used a walker. Administrator further stated the camera footage did not have any volume, therefore unsure if the alarm sounded. Administrator further stated if an alarm sounded, staff were required to respond immediately. Administrator confirmed the ambulance door was equipped with a WG alarm. When R1 returned from the hospital on 4/1/22, his WG was checked with the WG alarm on the ambulance door, and it did not alarm. A known functioning WG was also tested with the same door and the alarm did sound therefore concluding R1's WG bracelet was not functioning. Administrator stated placement of the WG bracelet was supposed to be confirmed every shift and the function it confirmed every night shift. The administrator further stated the expectation was that staff accounted for all residents throughout their shift and that medications would not be given outside the acceptable one hour before or one hour after scheduled administration time. When interviewed on 4/11/22, at 3:14 p.m. LPN-B stated he was in training on the evening shift of 3/31/22. LPN-B stated R1 could typically be seen in the hallway going to and from the smoking patio and during med pass but could not recall seeing R1 that evening. LPN-B further stated no one notified him that R1's dinner meal was untouched. LPN-B recalled working with NA-A and NA-B that evening. When interviewed on 4/11/22, at 3:24 p.m. NA-B stated the unit was short staffed that shift (3/31/22) but could recall seeing R1 walking in the hallway early in the shift. NA-B could not recall the exact time. When interviewed on 4/11/22, at 3:27 p.m. NA-A stated the unit was short staffed that shift (3/31/22) and could also recall seeing R1 at the beginning of the shift walking in the hallway. NA-A could not recall the exact time. NA-A stated he dropped off R1's dinner tray in his room but as a smoker, R1 went out to the smoking patio every 15-20 minutes. NA-A further stated not going back to pick up R1's tray until after the facility was notified of the elopement. The facility policy Safety and Supervision of Residents, last revised 7/17, indicated resident safety and supervision were facility-wide priorities. The policy further indicated resident supervision was a core component of the systems approach to safety. The type and amount of supervision was based on individual resident assessments and included risk factors such as unsafe wandering. The facility policy Elopement Guideline, dated 11/17, defined elopement as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of staff. The policy indicated the facility has a system of identification of residents. The method is designed to assist law enforcement and others identifying a resident who has left the facility without staff knowledge. Such identification methods could include an identification bracelet worn on resident wrist or label inside resident's clothing. The facility policy Documentation of Medication Administration, last revised 4/07, indicated date and time of the administration of a medication must be documented immediately after the medication was given and should never be documented as given prior to the actual administration. Actions taken by the facility immediately to ensure all resident's safety included: -The nurse supervisor on duty at the time the elopement accounted for all residents in the facility. -All doors with WG sensors were tested for functionality on 3/31/22. Door audits started on 4/1/22, and continued every shift. -WG bracelets were tested for functionality on the three remaining residents wearing a WG on 3/31/22. -All residents' CP were audited and updated if needed on 4/1/22. -Education on facility specific rounding (Resident Rounding) was developed and initiated on 4/1/22, for all nursing staff to ensure all residents were accounted for during each shift. All nursing staff were re- educated on safety and supervision, Elopement and missing person policy and protocols. A plan was initiated on 4/1/22 to provide above education to all nursing staff working that day and to ensure all were educated prior to their next shift. Staff were required to pass a knowledge quiz. -A nursing order was placed on all residents with WGs residing on a non-secured unit to have a visual check completed every two hours on 3/31/22. -R1 was placed on 15-minute checks upon his return to the facility on [DATE], at 4:30 p.m. On 4/4/22, at 9:30 a.m. R1's checks were changed to every two-hour check per above order. -The facility ordered a specialized identification bracelet for R1. The IJ that began on 3/31/22, was removed and the deficient practice corrected on 4/1/22, after the facility implemented the interventions listed above and initiated appropriate education for all nursing staff. Verification of corrective action was confirmed by observation, interview, and document review on 4/11/22, from 10:45 a.m. to 4:30 p.m. Nursing staff were observed rounding on and accounting for all assigned residents. Staff were observed checking the placement and functionality of WG bracelets. Variety of nursing staff interviewed confirmed education was provided regarding the elopement policy, staff's responsibility when a WG alarm sounds, accountability for residents at the beginning, middle and end of each shift, and what to do if a resident cannot be located. Sign-in sheets for Resident Rounding education confirmed education began on 4/1/22 and continued through 4/6/22. WG and door audits reviewed. Appropriate interventions initiated and deficient practice corrected on 4/1/22, therefore this was cited at past noncompliance.

Based on observation, interview, and document review, the facility failed to ensure smoking interventions were implemented for 1 of 3 residents (R1) who was assessed to smoke unsafely. This failure resulted in an immediate jeopardy (IJ) situation when R1, who was on oxygen, lit a cigarette in her room and sustained [CONDITION(S)] to her face, shoulder, and chest. The facility immediately implemented corrective action and the deficiency is being cited as past non-compliance. The IJ began on 5/30/21, at approximately 10:40 p.m. when the facility fire alarm sounded, and smoke was observed coming from R1's room. R1, who was noted to have smoking products on her lap, had observable [CONDITION(S)] to her face, shoulder, and chest. The administrator and director of nursing (DON) were notified of the IJ for R1 on 5/30/21, at 5:32 p.m. The facility implemented corrective action on 5/31/21, prior to survey therefore the deficiency is being cited as past non-compliance. Findings include: R1's Face Sheet dated 6/2/21, indicated R1's diagnosis included [CONDITION(S)] (COPD) and chronic respiratory failure with [CONDITION(S)] (low blood oxygen level). R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, independent with locomotion, received oxygen, and used tobacco products. R1's Physician Orders dated 10/8/18, indicated R1 was ordered oxygen at three liters per minute (LPM) via a nasal cannula. R1's care plan dated 10/29/2018, indicated R1 had her smoking privileges revoked, however, R1's medical record indicated she continued to smoke unsafely. R1's Nursing Assistant Care Sheet undated, indicated R1 was an independent smoker. R1's progress notes dated 1/27/20, at 2:56 p.m. indicated R1 lit a cigarette inside the facility's commons area and wheeled outside. The progress notes further indicated R1 verbalized a staff person told her this was acceptable. R1 was instructed she must be in the designated smoking area prior to lighting a cigarette. R1 acknowledged understanding. An incident report dated 1/27/20, indicated R1 lit a cigarette inside the facility's commons area prior to going to the designated smoking area. The incident report revealed R1 was provided reeducation which included cigarettes needed to be lit outside and in the designated smoking area. R1's nurse practitioner (NP) was notified. An incident report dated 3/1/20, indicated R1 dropped a cigarette on her foot and requested staff to change her socks. The incident report further indicated R1 sock was noted to have a small, melted hole. A facility incident report dated 12/29/20, indicated R1 was smoking inside the facility's commons area. R1 verbalized she had forgot and did not want to smoke outside as it was snowing. R1 was directed to smoke outside. R1's progress notes dated 1/4/21, 10:41 a.m. indicated R1 was found smoking a cigarette in the facility's commons area over the weekend. R1 verbalized she had lit a cigarette near an exit door and went outside. The progress notes further indicated the interdisciplinary team (IDT) discussed R1's previous smoking violations which included smoking inside the facility. R1 was informed she was no longer able to smoke at the facility. A smoking assessment dated [DATE], indicated R1 had multiple smoking infractions in which she lit a cigarette in a facility hallway prior to going to the smoking patio. The assessment revealed R1 was no longer able to smoke at the facility. A smoking assessment dated [DATE], indicated R1 failed to follow the facility's smoking policy and identified R1 was an unsafe smoker. R1's smoking privileges remained revoked. The smoking assessment further revealed R1 was known to ask other residents for cigarettes. R1's progress notes dated 4/9/21, 11:30 a.m. indicated R1 sustained an 18 centimeter (cm.) by 4 cm. cut to her leg when she, ran into a sign in the elevator. The progress notes further indicated a NP practitioner recommended R1 be transported to the hospital. It was documented R1 wanted to smoke, and she was reminded her smoking privileges were revoked. R1 stated, I'm going to smoke and returned to the floor five minutes later. A smoking assessment dated [DATE], indicated R1 was an unsafe smoker and did not follow facility policy. R1's smoking privileges continued to be revoked, however, was known to ask other residents for cigarettes. Although R1 was assessed as an unsafe smoker and was noted to ask other residents for cigarettes, R1's medical record lacked indication of subsequent interventions being implemented to help reduce the risk of her smoking. An incident report dated 5/30/21, indicated R1 was observed going to her room at approximately 10:20 p.m. 20 minutes later, the facility fire alarm sounded, and smoke was observed coming from R1's room. R1 exited her room and was wearing a nasal cannula which was disconnected from an oxygen tank. The oxygen tank, located near R1's bedside, was noted to be on fire. R1 denied smoking and verbalized she was unable to recall how the fire started. R1 was noted to have a cigarette package, four cigarettes, a lighter, and a half-smoked cigarette on her lap. R1 had smoke around her nose, mouth, right side of her face, and breast area. R1's gown was noted to be burnt in addition to some hair on the right side of her head. R1 was transferred to the emergency department. R1's emergency room note dated 5/30/21, indicated R1 presented with [CONDITION(S)] to two percent of her total body surface area. The [CONDITION(S)] were assessed to be indeterminate (unknown depth of a wound) and noted to be on R1's torso and face. The emergency room note further indicated the injury occurred when R1 used lighter, and it ignited an oxygen tank. A blowback (spark ignited oxygen) singed R1's face and chest. During an interview on 6/1/21, at 12:23 p.m. registered nurse (RN)-A stated the facility fire alarm went off at 10:40 p.m. RN-A stated she proceeded to the nursing unit, noticed smoke, and saw R1 exit her room. RN-A stated R1 was noted to have [CONDITION(S)] to her face, shoulder, and chest. RN-A stated R1's clothing was also burned, and a code-red was called (emergency response for fire or smoke). RN-A stated R1 denied smoking, however, R1 was noted to have cigarette package, four cigarettes, a lighter, and a half-smoked cigarette on her lap. RN-A stated she was not aware R1 had her smoking revoked and R1 was observed smoking outside 20 minutes prior to the fire. RN-A stated R1 was a regular smoker and smoked often. RN-A stated she had given R1 ten dollars, from R1's account, at the beginning of the afternoon shift on 5/30/21 to purchase cigarettes. When interviewed on 6/1/21, at 12:23 p.m. RN-B stated she was not aware R1's smoking revocation prior to the fire incident. RN-B stated R1 made her own decisions and was an independent smoker. RN-B stated R1 smoked whenever she wanted. When interviewed on 6/1/21, at 12:31 p.m. nursing assistant (NA)-A stated she was not previously aware of R1's smoking revocation. NA-A stated prior to the fire incident on 5/30/21, R1 could smoke, but not in the building. When interviewed on 6/1/21, at 12:34 p.m. NA-B stated R1 was a heavy smoker. NA-B stated R1 regularly stored her cigarettes and lighter next to her thigh or in her purse. NA-B was not aware of R1's smoking revocation until 5/31/21. During an interview on 6/1/21, at 1:20 p.m. assistant director of nursing (ADON) stated R1 was alert and oriented and had two smoking infractions for lighting-up cigarettes inside the facility during February 2021. The ADON stated R1's smoking privileges were revoked on 1/4/21, and confirmed R1's care plan also indicated R1's smoking privileges were revoked on 10/29/18. The ADON confirmed the smoking revocation was not transcribed on the electronic medical record (EMR) summary (notifies staff of changes) or nursing assistant care sheets which would had notified staff there was a change in R1's smoking privileges. The ADON verified the revocation of R1's smoking privileges was not communicated to facility staff. When interviewed on 6/1/21, at 1:21 p.m. RN-C stated she completed R1's most recent smoking assessments and was aware R1's smoking privileges were revoked. RN-C stated R1 previously smoked independently, however, R1 was noted to light cigarettes inside the facility twice. RN-C stated R1's smoking privileges were revoked in January 2021, however, R1 continued to smoke after the revocation and other residents also provided R1 cigarettes. RN-C stated nursing assistants do not look at a resident care plan and use nursing assistant care sheets. RN-C stated she had since updated R1's care sheet after the fire incident. RN-C stated R1's smoking revocation should had been communicated as, special instructions in the EMR and nursing assistant care sheets, however, this was not completed. RN-C stated she attempted to update nursing assistant care sheets once weekly, however, they did not always get updated. At this time, RN-C provided an updated copy of R1's nursing assistant care sheet which reflected the smoking revocation. RN-C was unable to recall when the update was completed. On 6/1/21, at 1:30 p.m. a mattress and multiple black garbage bags were noted in the hallway outside of R1's room. The mattress had a melted area approximately 3 inches (in.) by 3 in. near the outer edge. A gray/brown dust was covering the floor of R1's room. A black burnt area on the wood floor approximately 4 feet (ft.) long by 1 foot wide was noted. There was also burnt area on the floor approximately 2 ft. by 3 in. near a TV stand. When interviewed on 6/1/21, at 1:33 p.m. licensed practical nurse (LPN)-A stated he was present during R1's fire incident on 5/30/21. LPN-A stated around 10:30 p.m. the fire alarm sounded, and he was informed smoke was coming from R1's room. LPN-A stated he obtained a fire extinguisher and, as R1's door was opened, R1 came out of the room. LPN-A stated dark smoke came from R1's room and R1 had darkened areas to the right side of her face. LPN-A stated R1's gown was burnt and R1's skin to the right side of her upper body was exposed. LPN-A stated R1's oxygen tank was on fire and flames reached from the floor to the ceiling. LPN-A stated R1's was noted to have two half-smoked cigarettes, four additional cigarettes, and a lighter on her lap. LPN-A stated he was not aware that R1's smoking privileges had been revoked until education was provided after the incident. LPN-A verified he received education regarding residents's who smoke and oxygen use on 5/31/21. During an interview on 6/1/21, at 1:34 p.m. the director of nursing (DON) stated R1 was a smoker who had her smoking privileges revoked on 1/4/21. DON reported R1 had two infractions for not following the facility smoking policy. The DON stated the facility investigation revealed R1's smoking revocation was on R1's care plan, however, confirmed the information was not transcribed on the nursing assistant care sheet. During an interview on 6/1/21, at 1:40 p.m. a hospital registered nurse, RN-D reported R1 was admitted to the burn unit with second degree [CONDITION(S)] to the face, shoulder, and chest. RN-D stated, due to the [CONDITION(S)], R1 received daily dressing changes and struggled with pain control. RN-D stated R1 was at risk for an infection and slow wound healing. RN-D stated surgery was consulted for grafting of R1's shoulder [CONDITION(S)]. During interview on 6/1/21, at 3:19 p.m. the facility nurse practitioner (NP)-A reported smoking with use of oxygen could lead to harm. NP-A stated the greatest risks were [CONDITION(S)], death, or death to others. During an interview on 6/1/21, at 4:07 p.m. the facility physician (MD)-A from reported smoking with the use of oxygen could result in severe [CONDITION(S)] and/or death to the smoker and others who surrounded the smoker. MD-A verified R1 was an active smoker and stated, R1 used to take her oxygen off when smoking, but R1 huffed and puffed so severely without oxygen due to [CONDITION(S)]. Facility policy titled Smoking Guidelines revised 5/31/21, directed Residents are allowed to smoke only in designated areas: Inner Courtyard. Residents are not allowed to give others cigarettes. Residents will not bring hazardous material into smoking area, oxygen, medial gas, combustible, or flammable materials. Residents will be expected to report any safety concerns identified to facility associates. Residents' capability and deficits to smoke will be assessed upon admission, with change or condition/cognition, following any smoking related incidents. Residents smoking material may be removed and started by staff until smoking assessed can be completed. If a resident smoking assessment shows a deficit while smoking, this may require individualized interventions to compensate deficits for safety concerns. Residents not adhering to smoking policy will be coached and re-educated on the risk and benefits. If residents continue to put others at risk, the facility will assist the resident, family and ombudsman with a plan that meets the residents needs. This plan includes room searches, adaptive equipment, up to revocation of residents smoking privileges. The past non-compliance IJ which began on 5/30/21, was removed as of 5/31/21 after the facility had implemented a systemic plan to prevent recurrence which was verified through observation, interview and document review. The plan included: - Document review confirmed a facility document titled Smoking List dated 5/31/21, was created and corresponding care plans were updated on 5/31/21. - Document review confirmed 30 residents were educated on the facility's Smoking Guidelines as of 5/31/21. - Document review confirmed the facility conducted audits which included each resident's smoking status, smoking assessment dates, care plans, smoking agreements, risk versus benefit documents, and -incident reports were conducted on 5/31/21. - Review of staff education which included The Estates at St. Louis Park Facility Specific Protocols Resident Smoking (which included the facility's updated smoking protocol and smoking policy), and staff intervention related to unsafe smoking )indicated 67 facility staff recieved education on 5/31/21. The 57 remaining facility staff will complete their education on 6/1/21, prior to their scheduled shift. - Review of the facility Smoking Protocol confirmed it was updated on 5/31/2, which included revocation of smoking privileges, hazardous materials (including oxygen), and staff intervention related to unsafe smoking. - Review if R1's care plan verified was updated on 5/31/21to include staff interventions related to monitoring for smoking materials every shift, reapproaching regarding smoking cessation products, and providing education related to potential dangers of smoking and the facility smoking policy. These updates were added to the aid cares sheets. Interviews -When interviewed on 6/1/21, at 10:21 a.m. RN-E stated he received updated training on the on the smoking train and oxygen use. -When interviewed on 6/1/21, at 10:29 a.m. LPN.B stated she received education on the new smoking policy, which included oxygen, residents who smoked, and safety. -When interviewed on 6/1/21, at 12:23 p.m. RN-B stated on 5/31/21, she received education regarding resident's smoking, oxygen use, and accidents. RN-B stated she was required to sign-off on the education and complete a quiz. -When interviewed on 6/1/21, at 12:31 p.m. nursing assistant (NA)-A stated she she received education regarding resident's smoking, oxygen use, and accidents. -When interviewed on 6/1/21, at 12:34 p.m. NA-B stated NA-B verified he received education regarding resident's who smoke and oxygen use on 6/1/21.

Based on observation, interview and document review, the facility failed to ensure nursing staff were trained in emergency procedures to establish an airway for a resident with a [CONDITION(S)] for 2 of 2 residents (R4 and R5) reviewed for emergency [CONDITION(S)] procedures. In addition, the facility failed to provide ongoing monitoring of respiratory and suctioning status; failed to have required emergency supplies readily available; failed to develop a policy addressing [CONDITION(S)] emergencies for 2 of 2 residents that received [CONDITION(S)] care (R4 and R5). This deficient practice resulted in an immediate jeopardy (IJ) situation for R4 who died as a result of respiratory distress, and for R5 who was at risk for serious illness or death. The immediate jeopardy (IJ) began on [DATE], when the facility failed to respond adequately when R4 was in respiratory distress. Staff attempted to suction R4's [CONDITION(S)] but did not attempt to remove R4's [CONDITION(S)] inner cannula or outer cannula to establish an airway. R4 became unconscious and chest compressions were initiated. Emergency Management Services (EMS) were initiated but R4 was not able to be resuscitated. On [DATE], at 5:13 p.m., the director of nursing (DON), administrator, regional director of operations (RDO), regional nurse consultant (RNC), and the intern administrator were notified of the IJ. The IJ was removed on [DATE], at 1:25 p.m. after the facility implemented an acceptable removal plan. However, noncompliance remained at the lower scope of a G - isolated scope and severity level, which indicated actual harm that was not immediate jeopardy. Findings include: R4's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R4 was cognitively intact. The MDS further indicated R4 had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R4 had a feeding tube, required [CONDITION(S)] care, suctioning, oxygen therapy, and used bilevel positive airway pressure (BIPAP - a respiratory device to help keep airway open). R4's care plan dated [DATE], addressed [CONDITION(S)] care and indicated R4 was to be suctioned as necessary and noted extra [CONDITION(S)] tube and obturator (solid tube that facilitates removal/insertion of [CONDITION(S)] tubes) was to be at R4's bedside. R4's admission nursing assessments dated [DATE], and [DATE], indicated R4 had normal respirations, a [CONDITION(S)], oxygen, and required suctioning. R4's admission nursing assessment dated [DATE], indicated R4 had rapid respirations, a [CONDITION(S)], oxygen, required suctioning, and now had continuous positive airway pressure (CPAP). R4's Death in Facility tracking dated [DATE], indicated R4 died in the facility on [DATE]. R4's Final Autopsy Protocol report dated [DATE], indicated R4 rang her nurse assist bell and indicated to nursing home staff that she was having respiratory distress by pointing at her neck. Her [CONDITION(S)] was suctioned by nursing home staff without relief. She became unresponsive and was pronounced dead shortly thereafter. The report listed final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] --write progress note on [CONDITION(S)] status, including frequency of suctioning, tolerance, respiratory status, and any notable events, every shift. --change R4's [CONDITION(S)] dressing and inner cannula every eight hours. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's prescriber written order dated [DATE], indicated staff MUST CHART HOW MANY TIMES SUCTIONED PER SHIFT AND CHARACTERISTICS OF SPUTU[M] every day and evening shift. R4's progress notes from [DATE], to [DATE], revealed documentation only 12 shifts out of 303 shifts included documentation of R4's respiratory status, suctioning required, and characteristics of sputum. During a phone interview on [DATE], at 8:45 a.m., registered nurse (RN)-F stated he knew R4 well and when she was gurgling you knew she needed to be suctioned or she would ask to be suctioned. RN-F stated [CONDITION(S)] care, including changing R4's inner [CONDITION(S)] cannula, should happen every shift and the number of times she was suctioned was supposed to be documented in the progress notes each shift. RN-F stated he provided care to R4 the night before she died and there was nothing unusual about the shift, stating he suctioned her one or two times that night and her secretions were runny, like usual. RN-F stated R4 was okay when he gave her tube feeding at 6:00 a.m. RN-F stated staff received training on routine [CONDITION(S)] care but did not recall training about what to do if there was an emergency with the [CONDITION(S)]. During a phone interview on [DATE], at 9:00 a.m., family member (FM)-A stated he was concerned about the care R4 received. First, R4's room was at the end of the hallway, farthest from the nurses' station, which was where the emergency cart was stored. FM-A stated it was difficult for R4 to get staff to respond to her call light as it was not audible, so the family bought a bicycle horn for her to honk when she needed suctioning. FM-A expressed concern R4 was not being suctioned enough, the facility was not changing the inner cannula, and when R4 had problems breathing the morning of [DATE], licensed practical nurse (LPN)-A did not remove the inner cannula. During a phone interview on [DATE], at 9:37 a.m. FM-C stated the family selected this facility because they were told by the facility it specialized in [CONDITION(S)] care. FM-C stated LPN-A reported that on the day of the incident she heard R4's bicycle horn and when she entered R4's room, it looked like she was in respiratory distress and it was almost like she couldn't even take a breath. FM-C stated LPN-A told him usually when R4 needed to be suctioned, R4 had a gurgle sound but there was no sound when she entered R4's room. LPN-A could not suction any secretions from R4's [CONDITION(S)] so she turned up her oxygen and then R4 passed out. FM-C stated LPN-A told him she called for help and began CPR. During a phone interview on [DATE], at 10:30 a.m. RN-F stated if a person with a [CONDITION(S)] was found not breathing, the inner cannula should be removed to see if it was blocked and, if needed, the outer cannula could be removed. During an interview on [DATE], at 10:52 a.m. licensed practical nurse (LPN)-A stated LPN-B was assigned to R4 the day of [DATE]; however as she sat at the nursing station, she heard R4 honk the horn. LPN-A stated when R4 honked the horn before, it meant airway distress. LPN-A went into R4's room which took her about 15 seconds as it was at the end of the hallway. When LPN-A entered the room, R4 was lying on her bed and was pointing to her [CONDITION(S)]. LPN-A stated R4 was not inhaling and exhaling ,which had happened multiple times before, and was always relieved with suctioning R4. LPN-A also stated when this had happened before R4 had a gurgling sound/noise but this time it was different; there was no gurgling. LPN-A stated she opened the suctioning equipment and started to suction R4, but the catheter went all the way down, the full 40 centimeter length of the catheter, with nothing coming out, It was bone dry; no sputum, nothing. LPN-A stated she started to scream for help as she attempted to suction R4 and still nothing coming out. She then looked at the oxygen tank which was set on 3 liters and she turned it up to 6 liters hoping to get more air flow but still R4 was not inhaling or exhaling but was awake and struggling with breathing. LPN-A again tried to suction R4 as she screamed for help and at this time R4 became unconscious and had no pulse; LPN-A then put the bed flat and started chest compressions. LPN-B entered the room and LPN-A instructed LPN-B to call a Code Blue (alert when a resident is not breathing or does not have a pulse and gets other staff to respond to the room) and bring the crash cart into the room. LPN-A stated there was no Ambu bag in the room at the time she had responded to R4's call for help and that it was brought in with the crash cart. LPN-A stated after the Code Blue was called LPN-C, LPN-D, LPN-E and RN-I came to the room and at this point, they transferred R4 to the floor, continued doing chest compressions, suctioning and used the Ambu bag. LPN-A stated R4's chest would only rise when the Ambu bag was squeezed. LPN-A also stated from when she came into the room and when all the other nurses came into the room, neither R4's inner nor outer cannula were removed to check for clogging. During an interview on [DATE], at 12:31 p.m., LPN-B stated R4's room was at the end of the hallway because it was the biggest room and could hold all the necessary equipment. LPN-B stated she suctioned R4 one time the morning of [DATE], and nothing came out and she did not change R4's inner cannula. LPN-B stated later in the morning she walked out of another resident's room and saw LPN-A on R4's bed doing chest compressions. LPN-B stated she went into R4's room and LPN-A asked her to call a Code Blue. LPN-B stated she walked down the hallway to the nurses' station where she met RN-A; RN-A called the Code Blue and then called 911. LPN-B said she returned to R4's room and when other staff arrived, they moved R4 to the floor and continued chest compressions. LPN-B stated there was not an Ambu bag in R4's room and it came on the crash cart. LPN-B was not sure, but thought someone tried to suction R4. LPN-B stated she had received education on routine [CONDITION(S)] care but did not receive any training on what to do in case of an emergency for someone with a [CONDITION(S)]. During an interview on [DATE], at 12:42 p.m. LPN-A stated she did not remember any training on [CONDITION(S)] care emergencies and what to do when a resident was not getting air flow; Nothing with the inner cannula being taken out if there was no airflow. I know I can remove it. LPN-A further stated, at the time of R4's incident, the suction catheter was going all the way down, saying If I am suctioning and not getting anything with the catheter then maybe it was clogged somewhere else, I don't know. During an interview on [DATE], at 12:45 p.m. RN-H stated I have not been trained on [CONDITION(S)]'s in this facility. I was trained with another nurse here how to suction and change the dressing but official getting [CONDITION(S)] training here, no. RN-H also stated she worked on the unit where R4 resided, but again stated she had not received any special training. RN-H further stated although she was familiar with handling [CONDITION(S)] emergencies, she had learned it independently. During an interview on [DATE], at 12:52 p.m. LPN-G stated she worked with R4 at least once a week when the regular nurse was off. LPN-G also stated she had not received any training on [CONDITION(S)] emergencies but when R4 was transferred to the unit she had received the basic training on suctioning, cleaning, and replacing the [CONDITION(S)] from the director of nursing (DON). During an interview on [DATE], at 2:02 p.m. RN-G stated she had received basic [CONDITION(S)] care training but nothing on [CONDITION(S)] emergencies with airflow compromise. RN-G stated following R4's incident I went to YouTube to see if they were supposed to do chest compression on someone with a [CONDITION(S)]. I go online to learn how to do these things because we have learned about them in college, but they have never happened in real life. During an interview on [DATE], at 2:43 p.m. LPN-D stated she had responded to the Code Blue page on [DATE], when R4 went on respiratory distress. LPN-D stated when she arrived in R4's room LPN-A, LPN-B, RN-A, LPN-C, LPN-E and RN-I were already in the room and chest compressions were being done. LPN-D stated when she arrived in the room the crash cart was also already there and the nurses, including herself, did use the Ambu bag after they had transferred R4 to the floor from the bed. LPN-D stated between the chest compressions R4 did receive the two breathes using the Ambu bag and she had noticed the chest raising and falling but R4 was unconscious. LPN-D stated R4 was suctioned by multiple nurses and the catheter was going smoothly which indicated the airway was not obstructed; R4 did not have a pulse. LPN-D stated the inner cannula was never removed to check if it was clogged during the entire time. LPN-D stated when she had arrived at the room, she did not know how long the chest compressions had gone on for. When asked about [CONDITION(S)] emergencies training LPN-D stated she would use the Lavage suctioning (Inserting normal saline into the endotracheal tube and then to suck it up with the suction catheter to loosen the thick secretions). LPN-D further stated because she did not work with these residents, she did not know the procedure for [CONDITION(S)] emergencies. During an interview on [DATE], at 2:53 p.m. RN-C stated he was working on [DATE], when a Code Blue page was announced to R4's room. RN-C stated when he arrived in the room, there were multiple nurses in the room. At that time, the nurses decided to transfer R4 to the floor and continued with the chest compressions. RN-C stated when he arrived in the room the Ambu bag was being used and R4's chest was minimally rising with when the Ambu bag was squeezed. RN-C stated things went so fast, however, LPN-C did suction R4 and was not getting anything and LPN-D used the Ambu bag between the compressions. RN-C stated during the process R4's inner cannula was never removed to check for clogging. RN-C stated he worked occasionally at the unit where R4 resided and had been assigned to R4 before. When asked about the training he had, RN-C stated I believe when [R4] came they went through telling us how we deal with a patient with [CONDITION(S)] with a focus on suctioning. I believe they did for the emergency also. RN-C acknowledged he could not re-call who taught the training or when he had completed the training. During an interview on [DATE], at 4:18 p.m. with the DON and the regional nurse consultant (RNC), the DON stated when a resident had a [CONDITION(S)] it did not change the way the nurses were to start CPR; after they checked for patency, they would use the Ambu bag. The DON stated he would expect staff to remove the cannula if it was plugged, clean it, and replace it when using the Ambu bag. The DON stated it was documented on [DATE], that LPN-A was able to get the suction catheter into R4 easily and all the way down which meant the cannula was not plugged and was not occluded and that was when LPN-A started chest compressions. The DON stated because RN-C and LPN-D had said they saw R4's chest raising and falling when the Ambu bag was squeezed, the nurses did not need to re-position the [CONDITION(S)] by taking the [CONDITION(S)] ties off. The DON stated the emergency equipment R4 required for [CONDITION(S)] emergencies was what was in the facility policy and the Ambu bag was supposed to be in the crash cart at the nursing station. The RNC verified the nurses had been signing off all the emergency equipment was in R4's room including the Ambu bag. The RNC then stated she would have not expected LPN-A, who had responded first, to have used the Ambu bag until another person came into the room and then she would have stopped the chest compressions. The RNC also stated even though R4 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated he had spoken with RN-A and LPN-A after the incident and none of the nurses had reported anything abnormal had occurred. The RNC stated although LPN-A had indicated she had done CPR on R4 for five minutes, at times doing chest compressions alone would seem a long time. The RCN acknowledged this had been asked of LPN-A on how long she had been doing the chest compressions before the other nurses came into the room. The RNC then stated doing a comprehensive evaluation of the situation was good advice but was again not part of the facility policy in long term care to look back at a past code situation. During a phone interview on [DATE], at 9:33 a.m., medical doctor (MD)-A who discharged R4 on [DATE], from an acute care hospital back to the facility, indicated R4 had significant issues with oral and tracheal secretions, initially requiring suctioning every 3 to 4 hours. MD-A stated part of R4's problem was when she arrived at the acute care facility from the long-term care (LTC) facility, R4's [CONDITION(S)] cuff was deflated, so her oral secretions were draining down around the [CONDITION(S)] into her lungs and because she was always positioned on her left side, the secretions pooled into R4's left lung. MD-A stated they started R4 on glycopyrolate (medication to dry oral secretions) to dry her oral secretions to decrease R4's secretions to where she only needed to be suctioned a few times a shift. MD-A stated it was possible for R4 to develop an acute mucous plug, which would cause respiratory distress and it had happened just two days before R4 was discharged back to the LTC (long term care) facility on [DATE]. MD-A stated within a couple of hours of suctioning, she developed an acute mucous plug and they had to call a Code Blue to resuscitate her. MD-A explained that was why staff needed to be vigilant about suctioning and changing R4's inner [CONDITION(S)] cannula. Because of R4's excessive secretions, MD-A stated it would be highly unusual for R4 to be suctioned and be bone dry. MD-A stated staff should be monitoring suctioning and the amount of secretions they were getting. Finally, MD-A stated if R4 was having difficulty breathing and staff were unable to get secretions when suctioning, the inner cannula and possibly outer cannula should be removed to assure there was no mucous plug. Review of R4's physician notes from [DATE] to [DATE] revealed the following: -[DATE], noted R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -[DATE], indicated extra [CONDITION(S)] cannula's, obturator, an artificial manual breathing unit (Ambu) bag, and suctioning equipment were to be located in R4's room. -[DATE], ear, nose, and throat (ENT) provider indicated R4 had copious (profuse) secretions. During an interview on [DATE], at 9:39 a.m., RN-A stated when she was called to the unit, she went to R4's room where she saw LPN-A doing chest compressions on R4. RN-A stated she went down the hallway to the nurses' station to call a Code Blue and then she called 911. RN-A stated LPN-D took the crash cart to R4's room. RN-A stated someone tried to suction R4 but was not getting any secretions and she did not recall if any staff was using an Ambu bag on R4. R5 R5's annual Minimum Data Set (MDS) dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS indicated R5 required suctioning and [CONDITION(S)] care. R5's care plan dated [DATE], identified R5 had a [CONDITION(S)] related to [CONDITION(S)] (abnormal enlargement of the tongue) and R5 was independent with [CONDITION(S)] cares and suctioning. The care plan did not identify the Ambu bag was supposed to be in the room for emergency equipment at bedside. R5's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident uses (Shiley tube, cuffless [CONDITION(S)] #6). Verify items are in appropriate location, are functioning and are stocked in enough quantity. Obtain spare supplies from Northwest Respiratory immediately as needed. R5's nursing notes from [DATE], through [DATE], revealed 14 notes that included the frequency of suctioning, tolerance to procedures, respiratory status and any notable events, out of 180 shifts/opportunities. During a review of R5's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], at approximately 10:30 a.m., the Ambu bag was not located in R5's room but was on the crash cart which was at the nurses station, approximately 50 feet down the hallway. On [DATE], at 10:40 a.m. RN-G was observed in R5's room finishing up with assisting R5 with a warm washcloth R5 had requested for his face to relieve pain. RN-G stated she had attempted to do the [CONDITION(S)] cares but R5 had refused. When asked what emergency equipment was kept in R5's room, RN-G pointed to the obturator which was hanging right above the bed inside a clear plastic bag and the suction machine was on the nightstand. RN-G then went over to this cart in R5's room which had supplies and showed a box of spare trachs. When asked about the Ambu bag, RN-G stated this was kept at the nursing station on the crash cart. On [DATE], at 11:51 a.m. LPN-F stated for R5 the emergency equipment he was supposed to have in the room was the obturator in the wall. LPN-F also stated, We have the Ambu bag on the crash cart which stays at the nursing station and we have his room close to the nursing station if they found him unresponsive, they should bring the crash cart to the room within 5 seconds to use it. On [DATE], at 12:49 p.m. LPN-F reviewed R5's verified R5's medical record lacked notes of the nurses writing a note each shift on the frequency of suctioning, tolerance to procedures, respiratory status, and any notable events. LPN-F stated the nurses were supposed to complete the documentation and this was something she communicated to them each day to do and not to sign off anything without doing it. During a follow up interview on [DATE], at 4:44 p.m. the DON verified R4 had the order in the MAR/TAR regarding the emergency equipment. He stated this was a standard order that had been put in and all the nursing orders were put in as physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then stated he was going to re-read the facility policy and that he had changed the order for all future [CONDITION(S)] patients. The DON stated when he became the facility DON, no one had alerted him nurse training and competencies regarding care and emergencies for [CONDITION(S)] residents had not been done. The DON further stated when he became the DON there was no one in the staff development role and in [DATE], RN-J took the role; prior to that he did complete skills and competencies for some of the nurses. On [DATE], at 4:54 p.m., the director of nursing (DON) stated it was not the policy to place an Ambu bag in a resident room because an Ambu bag was on the crash cart at the nurses' station and they attempted to place residents with tracheostomies in a room close to the nurses' station. The facility's [CONDITION(S)] Care policy, dated ,d+[DATE], indicated an obturator must be taped above the bed on the wall at all times and included instructions on: 1) cleaning of removable cannula; 2) site and stoma care; 3) tracheal suctioning; and 4) speaking valves. There was no section on [CONDITION(S)] emergencies or directions on what to do when a resident with a [CONDITION(S)] had an emergency with their airway. IJ removal: The immediate jeopardy was removed on [DATE], at 1:25 p.m. after it was verified the facility had appropriate supplies and emergency equipment for [CONDITION(S)] in R5's bedside. R5's care plan was reviewed and remained current and orders for [CONDITION(S)] emergency prep to be in the resident's room was implemented that included a spare [CONDITION(S)], cannula's, obturator, Ambu bag and suctioning equipment. Also, the facility procedure for [CONDITION(S)] care was reviewed and revised to include emergency procedures for [CONDITION(S)] emergency care and supplies at bedside as necessary. The staff education regarding knowledge of the supplies and equipment procedures for tracheostomies was initiated for licensed nurses and remained ongoing with staff being educated prior to the start of their next shift. Education materials were mailed to the staff who were on-call and not scheduled, for review prior to them being scheduled for a shift.

Based on observation, interview and document review, the facility failed to correctly transcribe and clarify admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) for R2 when the facility failed to provided medication that resulted in hospitalization related to cardiac changes. The IJ began on 2/16/21, when R2's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ was identified on 3/3/21, and the administrator was notified of the IJ at 2:55 p.m. on 3/3/21. The IJ was removed on 3/4/21, at 12:30 p.m., but non-compliance remained at the lower scope and severity level of G. Findings include: R2's Entry tracking record indicated R2 was admitted from an acute hospital on 2/16/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Hospital Transfer Orders dated 2/16/2, indicated potassium chloride ER (extended release) 20 mEq (milliequivalents per liter) two tablets by mouth daily for low amount of potassium in the blood. The orders also indicated R2 was to receive potassium chloride ER 20 mEq one tablet by mouth two times a day related to low potassium levels. Hand written notation to the side of the order indicated,Duplicate therapy please clarify. R2's Medication Error Reconciliation Form dated 2/23/21, indicated there were, 2 [two] orders for potassium present on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's progress notes dated 2/22/21, at 1:50 p.m. identified R2 had blood drawn for labs and lab results came back critical (2.3) for her potassium. An order was received by the provider on 2/22/21, to send R2 to the emergency room for evaluation. (normal level for potassium is 3.5-5.5 mEq, critical level is below 2.5 mEq) On 3/2/21, at 10:54 a.m. R2 was interviewed in her room. R2 stated she was re-hospitalized six days after her admission to the nursing home for low potassium due to slow metabolism and kidneys not working well. R2's Interagency Assessment and Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 3/2/21, at 1:50 p.m. registered nurse (RN)-B stated she had done the initial order input for R2 from the hospital faxed orders and had written on the fax the potassium order needed to be clarified. RN-B stated she assumed someone else would clarify the order when R2 arrived from the hospital to the facility if the hospital had not made a change. RN-B stated now she would have called the hospital when the fax came in and requested a clarification. RN-B stated no one clarified the orders for potassium and no one made any documentation in the progress notes this needed to be clarified. RN-B stated R2 did not receive prescribed potassium chloride for six days and missed 17 doses. RN-B verified R2 was readmitted to the hospital on 2/22/21, for critically low potassium level which could have resulted in death. RN-B reviewed R2's readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-B stated she had completed reviewing the orders on 3/2/21, after survey had started. During interview on 3/3/21, at 12:51 p.m. nurse practioner (NP) stated the missed potassium order was a significant medication error. R4's admission MDS dated [DATE], indicated R4 had been admitted to the facility on [DATE], and was severely cognitively impaired, and did not display verbal or physical behaviors toward others or refuse cares. R4's MDS also indicated R4 received assistance with all activities of daily living and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Medication Error Reconciliation Form dated 12/16/20, indicated that on 12/15/20, an order was given for [MEDICATION(S)] (antipsychotic medication) 5 mg/milliliter (ml) 2.5 mg (0.5 ml) IM (intra muscular) q (every) four hours PRN (as needed). The Medication Error Reconciliation Form revealed the order was transcribed in the electronic health record as [MEDICATION(S)] 5 mg/ml inject 2.5 milliliters IM Q 4 hours PRN. The Medication Error Reconciliation Form further indicated the outcome to R4 was R4 fell asleep. R4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 3/3/21, at 7:47 a.m. the DON stated RN-A received a verbal order from the nurse practioner for 2.5 mg of [MEDICATION(S)] but wrote 2.5 ml. The DON stated the first dose was taken out of the emergency kit, and required three vials to get the full dose. The DON stated that RN-A did not have another nurse cosign the order. The DON said RN-C failed to question the order, written as milliliters not milligrams and gave the medication as entered into the computer. The DON stated licensed practical nurse (LPN)-B, identified the error on 12/16/20. The DON stated all staff involved in the error received education. The DON stated there was potential excessive sedation which could have led to falls. The DON verified R4 did not fall as a result of the significant medication error. During interview on 3/3/21, at 11:32 a.m. the pharmacist stated the dose of [MEDICATION(S)] was not out of range depending on the residents history. Pharmacist did state the increase in amount of [MEDICATION(S)] from what was ordered would be considered significant error. During interview on 3/3/21, at 12:51 p.m. nurse practioner (NP) stated giving five times the prescribed dose was a significant medication error. During interview on 3/2/21, at 3:15 p.m. the director of nursing (DON) verified that R2 did not receive prescribed dose of potassium chloride ER for six days because staff had failed to clarify and transcribe the order at the time of R2's admission. The DON stated a new process had been implemented to prevent reoccurrence of the transcription error. The DON stated all nurses and health unit coordinators were to have completed education prior to their next shift. The DON stated education was started on 2/23/21. The DON verified seven nurses and two nurse supervisors had not completed the training for the new process as of 3/2/21. The DON verified four nurses had worked without the training from 2/26/21 to 3/1/21, and in that there had been three admissions or readmissions over the weekend and one resident had been seen in the emergency room . The DON stated it was his expectation that they would have followed the new process including transcribing and clarifying all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Facility Medication Error Procedure reviewed January 2020, indicated the relevant significance of an error was a matter of professional judgement. The procedure instructed staff to follow three guidelines for determining significance: resident condition, drug category and frequency of the error. The immediate jeopardy that began on 2/16/21, was removed on 3/4/21, when the facility revised their facility procedure for weekend and evening admissions or readmissions to include triple check of order transcription and clarification, transcription of all orders received and documentation in the electronic health record of order clarification. The facility reviewed admission and readmission resident orders since 2/26/21, and provided education to all health unit coordinators and licensed nursing staff of revision to the Admission Transcription Process. Facility developed and implemented a plan to ensure education was completed for designated staff prior to working their next shift. Documention review of the Admission/readmission Transcription Process imitated 2/23/21, and revised 3/3/21, identified 12 nursing staff were educated on 3/3/21 and 3/4/21. Documention of email correspondence dated 3/4/21, was also reviewed and outlined education to nursing staff about the Admission/readmission Transcription Process. Interviews with nursing staff also verified education that was received.

Based on interview and document review, the facility failed to protect 1 of 3 residents (R1) from abuse. Physical abuse occurred when three staff members held R1 down against her will while they administered a medication rectally on [DATE], which resulted in an immediate jeopardy (IJ) situation. The IJ began on [DATE], when the facility staff failed to protect, prevent, and report a witnessed observation of R1's physical abuse. The IJ was identified on [DATE], and the director of nursing (DON) and administrator were notified at 1:56 p.m. of the IJ. The IJ was cited at past non-compliance because the facility had implemented a thorough investigation, facility wide training of staff, and showed evidence of compliance as of [DATE]. Findings include R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE], indicated R1 had a severely impaired cognition and did not display physical or verbal behaviors towards others. R1's care plan dated [DATE], indicated R1 had altered cognition due to alcohol liver failure and needed time to communicate her needs/wants. The care plan directed staff to provide cues, reorientation and supervision as needed. The care plan also indicated on [DATE], R1 started to become more lucid, aware, and required assist of one from staff. A review of physician orders [REDACTED]. During further review of R1's July Medication Administration Record, [REDACTED]. A nursing note dated [DATE], by RN-A indicated R1 adamantly refused to have [MEDICATION NAME] solution given rectally and that risks and benefits were explained, but R1 continued to refuse. During interview on [DATE], at 8:43 a.m. nursing assistant (NA)-A identified that an incident involving two nurses and R1 had occurred on the evening of [DATE], where two nurses held R1 down while they administered R1's enema. NA-A then indicated that RN-A had approached R1 to administer the enema but R1 refused it, but then after a few minutes RN-A returned with RN-B and NA-A, to administer the enema. NA-A further indicated that upon entering the room, R1 again refused the enema. NA-A also indicated R1 was yelling and screaming, and that RN-B held R1's hands, and mouth and while holding her down in bed, RN-A administered the enema. NA-A then indicated the incident was never reported to the facility. NA-A further indicated that the incident was reported when R1 had died and that the incident had occurred a week or two prior to being reported to the State Agency by NA-A, on [DATE]. On [DATE], at 8:13 a.m., during interview, the facility administrator and DON notified surveyor that after learning about the incident from the surveyor on [DATE], both RNs and NA were suspended and the SA was notified immediately. The DON indicated phone interviews were conducted with both RNs and NA, where it was learned that the incident happened on [DATE]. The incident had not been reported to the facility immediately per the Abuse Policy and was not reported to the SA until [DATE], by NA-A. The DON also identified that both nurses admitted that the incident, as described by NA-A, had occurred. The DON then indicated that RN-A made a statement that she went to give R1 the medication but R1 refused it, then RN-B and NA-A, came in the room, they put a mask over R1's face because R1 was spitting at them. RN-B then held R1's hands down while RN-A administered the enema. The DON also explained that RN-A was asked why she felt that RN-A and other staff felt there was such an importance of R1 getting this medication, and RN-A indicated it was in the best interest of R1. The DON then stated I asked if the order told her (RN-A) to hold her (R1) down and force her, (RN-A) stated no. The DON indicated other nurses were interviewed on the floor where R1 resided at that time, all the nurses indicated R1 would refuse her medication but R1 needed to be re-approached. The DON also indicated the nurse practitioner (NP) was interviewed and asked if the intent of the order was for staff to force R1 into getting the medication and NP indicated the order was never meant to force anything on R1. The DON further identified the NP indicated the order for R1 was changed on [DATE], due to R1's unresponsive state to receive the medication rectally, but later the order was changed again on [DATE], for staff to either give orally or rectally due to R1 becoming more alert and responsive. On [DATE], at 11:35 a.m. during a follow up interview the DON stated, When the staff involved were interviewed, they all acknowledged they performed a medication administration against R1's will. The DON also stated, (RN-A) did say 'we made her (R1) do it,' and that (RN-B) said 'we put a mask on her because she was screaming and spitting.' Although the facility staff failed to report the allegation of resident abuse to facility management on [DATE]; upon learning of the incident of [DATE] when brought to the attention by the surveyor, immediate action took place. The incident was reported immediately to the SA, and RN-A, RN-B, NA-A, were suspended pending investigation. A thorough investigation took place and the facility was able to verify corrective action had been implemented, including RN-A, RN-B and NA-A being terminated. The facility continued with a plan to educate all staff on the importance of reporting, protecting and preventing abuse, which began [DATE], and continued to [DATE]. In addition, the facility planned to have staff take a competency quiz at a later date regarding the information taught about abuse and reporting. It was determined that the majority of staff had been trained by [DATE], and therefore, this deficient practice is being cited at Past Noncompliance. Review of Monarch Health Management policy, Abuse Prohibition/Vulnerable Adult Plan revised [DATE], indicated that the purpose is to ensure that residents are not subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse. The policy further indicated that all staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin. Also that reporting must occur immediately to a supervisor and that reporting to the state agency must be reported no later than 2 hours after forming the suspicion of abuse.

Based on observations, interview and document review, the facility failed to conduct a comprehensive assessment of aggressive behavior and implement interventions to protect other residents from R1 who was involved in multiple altercations involving other residents on the unit. In addition, failed to provide adequate supervision as R1 continued to wander and sleep/lay in other residents beds, causing other residents distress. R1 subsequently became agitated and was physically aggressive when he threatened and hit other residents. R2, R3, and R4 were identified to be in an immediate jeopardy situation related to risk for serious injury, harm, impairment or death due to the physical aggression by R1. R1's behaviors had the potential to affect all 20 residents residing on the Advanced Alzheimer's Care Unit (AACU) wing. The immediate jeopardy began on 5/9/20, when the facility failed to protect R2 from R1's physical abuse. The IJ was identified on 6/11/20, the director of nursing (DON), administrator, administrator interns, and the assistant director of nursing were notified at 5:05 p.m. The immediate jeopardy was removed on 6/12/20, at 9:30 a.m., after it could be verified the facility had implemented an acceptable removal plan, however, noncompliance remained at the lower scope and severity level of E, a pattern with no actual harm with potential for more than minimal harm. Findings include: R1's face sheet dated 6/12/20, indicated [DIAGNOSES REDACTED]. R1's annual Minimum Data Set ((MDS) dated [DATE], identified a brief interview for mental status (BIMS) of 0, indicating severe cognitive impairment. R1 was ambulatory and wandered throughout the unit. R1 was moved to the locked unit in 12/19 due to elopement. R1's behaviors had escalated since admission to the unit. R1's physician visit notes dated 5/12/20, indicated reports of increased agitation and restlessness. R1's care plan initiated 6/3/19, identified an alteration in cognition related to [DIAGNOSES REDACTED]. It also identified socially inappropriate disruptive behaviors such as laying/sleeping in other residents' beds, yelling, pushing, and hitting other residents. R1's behavioral approach included allowing time to communicate his needs/wants, redirecting him to his bed when he was in others rooms, providing cues, reorientation and supervision as needed. During observations on 6/11/20, at 12:46 p.m. R1 went into R4's room and laid down in her bed. -At 1:05 p.m. the licensed practical nurse (LPN)-A was observed to enter R4's room, however, did not redirect R1 out of the room. LPN-A left the room and R1 continued to lay on R4's bed until 1:18 p.m., when nursing assistant (NA)-A wheeled R4 in her room via wheelchair. At this time R4 observed R1 laying on her bed and yelled, What is he doing there? NA-A called R1's name and attempted to physically remove him from the bed. At this same time social services designee (SSD)-A came into R4's room and was observed to offer R1 a 7-Up and was able to redirect him out of R4's room. Additional altercations, involving R1, were reviewed, and identified the following: A Progress Note (PN), dated 5/9/20, identified R1 had been known to go into other residents' rooms and lay in their beds. It further indicated, R2 had caught R1 in her room again and when R2 was on her way to the dining room, R1 went after her, pushed her against the door to the dining room, and went after her with his fist. R2 said R1 had scratched her arms and grabbed her chest. A PN, dated 5/22/20, indicated R2 was in her room and when she came out of the bathroom, R1 was in her room. R2 yelled at R1 and R1 pushed R2, hitting her in the chest, which resulted in a red mark. R5, identified as having intact cognition, per MDS dated [DATE], witnessed an altercation between R1 and R2: - A PN dated 6/6/20, identified R5 reported, that guy (R1) was in R2's room again and they both screamed at him to leave. R5 witnessed R1 hitting R2 in the right arm/shoulder two times. The intervention identified at this time was to keep R1 on the unit, and to transfer R2 to another room off the unit after securing a Wander Guard on R2's right wrist, due to risk for elopement. A PN dated 6/10/20 at lunch time, identified R1 had gone up to R3 and took his drink off of his meal tray. R3 then got upset and told R1, That is mine, get the hell away from here! Staff then came in between the two residents to intervene. R1 started swinging his fists towards R3. Staff was able to separate the two residents and no one was injured. R1 then walked away and started pacing around the unit as R3 continued to eat his lunch. The DON was interviewed on 6/11/20, at 2:57 p.m., regarding the multiple altercations that had occurred between R1, and other residents, as noted above on 5/9/20, 5/22/20, 6/6/20 and 6/10/20. When asked what interventions were put in place to protect R1 and other residents in the unit, the DON said R1 had always been known to wander and it was not a problem before R2 was transferred to the unit from 2 East. The DON explained that R2's cognitive level was above the level of other residents on the unit, R2 was aware of where her room was, and was able to use her bathroom per self, which posed a problem if R1 was laying on her bed. DON said the facility initially put both residents, R1 and R2, on safety checks (30 minutes), after altercations occurred. The DON explained that she had checked with the staff nurses and nurse practitioner (NP) to inquire if R1 had become more aggressive and also stated lab work had been done to see if R1 had an infection. The DON stated with the altercation on 5/9/20, R1 was given a one time dose of [MEDICATION NAME] (antipsychotic, used to treat [MEDICAL CONDITION]) and it was recommended to increase [MEDICATION NAME] (restores the balance of natural substances in the brain), however, after a couple of days R1 went back to baseline. Regarding the altercation that occurred on 5/22/20, DON said the facility started talking about the fact that R1 continued to go into R2's room and so the altercations continued. The interdisciplinary team (IDT) discussed transferring R2 to a different unit, however, the DON acknowledged the move had not taken place and an additional altercation occurred between R1 and R2 on 6/6/20. The altercation on 6/6/20, DON said she was at the facility when the incident took place, and a decision was made to put a wander guard on R2 and move her to another unit. When asked by the surveyor what they did to protect other residents on the unit from R1, she said, We didn't really do anything. She also said the NP recommended increasing R1's dose of [MEDICATION NAME], but the facility did not want to chemically restrain him. (R1) likes to go into (R2's) room, and explained that was why R1 and R2 were constantly having altercations. When surveyor asked why R2, who was not the aggressor, was now being transferred to a different facility, the DON did not respond. Regarding the altercation on 6/10/20, DON said she was not aware of the incident between R1 and R3. The DON reviewed R1's and R3's medical records and verified the nurse had only documented the incident in R1's record. The DON read the progress note and she confirmed it was a resident to resident altercation but again said she was not aware of it and should have been informed. She also said, I think he (R1) needs to go. She said that she had checked with the nurses who reported R1 had not been more aggressive to residents, but to staff. The DON also said the facility is not able to provide one to one supervision to R1 ongoing. The DON said that her expectations were for staff to redirect R1 out of other residents' rooms, I will talk to the administrator to see if someone can watch him until we come up with a better plan. We don't want to snow him, that's not an option. I will talk to the administrator and the NP to see what we can do immediately to protect the other residents. On 6/11/20, at 1:19 p.m. NA-B stated, He (R1) will wander into every room and he keeps coming in and out of rooms all day and you will not find him in just one particular room. We talk to him and he will sometimes listen but at times he is hard to re-direct and we tell the nurse and nurse manager. There was an incident with (R2) and he kept going to her room several times and he would not listen and (R2) was upset. We would redirect him but he doesn't listen and will yell at you and tell you **** you. We are to redirect him when we see him in other resident's rooms. We are supposed to report all allegations of resident to resident to the nurse immediately. He is aggressive both verbally and physically and will hit both staff and residents. NA-B explained that R1 will do this when he is re-directed, and stated, A lot of the residents in the unit have dementia and will not be able to report if he did anything to them because they will forget. It's hard to keep up with him. On 6/11/20, at 1:20 p.m. NA-A said R1 tends to wander and go into other residents' rooms. NA-A was told to sit with R1 in his room until he calms down. NA-A also said he has had to do this several times per shift. On 6/11/20, at 1:23 p.m. social services director designee (SSD)-A said R1 often wanders into other residents rooms. She said redirection works sometimes but he can get volatile. She also said some of the residents don't understand R1's behavior and question why he is in their room. On 6/11/20, at 1:28 p.m. LPN-A stated all allegations of resident to resident altercations were supposed to be reported to the DON or administrator to be investigated. LPN-A also stated R1 required to be constantly re-directed, was combative and staff were supposed to walk away when he was combative and then re-approach. LPN-A further stated staff continued to re-direct him out of other resident rooms, however, he would still find another resident's bed, which was an on-going problem. When asked what else had been tried to keep other residents safe in the unit, as R1 had several altercations with residents on the unit, LPN-A stated re-directing, re-approach and offering him candy or pop. Nothing in particular he is kind of hard depending on his mood. The facility Abuse Prohibition/Vulnerable Adult Plan revised 12/16, indicated the purpose of the policy was to ensure that residents were not subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals or self abuse. The policy also directed staff to report any situation that was considered abuse or neglect immediately to the supervisor who would assess the situation to determine if any emergency treatment or action was required. The policy also directed staff immediately upon learning of the incident; staff was to take necessary steps to protect residents from possible subsequent incidents of misconduct while the matter was being investigated. The policy further directed if it was resident to resident abuse, the resident who was the abuser was to be removed to a safe environment to ensure that all other residents remained safe. The immediate jeopardy was removed on 6/12/20, at 9:30 a.m. after it was verified the facility had reviewed and revised R1's care plan to include 1:1 supervision intervention and attempt to send R1 to a geriatric -psych hospital for further evaluation and treatment. The facility reviewed and revised care plans for like residents in the unit and the policy and procedures for abuse prevention, safety, supervision, accidents and resident to resident altercations. The staff education was initiated and remained ongoing regarding proper interventions for safety and supervision of residents after resident to resident altercations. Also the staff were educated on R1's plan of care regarding interventions and supervision. In addition, R1 was transferred out of the facility on 6/12/20, at 10:23 a.m. to the hospital for evaluation due to increased behaviors. The non-compliance remained at the lower scope and severity level of E because the facility failed to put in place interventions to protect all other residents who were vulnerable and with advanced dementia/Alzheimer's, who resided in the AACU wing, from abuse.

Based on interview and document review the facility failed to implement adequate supervision and safety measures for 1 of 2 residents (R2) reviewed for accidents. This resulted in actual harm for R1 who opened a window on the third floor of the facility and jumped out resulting in multiple fractures. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he was severely cognitively impaired and was independent with ambulation and transfers. The MDS indicated R1 displayed wandering behaviors but indicated the wandering did not place him at risk for getting to a dangerous place. R1's care plan dated 3/9/2020, identified a risk for elopement related to cognitive impairment. The care plan indicated R1's elopement assessment indicated he was at risk. The care plan was updated 3/28/20, to include, windows were checked and secured by maintenance and identified R1 had expressed wanting to go to Kwik Trip and staff had brought in food from Kwik Trip to address his wants. During observation of the third floor memory care units on 4/1/20, at 8:22 a.m. the windows on the unit were observed to have white plastic [MEDICATION NAME]. The windows on the unit slid to the side to be opened and the [MEDICATION NAME] were screwed to the top and the bottom of the window frames. The [MEDICATION NAME] were secured from the outside of the frame to approximately four inches from the sliding pane of the window. R1's Elopement Risk Evaluation dated 3/24/20, indicated he had attempted to elope from the facility one or more time, was disorientated and wore a Wanderguard (a system used to secure, lock and alarm specific doors if a resident attempted to leave) bracelet. The evaluation indicated on 3/24/20, R1 was seen by staff yelling out the window asking for someone to take him to Kwik Trip. The evaluation further indicated R1 had also got on the elevator when staff came to the third floor and the Wanderguard system activated. R1's facility Progress Notes identified the following: 3/24/20, Writer heard alarm go off and met housekeeper who had come from the elevator. Writer asked housekeeper if anyone had entered the elevator and was told R1 had gotten on the elevator to go down. Writer went down stairs and brought R1 back up to the unit. 3/24/20, Staff members reported R1 opened the window in the television room on the unit and was screaming out the window. R1's head was half way out the window. Noted screws keeping window in safe position were out and maintenance fixed the problem. 3/24/20, Writer spoke to R1's family member (FM)-A to discuss his behavior. R1 was seen trying to open a window on the unit. R1 was slamming the window back and forth and was able to get the window to slide open and put his head outside the window. R1 was yelling down to some people in the parking lot. Staff witnessed the event. Maintenance checked all the windows on third floor to make sure they were working properly. Writer also informed FM-A that R1 had gotten on the elevator that morning. FM-A was upset about the events that took place, writer assured FM-A that R1 would be kept safe. Plan to move R1 to the more secured unit. 3/27/20, during breakfast time staff noted alarm going off. R1 had pulled his call light out of the wall. R1 was observed trying to unscrew the window at the end of the hallway with a spoon. When asked what he was doing, R1 stated he needed to save his baby and said I will jump from window, maybe I break my leg, but it is OK. A little later R1 was walking into other residents rooms and stating, I am looking for loose screws to get out of the window. 3/28/20, Writer was approached around 9:00 a.m. by house keeping staff that was coming into work that someone was lying on the ground in the employee entrance parking lot. Staff went immediately to check on resident who was later identified as R1 who lived on the third floor of the facility. 911 was called and R1 was taken to the hospital. 3/28/20, R1 was in a pleasant mood this morning. After breakfast R1 was seen seated in the hallway near the end of the corridor. After some time, another resident approached writer and reported that someone broke the window. Writer got up to check and noted a crowd forming outside around R1. 3/28/20, Writer spoke to FM-A regarding incident. Informed FM-A R1 got out the window of another residents room and landed outside on the grass. Informed FM-A that staff had seen him shortly prior to being outside on the grass and he had been pleasantly sitting in a chair. FM-A was informed that it appeared R1 had broken the [MEDICATION NAME] on the window frame and pulled out the screws that held the [MEDICATION NAME] in place. At time of call, facility staff were not aware which hospital R1 was sent to, later found out and informed FM-A. 3/28/20, Call made to hospital. Per emergency department nurse, R1 sustained a rib fracture, compression fracture and burst fracture (injury to the spine). No head injury or brain bleed noted on scan. R1 was to be admitted to the intensive care unit for observation. A nurse practitioner visit note dated 3/27/20, indicated R1 reported he was being kept at the facility and believed he needed to leave. R1 was packed, wearing a coat and in constant motion looking for bus stop, airport and constantly walking around the facility checking doors. R1 had recently forced open a window on the third floor, knocked out the screen and with his head out the window was yelling at staff on the ground floor. An Incident Review and Analysis dated 3/28/20, indicated R1 admitted to the facility on [DATE]. R1 began displaying exit seeking behaviors a few weeks after admission and had a Wanderguard placed since admission. The incident review indicated maintenance had checked windows on the third floor on 3/24/20, and all were secured and bolted. On 3/28/20, maintenance checked all windows again and fully secured the windows so they could not be opened and on 3/30/20, new window blocks were installed. A facility investigation file was reviewed and included the following: A document titled (R1) incident dated 3/28/20, indicated per licensed practical nurse (LPN)-A, R1 had eaten his breakfast later than the other residents. A house keeper coming in for her shift saw R1 on the ground. The house keeper reported it to the nurse supervisor on duty. At the same time, another resident on the unit approached LPN-A, and said someone had broken a window. This was all around 9:30 a.m. The paramedics arrived and took off R1's shoes to see if he could wiggle his toes, which he was able to do and was also able to wiggle his fingers. Staff reported it looked like R1 had dragged himself toward the sidewalk. Prior to the incident staff said R1 was pleasant, ate his breakfast and was seated at the end of the hall by the window. The report indicated a nursing assistant (NA) stated he had been helping residents from the dining room and had seen R1 in the hallway. The report indicated no apparent tools were used to break the window [MEDICATION NAME] off. During interview on 4/1/20, at 8:29 a.m. social worker (SW)-A stated prior to the installation of the long window [MEDICATION NAME], the windows had a four inch metal block attached to the frame to prevent the windows from opening more than four inches. SW-A stated the blocks were changed on Monday (3/30/20), he believed. SW-A stated the Friday prior to R1 jumping out the window, R1 had been agitated and wanted to go back to, or thought he was in Wisconsin. SW-A stated on Saturday (3/28/20), he received a call that R1 had jumped through a window. SW-A said he found the [MEDICATION NAME] and stated, I can't tell you how he got it out because they were all re-checked and tightened by maintenance the previous week. SW-A said he noted the metal [MEDICATION NAME] was torn and jagged. At 9:15 a.m. LPN-B stated R1 was a pretty new admit and stated he had his days and nights turned around and was sleeping during the day and awake at night. LPN-B stated R1 kept asking for the Kwik Trip and stated it was reported to her that he was exit seeking at times so a Wanderguard had been placed. LPN-B stated she was not in the facility the first time R1 removed a [MEDICATION NAME] from the window and said two other staff members alerted her. The two staff members told her at a little before 7:00 a.m. R1 popped the screen off the window and was able to get his head out of the window and was yelling for the Kwik Trip. LPN-B stated the maintenance staff was fixing the window when she arrived on the unit and told her R1 must have somehow gotten the bolt off the window. LPN-B stated after the incident, maintenance checked all the windows on the third floor. LPN-B stated after that incident R1 was moved to the more secured side of the unit. LPN-B stated she was not aware R1 had jumped out the window on the 28th until she returned to work the following Monday. LPN-B said R1 had gone into another resident's room and jumped out the window on to the grass and on Monday following the incident maintenance went through and replaced all of the blocks on the windows. At 9:31 a.m. NA-B stated the day R1 jumped out the window he had come in at 6:00 a.m. and R1 was seated on the other side of the door of the secured unit. NA-B said, At night they keep the doors open between the two units. NA-B said R1 ate breakfast and went back to bed. In regard to the resident whose window R1 jumped out of, NA-B said he had been in the room and went to throw the garbage away and when he returned he saw the other resident with the nurse in the hallway. NA-B said the nurse told him someone had gone through the window. NA-B said he saw the block and said it was sitting on the ledge with the screws out of it. He said R1 was able to pry it loose somehow. NA-C was also present and stated after breakfast he went on break. He stated he had last seen R1 in the dining room. NA-C stated R1 ate breakfast and went to his room. At 9:57 a.m. maintenance (M)-A stated on 3/23/20, R1 had managed to take off one of the [MEDICATION NAME] on the windows. M-A stated he went upstairs and screwed it into different holes and said he had to use a power tool to fix it. M-A stated he had asked if R1 had any tools. M-A stated because of the window and the traffic, the nurse had moved R1 to the other side of the unit and made sure he did not have a window bed. M-A stated he performed an audit of all the windows to make sure all the windows had two screws in them. M-B, also present stated it appeared R1 may have taken the window and kept slamming it until the [MEDICATION NAME] popped out and stated that was why they decided to use double stops, one at the top of the window and one at the bottom. M-B said it seemed like it would have taken a while and made some noise. M-B further stated the original [MEDICATION NAME] had self tapping screws and would not have been able to be removed with a screw driver or a utensil. At 10:31 a.m. the director of nursing (DON) stated, based on the investigation R1 had been in the dining room at breakfast time, around 8:30 a.m., then was seated at the end of the hallway wearing his jacket. The DON said she had seen the metal [MEDICATION NAME] and it looked like it had been pried open and two four inch screws had been removed. At 1:48 p.m. FM-A stated the facility had called her on Saturday morning and told her R1 had been dressed, ate breakfast and then approximately 15 minutes after that he went out the window. FM-A said she was told the previous Tuesday R1 had opened a window and gotten his head out of the window. FM-A said it was really frustrating because that same morning a house keeper had come to the unit and let R1 get into the elevator. FM-A stated LPN-B had asked her what they (the facility) should do and told her that maintenance had checked all the windows and made sure they were secure. LPN-B then called her back and said she wanted to move R1 to the other unit that's more secure so he couldn't get on the elevator but stated this all happened on the overnight shift when the doors were all open so it wasn't any more secure. FM-A stated when she got the call after R1 went out the window it was around 11:00 a.m. and the facility did not know what hospital R1 had been taken to. FM-A said the hospital told her R1 also had a concussion. FM-A stated R1 told her he wasn't happy at the facility and had called and said he wanted to leave. At 2:31 p.m. LPN-A stated R1 had breakfast around 8:00 a.m. on the 28th. LPN-A said the last time she had seen him he was seated at the end of the hallway. LPN-A said she was not sure what time it was and stated she was at the nurse's station on the phone when another resident came and told her someone had broken a window. LPN-A stated she looked out the window of the nurses' station and saw everything and went outside. LPN-A said she saw the screen was out of the window. LPN-A stated she was not aware R1 had opened a window a few days prior. LPN- A further stated she did not recall hearing anything unusual the morning before R1 jumped out the window but stated the television was on in the dining room and a radio was on in the room R1 jumped out of. During interview on 4/2/20, at 8:23 a.m. the administrator stated on March 28th, she received a phone call from the nurse that R1 had jumped out the window on the third floor. The administrator stated after talking to the staff she learned he jumped from another resident's window. The administrator stated it appeared R1 had broken the metal [MEDICATION NAME] off the window but was unsure how as there was no evidence he used any tools. She said after the first time R1 had broken a [MEDICATION NAME] off the window, he had maintenance go around the unit and tighten all of them. The administrator further stated R1 was had not been placed on increased monitoring after the first event.

Based on interview and document review, the facility failed to ensure the safety of 1 of 1 residents (R1) who was cognitively impaired and was sent to a medical appointment unsupervised, did not return and went missing. This resulted in an immediate jeopardy (IJ) situation for R1 when the facility failed to ensure appropriate, systemic actions were taken to prevent similar occurrences for others that require supervision, after R1 was identified as missing. The IJ began on 5/28/19, when R1 was sent to a medical appointment out of the facility unsupervised, despite having known cognitive impairment. R1 did not return following the medical appointment, nor was R1 able to be located for several days; ultimately he was found hospitalized with fever, [MEDICAL CONDITIONS] due to [MEDICAL CONDITION]. On 5/31/19, at 6:50 p.m. the facility administrator and director of nursing (DON) were notified of the IJ for R1. The IJ was removed on 6/2/19, at 10:22 a.m., however, non-compliance remained at the lower scope and severity of isolated, actual harm that is not immediate jeopardy (Level G). Findings include: R1's Admission Record dated 6/03/19, indicated he admitted to the facility on [DATE], and had a legal guardian. R1 had pain in his right lower leg, alcohol use disorder, hypertension (high blood pressure), [MEDICAL CONDITION] ([MEDICAL CONDITION] disorder) and history of homelessness. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had short term memory loss, had modified independence with some difficulty in new situations with daily decision making. R1's annual MDS dated [DATE], indicated R1 had short term memory loss, had moderately impaired cognition, made poor decisions and required cues and supervision. Further, the MDS identified R1 required extensive assistance with mobility, needed a wheelchair and consumed opioid medications on a daily basis. R1's Activities of Daily Living (ADL) Care Area assessment dated [DATE], indicated history of alcohol use disorder and was at risk for ADL inability due to his inability to ambulate and needing assist of one with ADL's. In addition, the care area assessment (CAA) indicated mood/behavior and safety issues which included rejection of care. R1's care plan dated 6/21/18, indicated R1 had an alteration in short-term memory and impaired decision making skills along with a history of alcohol use and homelessness. R1 was identified as being frequently incontinent of bowel and required extensive assistance of two for activities of daily living, the care plan identified R1 had a history of [REDACTED]. The care plan lacked any information if R1 required supervision with off-site activities or medical appointments despite being identified as having cognitive impairment with impaired decision making and a history of alcohol use. On 12/10/18, R1 was seen by Associated Clinic of Psychology (ACP) due to staff reported he had been discharged from a (name of facility removed) Board and Care and failed there. The report further indicated knowing he had a subdural hematoma (caused by severe head injuries, bleeding and increased pressure on the brain) and that R1 admitted going to chemical dependence treatment according to the report too many times. In addition, the report indicated it is possible to conclude that he does suffer cognitive decline possibly from those two sources perhaps in the moderate range, based on his continued problematic life patterns and failure to live even with a modicum of continuity. Furthermore the assessment indicated He believes that he was told that once his leg is clear of infection he would be free to leave. He states staff do not allow him to have clothes as they fear that he would leave if he did. He expressed that he does not know how he got a guardian or why he needs one but she is preventing him from leaving. He complained of the way some staff interact with him and his frustration that no one provides him with any answers. He has minimal insights to his deficits and believes that he could safely live independently in the community even though he has failed to do so several times prior to his current placement. The assessment indicated staff should validate his distress related to not wanting to be at facility and commend him for staying here as they are invested in improving his overall well-being.: R1's Order Summary Report signed 3/21/19, identified R1 received [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 1000 milligrams (mg) twice daily for [MEDICAL CONDITION] disorder, and [MEDICATION NAME] (a narcotic pain medication) 5 mg twice daily and as needed for pain. R1's progress note dated 5/28/19, indicated R1 had an appointment at Hennepin County Medical Center (HCMC) at 1:30 p.m. with infectious disease for his wound on his right leg. The note indicated he would be picked up on the unit at 12:45 p.m. and R1 was given an appointment reminder. The note lacked any information on who, if anyone, would be supervising R1 during the appointment. Further, a subsequent note on 5/28/19, at 4:30 p.m. identified, Administrator and DON updated the resident was nowhere to be found after his clinic appointment at HCMC. Transportation Company contacted to verify report. HCMC was immediately contacted to find out the timeline of incident and to request camera footage. Received report from HCMC that resident was last seen in camera footage leaving the building thru the back door towards the parking lot at 2:39 p.m., shortly after his appointment. St(NAME)Police Department was contacted to report missing person. An Incident Summary Report dated 5/28/19, at 6:34 p.m. indicated Resident was at an appointment at HCMC clinic today and transportation was set for him to return. When transportation arrived at HCMC for pick up resident was not waiting in the lobby. Upon immediate search, HCMC staff did not locate resident in the hospital or clinic. Facility staff was immediately in contact with HCMC to determine if security could locate him on camera to see where he may have gone. HCMC staff eventually informed the facility that resident was seen on camera leaving the back doors of the clinic/hospital into the parking lot and not the normal entrance where the transportation picked him up. Resident was assessed on 4/10/19 for elopement risk, and assessment indicated he was not an elopement risk. Resident has not eloped from this facility nor has he ever attempted to elope from the facility since he has resided here. Guardian and medical doctor (MD) notified, facility will continue to work with police and HCMC to locate patient. During interview on 5/31/19, at 9:30 a.m. the facility administrator stated R1 had been missing after his medical appointment since 5/28/19, and still had not been located. The administrator added she had been looking for R1 since he went missing on the streets since he was known to have been homeless prior to coming to the nursing home, along with his history of leaving past facilities against medical advice (AMA). R1's Elopement Risk assessment dated [DATE], indicated he was not at risk for elopement. The assessment did not include history of leaving facilities against medical advice (AMA), and a history of alcohol use. In addition, the assessment failed to indicate he had impaired cognition, made poor decisions and required cues and supervision. R1's medical record lacked any evidence R1 had been assessed or screened to determine and/or verify his safety if left unattended during outside appointments despite having moderate cognitive impairment. During interview 5/31/19, at 10:45 a.m. health information staff (HI)-A explained she typically set up R1's appointments and he had always went to them unsupervised and returned without issue. HI-A verified she did not obtain R1's guardian's consent, nor notify the guardian of R1's appointment at HCMC on 5/28/19. HI-A stated she was disciplined for this and told to call R1's guardian for future appointments, however, received no new instructions or process changes for setting up R1 or other residents' appointments who had cognitive impairment to determine or ensure supervision is provided when needed. During interview on 5/31/19, at 11:02 a.m. licensed practical nurse (LPN)-A stated R1 had cognitive impairment with resulted poor memory. LPN-A added, At times I would give him his medications and later he would tell me he had not received them. When interviewed 5/31/19, at 11:05 a.m. social worker designee (SWD)-A stated he had arranged for R1 to transfer to a group home but he had decided since he wanted his leg to heal first he did not want to transfer to another facility. SWD-A then stated he was surprised he had went missing. When interviewed on 5/31/19, at 11:30 a.m. nursing assistant (NA)-A stated she often delivered R1's meal tray(s) to his room, however, at times he would forget he had already delivered it and would ask for them again. During interview 5/31/19, at 1:06 p.m. the administrator stated when they assess the residents for elopement risk they look at if they are there own person or if they have a guardian, cognitive status and history of elopement. The administrator stated the guardian should have been contacted for his appointment and informed how R1 would get there. In addition the administrator stated she was not aware that the MDS indicated R1 was moderately impaired cognition, made poor decisions and required cues and supervision. On 5/31/19, at 1:54 p.m. the HCMC clinic administrator was interviewed and explained the clinic lobby staff does not provide ongoing supervision of the nursing home residents when they arrive for appointments. If someone required such, it would be up to the nursing home or family to provide that. When interviewed on 5/31/19, at 3:30 p.m. the Twin Cities Transportation (TCT) administration stated they routinely transport patients and resident from the nursing home to clinic appointments. They verify the resident is dropped off only, are unsupervised until they are picked back up when the clinic desk calls for a return pick-up. TCT Administration further stated that the clinic did call for a return pick-up following R1's appointment and they were told it would be over an hour wait time. When interviewed on 6/03/19, at 10:00 a.m. HI-B stated she did not inform the guardian of R1's appointments and she thought R1 was his own responsibility. HI-B further stated she had been educated that she should had always contacted the guardian, inform them of appointments and check if it was ok if they went unsupervised. During interview on 6/04/19, at 9:07 a.m. R1's guardian (GA)-A stated the facility had been told upon admission R1 had left previous facilities AMA and she did not feel that R1 was safe to go on appointments unsupervised. GA-A stated she had not even been informed R1 had an appointment scheduled or set-up for 5/28/19 at HCMC which was upsetting to her. Further, GA-A stated R1 had history of leaving facilities and going out drinking, so GA-A felt R1 was not safe to be left alone unsupervised while at any medical appointments and had informed the facility of this upon admission. A Hospital Encounter Note dated 6/03/19, at 6:03 a.m. indicated R1 was admitted to HCMC with [MEDICAL CONDITION], increased right leg pain, fever and [MEDICAL CONDITION](high heart rate). The report further indicated that upon admission, R1 was intoxicated, disheveled, requested food and [MEDICATION NAME] (pain medication) and was provided antibiotics and fluid in the emergency room . R1 was then admitted [MEDICAL CONDITION] (infection) due to [MEDICAL CONDITION]. A facility Elopement Risk Evacuation dated 4/10/19, indicated he had no history of elopement, alert and orientated, accepting of placement, no behaviors, no dementia and was not at risk for elopement. Although the assessment indicated R1 was alert and orientated, the assessment did not include information that R1 had a history of [REDACTED]. The immediate jeopardy that began on 5/28/19, was removed on 6/2/19 at 10:22 a.m. when the facility had assessed residents for supervision for medical appointments, developed care plan interventions for residents at risk and educated staff on Missing Resident/Elopement Policy, Abuse Prevention/Vulnerable Adult Plan pertaining to elopement, and the facility policy regarding Appointment and Travel Arrangements.

Based on interview and document review, the facility failed to comprehensively assess falls in an effort to determine causal factors for 1 of 3 residents (R6) reviewed for accidents. This resulted in actual harm for R6 who sustained a [MEDICAL CONDITION] following a fall in the facility. Findings include: R6's annual Minimum Data Set ((MDS) dated [DATE], indicated he was moderately cognitively impaired, required extensive assist of one staff for transfers and toileting, did not ambulate during the assessment period and was unsteady during transfers. The MDS further indicated R6 was frequently incontinent of bowel, always incontinent of bladder and sustained two or more falls since the previous assessment. R6's care plan identified a risk for falls secondary to a history of falls, difficulty walking and [DIAGNOSES REDACTED]. Resident had three falls this quarter, one which sent him to the hospital because of a laceration. Resident is at risk for fall with injury, pain and overall decline. R6's care plan dated 9/18/18, was reviewed. Interventions included: complete bowel and bladder assessments as needed, apply footwear to prevent slipping, offer toileting when indicated and encourage call night use. The care plan further indicated R6 was unlikely to use his call light. Review of R6's Fall Review Evaluations and correlating facility Progress Notes identified the following: -Progress note dated 10/19/18, indicated R6 fell attempting to self transfer and sustained a laceration to his forehead. R6 was reminded to use his call light, physican notified and R6 was sent to the hospital. A second noted dated 10/19/18, indicated R6 returned with five sutures to his forehead. The medical record lacked evidence the fall was reviewed for causal factors. -Progress Note dated 11/1/18, indicated R6 was noted sitting on the floor in front of his wheel chair at 6:45 a.m. R6 was reminded to use his call light. A correlating Incident Review dated 11/1/18, indicated R6 was incontinent at the time of the fall but lacked current or new fall interventions put into place. -Progress Note dated 11/5/18, indicated R6 was found sitting on the floor between his bed and wheel chair after supper at 6:30 p.m. A follow up note dated 11/5/18, indicated R6 was reminded to use the call light for help, incontinent of bowel and bladder and had a small stool. The record lacked evidence of an incident report. -Progress Note dated 11/20/18, indicated at 4:20 a.m. staff heard a big bang in the nearby room. R6 was found on the floor. R6 hit his head on the floor resulting in a swollen forehead on the right side and complained of hip pain. A correlating Incident Review and Analysis dated 11/20/18, indicated R6 self transferred and did not lock wheel chair brakes. Current interventions included a clutter free environment. Fall reviewed with nurse practitioner and guardian during care conference and considered adding auto lock brakes to wheel chair. Guardian requested to wait until therapy could evaluate. The review further indicated prior falls were reviewed. Times of falls: 1:41 a.m. (no date) attempting to self transfer from bed, 11/1/18, 6:45 a.m. attempting to transfer bed to wheel chair, bed noted to be wet. 11/5/18, 6:30 p.m. attempting to transfer from bed to wheel chair, 11/20/18, attempting to transfer from bed to wheel chair. Complete new pain assessment, currently receives no pain medications. Review of R6's pain assessments identified a scheduled MDS pain assessment completed 11/30/18, that did not identify any pain. -Progress Note date 12/7/18, indicated R6 was found lying on the floor in the bathroom at 1:30 p.m. R6 stated, I lost my balance when I transferred to the bathroom. R6 reminded to call for assistance. A correlating Incident Review and Analysis dated 12/10/18, indicated R6 was trying to transfer to the toilet at the time of fall. No current interventions were identified nor were new interventions implemented. -Progress Note dated 1/3/19, indicated at 6:15 p.m. R6 was found lying on the floor on his back by his bed. Noted old scabs on both knees, old bruises to top of both hands. A correlating Incident Review dated 1/7/19, did not identify causal factors. Current interventions indicated, I will have pharmacy do a med (medication) review. The report lacked evidence of further analysis. -Progress note dated 1/8/19, indicated R6 was complaining of pain on his left lower abdomen and was sent to the hospital for evaluation. Review of a hospital history and physical dated 1/8/19, indicated R6 presented to the emergency department with diffuse abdominal pain. Per nursing home staff he had been increasingly confused and agitated over the last several days. R6 poor historian but able to indicate he had lower abdominal pain, worse on the right side. Initially a urinalysis was obtained and foley catheter (urinary) inserted with removal of large amount of urine. The following day, pain did not improve and a computed tomography (CT or CAT scan, allows doctors to see inside your body using a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues) was obtained which showed a right comminuted and displaced femoral neck fracture. During interview on 1/31/19, at 11:02 a.m. licensed practical nurse (LPN)-A stated R6 had been having an increase in the number of falls. LPN-A stated R6 had not been having increased behaviors but kept thinking he could transfer himself. She stated R6 used to be able to transfer independently but over time his ability decreased and could not remember to ask for help. LPN-A stated the guardian had called and wanted to know what could be done about the falls and LPN-C stated the facility did not use bed alarms or mats on the floor. LPN-A stated at the time of R6's falls she was the unit coordinator but was still working on the floor passing medications and completing treatments. In regard to the process for follow up after a fall, LPN-A stated she completed the Incident Review and Analysis form to go over any causative factors she could find for the fall and any measures to prevent future falls. She stated while the falls were reported to the interdisciplinary team, the incident reports were only completed by her. She stated when R6 fell on [DATE], and sustained the [MEDICAL CONDITION] an incident report was not completed, on 11/1/18, when he fell and had been incontinent, LPN-A stated, I think I got therapy for him. After the fall on 11/20/18, LPN-A stated R6 had an x-ray done but she was not aware of it. LPN-A stated when R6 was hosptalized on [DATE], she called and was told by nursing that R6 had a [MEDICAL CONDITION] and due to a heart condition could not have surgery and the next thing she knew he had passed away. LPN-A indicated the fracture was a result of the fall on 1/3/19. During interview on 1/31/19, at 11:27 a.m. the director of nursing (DON) stated following a fall the nurses complete an incident form and the fall was discussed with the interdisciplinary team to determine if further action needed to take place. The DON stated the nurse manager was expected to fill out the Incident Analysis and stated, we found out that wasn't happening as often as it should have.

Based on observation, interview and document review, the facility failed to assess and implement interventions for non-pressure related skin concerns for 1 of 1 resident (R2). This resulted in actual harm for R2 who experienced progressive decline of a skin condition and uncontrolled pain resulting in hospitalization . In addition, the facility failed to follow physician orders [REDACTED]. Findings include: R2's prospective payment system 14 day minimum data set (MDS) 12/1/18, indicated she was moderately cognitively impaired, required extensive assistance from two staff for activities of daily living (ADL)'s and had moisture associated skin damage (MASD). The MDS further indicated [REDACTED]. R2's initial care plan dated 11/15/18, identified problems including: self care deficit with ADLs, and a potential for alteration in skin integrity related to impaired mobility and incontinence. Interventions directed staff to perform weekly skin assessments and to provide skin treatments as ordered. An untitled, undated nursing assistant care sheet, directed staff to assist with turning and repositioning every two hours and as needed. On 12/18/18, R2 was continuously observed from 6:25 a.m. to 9:25 a.m. At 6:25 a.m. R2 was lying in bed. At 9:07 a.m. nursing assistants (NA)-A and NA-B entered R2's room to perform morning cares. R2 stated, Please, I'm very uncomfortable, I need to roll over, come on, I'm very uncomfortable, Please move me, oh, come on please roll me, I'm very uncomfortable, please help me, Oh my God, please help me. At 9:11 a.m. NA-A left the room and returned with supplies, the staff still had not repositioned R2. At 9:16 a.m. RN-A entered R2's room. RN-A stated, her (R2's) skin is very broken down. At 9:18 a.m. R2 stated, I'd like to get off my butt. NA-A and NA-B removed R2's incontinent brief to perform cares, R2's perineal area and labia were bright red in color. RN-A stated her (R2's) bottom is very red, she usually has a lot of pain, it [MEDICAL CONDITION] they wipe her up. RN-A further stated when R2 was sitting she had the same amount of pain. When turned, R2's buttocks were also noted to be very red with multiple open areas. Review of R2's electronic health record identified the following: Weekly Skin Inspections noted: 11/15/18, Skin Assessment identified reddened area on buttocks. 11/29/18, Skin Assessment identified reddened area on buttocks. R2's medical record lacked evidence of any further skin assessment. Physician visit notes included: 11/30/18, R2 had complaints of pain in groin and buttock due to rash. 12/6/18, R2's buttocks were very red and irritated looking with [DIAGNOSES REDACTED] and slight [MEDICAL CONDITION]. The note indicated, Had [MEDICATION NAME] (antifungal cream) cream ordered however, they just got it in. Previous tube of cream disappeared. Skin: buttocks very red and inflamed. 12/13/18, R2 had ongoing painful rash. R2 with painful rash all over peri-area and buttock. Staff reported R2 hollering at night. The facility's Interdisciplinary Progress Notes revealed: 12/3/18, R2's family member complained that R2 was sent home over the holiday weekend in a soiled incontinent product and upon changing, R2 was wearing two incontinence products. Family stated both incontinent products were soaked. 12/6/18 - R2's buttocks and groin areas were very red and open. R2 was uncomfortable and in pain, crying out loud. 12/6/18 - R2 finally asleep after she had a long exhausting day due to skin breakdown. 12/10/18 - R2 continued to have reddened buttocks and groin area. R2 continued to yell out loud due to discomfort in buttocks. 12/10/18 - [MEDICATION NAME] cream, apply to buttock and upper thigh area two times per day, to be delivered tomorrow. 12/11/18 - Social services received a call from Hennepin County adult protection services that they received reports that R2 had gone home for Thanksgiving with some diaper rashes and was denied pain medications. Interdisciplinary team reviewing. 12/12/18 - R2 buttocks was now red, raw and irritated. R2 was yelling out at the top of her voice in excruciating pain. She was unable to be re-directed or comforted. Received an order to give a one time dose of [MEDICATION NAME] and to continue to apply ordered cream. R2 continued to yell out in pain. During interview on 12/18/18, at 9:41 a.m. NA- B stated when R2 was admitted to the facility she'd had redness on her bottom, but no open areas. On 12/18/18, at 12:31 p.m. RN-A stated during the observation earlier that day she'd observed R2's skin to be really red, broken down raw skin, with areas that looked like a popped blister. RN-A stated she'd seen about two of those blistered areas that were red, puffy and raw. On 12/18/18, at 12:37 p.m. NA-A was asked when R2 had been changed or repositioned prior to the 9:00 a.m. observation. NA-A stated R2 had last been taken care of by the night shift staff at 6:00 a.m. On 12/18/18, at 1:29 a.m. RN-B stated he had been assessing R2's skin but had not documented anything. RN-B stated the nurses were looking at R2's skin every day and should have completed a skin assessment weekly. RN-B stated this was something he should have been following up on. RN-B further stated he had seen R2's skin that morning and stated, it was a little worse than it had been the previous week. He further stated when he'd looked at her this morning, she had a bunch of tiny little open spots. During interview on 12/19/18, at 11:13 a.m. the director of nursing (DON) stated he knew the staff were struggling to manage R2's skin alterations and stated it had been discussed at the morning meeting. The DON stated on shower days the nurses should have completed weekly assessments and stated the nurse manager should be monitoring for completion. The DON stated the assessment should have included a visual description, and documentation of measurements, redness, and presence of pain. During interview on 12/19/18, at 10:28 a.m. the hospital RN stated she had seen R2's skin. The Fairview RN described R2's skin as red and excoriated with open spots. At 10:56 a.m. on 12/19/18, the certified nurse practitioner (CNP) stated R2 had a rash in her peri-area that was very tender to the touch. The CNP stated she had seen the front but had not seen R2's buttocks. During a subsequent interview on 12/19/18, at 3:00 p.m. the hospital RN stated the hospital wound nurse had seen R2 that afternoon. She read the wound nurse notes that described R2's skin as follows: Wound base with scattered, spotty areas of pink, red, raw, moist denuded tissue especially around there perineal and peri-labial areas. Right inner buttock contained two small superficial opening less than one centimeter each and two small scabs around the per-anal area. R2's skin alteration was described as painful by the wound nurse. A policy related to skin assessment was requested but not received. R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's 30 day Minimum Data Set ((MDS) dated [DATE], indicated R1 had intact cognition and R1 had an indwelling catheter (including suprapubic catheter). On 12/18/18, at 6:27 a.m. R1 was observed awake and had the call light on. During the observation a Foley catheter collection bag was observed under the bed lying on the floor. R1 stated he had a Suprapubic catheter and pulled his shirt and showed surveyor. When asked if he had any problems with the catheter, R1 stated he had been to the hospital multiple times to have it changed because the staff at the facility stated they would not do it. R1 stated the catheter leaked all the time, had blockage due to sediment build-up and he would sit on wet bedding which staff did not change timely due to being short of help at times. Review of R1's Telephone Physician order [REDACTED]. There was no evidence in the record R1 had seen the urologist. During further review of the interdisciplinary (IDT) notes it was revealed on 10/6/18, 10/7/18, 10/8/18, 10/15/18, 12/4/18, and 12/5/18, multiple staff had indicated R1's Suprapubic catheter was observed and/or R1 had complained about the bypassing. The IDT note dated 10/15/18, 12:01 a.m. indicated R1's catheter was bypassing and an order had been obtained for R1 to see a urologist. The writer indicated the order was going to be followed up by the health unit coordinator (HUC) and the morning nurse. On 12/18/18, at 8:58 a.m. HUC-A when asked if R1's appointment had been set up she stated she would look through the actual physical chart to see if the referral sheet was in the chart as this was before the facility went to Point Click Care (PCC). At 9:02 a.m. HUC-A stated when R1 was admitted to the Transitional Care Unit (TCU) directed the surveyor to the HUC-B in the TCU. HUC-A verified R1's appointment was not in the calendar at the current unit. At 9:17 a.m. HUC-B reviewed the TCU calendar from 10/1/18, through 12/1/18, and verified R1 had no scheduled appointment to the urologist. HUC-B stated R1 would set up his own appointments and rides, and stated He is with it. When asked if R1 knew he had an order to set up an appointment with urologist HUC-B stated the order had been noted by a nurse and she was not sure if this had been communicated to R1 to set the appointment. HUC-B stated she needed sometime to look through the medical record to see if R1 had seen the urologist. On 12/18/18, at 9:27 a.m. when asked about the urologist appointment, R1 stated he did not know there was an order to schedule an appointment. Resident stated I schedule my appointments and did not know about it until today. You are the first one to say it to me. R1 stated when he had been at the hospital, the doctor had told him all suprapubic catheters always leaked and he would have not minded going to the specialist for a second option. On 12/18/18, at 10:37 a.m. the administrator in training stated she had looked through the medical record and was not able to see the order surveyor was inquiring about. She stated R1 was a very private person and liked to make his own appointments. Surveyor showed the administrator in training the telephone Physician order [REDACTED]. After she reviewed the order the administrator in training stated the staff should have communicated the order to R1 so R1 would schedule the appointment. On 12/18/18, at 9:52 a.m. the DON stated when orders were physically written in the chart the nurse or HUC pulled the red tab to alert the staff of a new order. The DON also stated on a regular day the HUC processed the orders and after hours the nurses were responsible for processing the orders and when the order was transcribed /completed it was supposed to be noted. The DON further stated every night, as far as he knew from when he'd been a staff nurse, the night nurse was responsible for double checking the orders to make sure they were done correctly. The DON added, apparently that is not happening. Further, the DON stated the facility did not have a policy regarding this.

Based on observation, interview and document review, the facility failed to implement interventions for pain control for 1 of 1 residents (R2). This resulted in actual harm for R2 who experienced uncontrolled pain resulting in hospitalization . Findings include: R2's prospective payment system 14 day minimum data set ((MDS) dated [DATE], indicated she was moderately cognitively impaired, required extensive assistance from two staff for activities of daily living (ADL)'s and had moisture associated skin damage (MASD). The MDS further indicated [REDACTED]. The MDS identified the use of PRN pain medications but no non-pharmacological interventions. R2's initial care plan dated 11/15/18, identified an ADL self care deficit and a risk for alteration in comfort related to pain. The care plan directed staff to monitor and document on pain, attempt non-pharmacological interventions, administer [MEDICATION NAME] as ordered and evaluate effectiveness. An untitled, undated nursing assistant care sheet directed staff to assist with turning and repositioning every two hours and as needed. A review of R2's Medication Administration Record [REDACTED]. On 12/18/18, R2 was continuously observed from 6:25 a.m. to 9:25 a.m. At 6:25 a.m. R2 was lying in bed. At 9:07 a.m. nursing assistant (NA)-A and NA-B entered R2's room to perform morning cares. R2 stated, Please, I'm very uncomfortable, then stated I need to roll over, come on, I'm very uncomfortable, Please move me, oh, come on please roll me, I'm very uncomfortable, please help me, Oh my god, please help me. At 9:11 a.m. NA-A left the room and returned with supplies, the staff still had not repositioned R2. At 9:16 a.m. RN-A entered R2's room. RN-A stated her (R2) skin is very broken down. At 9:18 a.m. R2 stated I'd like to get off my butt. NA-A and NA-B removed R2's incontinent brief to perform cares, R2's perineal area and labia were bright red in color. As the NA's were cleaning R2's perineal area R2 was yelling out, It hurts, it burns, oh for gods sake it burns. RN-A stated her bottom is very red, she usually has a lot of pain, it [MEDICAL CONDITION] they wipe her up. RN-A further stated when R2 was sitting she had the same amount of pain. When turned, R2's buttocks was noted to be very red with multiple open areas. R2 had stool in her brief and as NA-A and NA-B cleaned her bottom she continually called out in pain stating, It burns, don't you understand that? Review of facility Progress Notes identified the following: - 12/6/18 - R2's buttocks and groin areas were very red and open. R2 was uncomfortable and in pain, crying out loud. Tylenol was given, R2 slept for about two hours and began crying out again. - 12/6/18 - R2 finally asleep after she had a long exhausting day due to skin breakdown. - 12/10/18 - R2 continued to have reddened buttocks and groin area. R2 continued to yell out loud due to discomfort in buttocks. - 12/11/18 - Social services received a call from Hennepin County adult protection services that they received reports that R2 had gone home for Thanksgiving with some diaper rashes and was denied pain medications. Interdisciplinary team reviewing. - 12/12/18 - R2 buttocks was now red, raw and irritated. R2 was yelling out at the top of her voice in excruciating pain. She was unable to be re-directed or comforted. Received an order to give a one time dose of [MEDICATION NAME] and to continue to apply ordered cream. R2 continued to yell out in pain. - 12/12/18 - Physician from [MEDICAL TREATMENT] called to inquire about R2's care and what we were doing to help with her pain. Writer explained that facility had reached out to primary care provider and requested pain medication. - 12/12/18 - Physician was contacted and R2 was added to his patient list for tomorrow to assess and treat increasing pain R2 has been having related to buttock redness, frequently calling out in pain last few days. - 12/12/18 - [MEDICATION NAME] cream for pain relief of buttocks not yet delivered. - 12/13/18 - R2 screamed and yelled most of the night due to pain in buttocks. R2 received as needed Tylenol as ordered, but not helpful, [MEDICATION NAME] applied. - 12/14/18 - Doctor resumed pain management with [MEDICATION NAME]. - 12/14/18 - [MEDICATION NAME] cream not applied, was not available. - 12/15/18 - 12/17/18 - [MEDICATION NAME] administered for pain relief. R2's MAR indicated [REDACTED]. The last dose of [MEDICATION NAME] was administered on 12/17/18, at 1:40 p.m. A facility Progress Note dated 12/18/18 indicated R2 had in increase in pain and was calling out most of the morning. R2 started the unstoppable calling out around 8:00 a.m. Resident was given the maximum of as needed [MEDICATION NAME] and it was ineffective. An hour after receiving the [MEDICATION NAME] R2 was still calling out with no apparent effect. Physician order [REDACTED]. R2 was combative with staff and paramedics, paramedics applied hand cuffs to complete the transfer. During interview on 12/18/18, at 1:29 p.m. RN - B stated R2 had received the [MEDICATION NAME] at about 9:30 a.m., even though the Progress Note written by him identified R2 had been calling out since 8:00 a.m. During interview on 12/19/18, at 9:40 a.m. RN-A was interviewed about why she did not intervene during R2's care the previous day with pain medication or the topical [MEDICATION NAME] while R2 was crying out in pain. RN-A stated she thought the [MEDICATION NAME] had been discontinued and stated she was not sure if it was ever received from the pharmacy. RN-A stated it was not in the medication or treatment cart and had not been available the previous day either. On 12/19/18, at 9:45 a.m. RN-B was asked about the [MEDICATION NAME]. RN-B stated, my understanding was that it was not available, last I heard it was not here from pharmacy. On 12/19/19 at 11:13 a.m. the director of nursing (DON) stated he would have expected the staff to use the [MEDICATION NAME] prior to cares. The DON further stated if the nurse was in the room during care and heard how difficult the pain was to bear, he would expect the nurse to halt cares and intervene. A facility policy titled Pain Management Protocol, undated, identified the facility to ensure residents with or at risk for pain had an effective pain management plan in place. The policy directed staff to identify residents with pain and collaborate to establish an effective pain management plan. Nurses to assess pain upon admission, quarterly, with change of condition and when there was on on-set of new or worsening pain. If prescribed medications are not available or there is a delay in obtaining medications, the provider would be notified and alternative interventions obtained.

Based on interview and document review, the facility failed to provide adequate supervision to prevent accidents for 1 of 32 residents (R1) reviewed who smoke and was not reassessed for smoking when R1 returned to the facility after a hospital stay and received a new physician's orders [REDACTED]. R1 smoked unsupervised, with his oxygen on. The oxygen and tubing ignited and the resident experienced second degree burns and was hospitalized . The failure of the facility to identify the need to reassess the resident who required oxygen use after a change in condition, and to supervise resident smoking areas placed all 32 residents who smoke at risk for immediate jeopardy. The Immediate Jeopardy began March 31, 2017 when the resident returned to the facility after a hospital stay with a new physician order [REDACTED]. R1 smoked unsupervised, with his oxygen on. The oxygen and tubing ignited and the resident experienced second degree burns and was hospitalized . The Administrator and Director of Nursing were notified of the Immediate Jeopardy on April 11, 2017. Noncompliance remained at the lower scope and severity level of isolated actual harm that is no immediate jeopardy. Findings include: R1's medical record was reviewed. R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1's smoking assessment, dated 3/2/2017 indicated R1 was a smoker who smoked three to four times daily. R1 did not use supplemental oxygen. R1 was an independent smoker. A physician's note, dated 3/14/2017 indicated R1 exhibited significant memory loss. Nursing notes dated 3/20/2017 indicated R1 went to the hospital related to a change in condition when his oxygen saturations dropped and he experienced new edema. Nursing notes dated 3/31/2017 indicated R1 was readmitted back to the facility from the hospital on [DATE] after he was hospitalized and treated for [REDACTED]. R1's physician orders, dated 4/4/2017 indicated R1 had a new order for oxygen two to five liters via nasal cannula as needed for comfort. R1's medical record , after return from the hospital, did not indicate a reassessment of R1's smoking safety. Nursing notes dated 4/8/2017 indicated on 4/8/2017 at about 5:00 p.m. R1 had his oxygen on while smoking in the courtyard, it ignited and R1's face was burned. A review of the hospital record, dated 4/8/2017 indicated R1 was admitted to the hospital's burn unit with 1% total body surface area second degree burns to his face. During an interview on 4/10/2017 at 2:10 p.m., Activities Assistant (AA)-H stated the courtyard is a designated smoking area for residents who are independent smokers. The courtyard is unlocked and open for resident use 24 hours per day and seven days a week. All residents, including non-smokers, residents with oxygen and residents who require supervision with smoking are allowed in the courtyard. AA-H stated she was not aware if any staff supervised the courtyard. During an interview on 4/10/2017 at 4:00 p.m., RN-E stated R1 was readmitted back to the facility from the hospital on [DATE]. Although R1 was known by facility staff to be a smoker and R1 had a new physician's orders [REDACTED]. RN-E stated she was not aware of which residents require supervision while smoking, RN-E added residents are known to give one another cigarettes in the courtyard. During an interview on 4/10/2017 at 4:30 p.m., Licensed Clinical Social Worker (LSW) - F stated that although the independent residents smoke in the courtyard, no staff supervise the residents smoking in that area. During an interview on 4/11/2017 at 11:30 a.m., R3 stated residents smoke in the courtyard. She was not aware which residents require supervision with smoking. Often when a resident pulls out a lighter to light a cigarette, other residents pass around the lighter to light all their cigarettes. R3 stated residents often buy cigarettes from one another. During an interview on 4/11/2017 at 12:00 p.m., R2 stated on 4/8/2017 R1 came out into the courtyard with a cigarette butt that was about 2 1/2 inches long. R2 did not know where the cigarette came from. R1 requested a light for his cigarette, so she lit it with her lighter. As soon as she lit it, R1's oxygen tubing ignited in a flash and it was burning while on R1's face. R1's beard and mustache were on fire. R2 pulled the oxygen tubing off of R1, threw it on the ground, stomped on it, then turned off the oxygen. R2 stated no staff were present in the courtyard. R2 was not aware if any staff supervise residents smoking in the courtyard, but no one did on this day. R2 stated she was frightened by the incident and thought a staff member should have been supervising R1 and his smoking that day. During an interview on 4/12/2017 at 10:50 a.m., LPN-D stated she worked on 4/8/2017 and at about 3:00 p.m. R1 got out of bed and was short of breath, so she put his oxygen on him. At about 4:30 p.m. LPN-D found R1 in the courtyard, where residents smoke, and he had his oxygen on. LPN-D stated she removed him from the courtyard and asked him not to return, but did not supervise him or remove his oxygen because she did not know he was a smoker. At about 5:00 p.m., another nurse called to tell her that R1 had attempted to smoke with oxygen on and had burned his face. LPN-D stated she did not call 911, but called the hospice nurse to see what she should do for the resident. LPN-D stated she checked R1's vital signs, which were within normal limits and cleaned the blackened areas on his face from the fire. LPN-D stated the skin on his forehead was blackened, but she could not recall what other areas of his face were burned. LPN-D did not call 911, and did not call R1's physician because he was a hospice resident, and she understood she was to call the hospice nurse first for any patient condition change. The hospice nurse did not get to the facility for a long time (exact time unknown.) Once the hospice nurse arrived, they decided to call 911 for R1, and R1 was transported to the hospital at about 7:00 p.m., approximately two hours after the fire. During an interview on 4/12/2017 at 2:40 p.m., R1's family member stated he was concerned about the fire and burn that R1 experienced. R1's family member stated he thought the facility did not respond to the injury fast enough and questioned why the staff did not send R1 to the hospital right away after R1 was burned. Additionally, R1's family member expressed concern related to how R1 was able to smoke while on oxygen. The policy titled Smoking Guidelines, undated and provided by facility staff revealed: Designated Smoking areas: Residents are allowed to smoke only in designated smoking areas: The smoking room on 2nd floor within the facility and in the Courtyard . Smoking Assessment and Individualized Plan: Resident's capability to and deficits to smoke will be assessed upon admission, quarterly, and following any smoking related incidents and an individualized plan will be developed. A resident may be allowed to smoke independently if has been determined that the resident had the capability to safely smoke independently .Facility has the responsibility to ensure that residents receive adequate supervision and assistance devises to prevent accidents and provide care to residents in a manner that helps promote quality of life .Residents will not bring hazardous materials into the designated smoking areas - i.e. oxygen, medical gas, combustible or flammable materials. The policy titled Fire Plan, undated and provided by facility staff revealed: In case of fire remain calm at all times and remember rescue anyone in immediate danger .activate the fire alarm system .Upon hearing the alarm signal Code Red announcement, the telephone operator/charge nurse/person in charge shall immediately notify the local fire department .by calling 911. The immediate jeopardy that began on March 31, 2017 was removed and the administrative staff were notified on April 13, 2017, after verification of through observation and interviews confirmed the facility implemented actions to remove the immediacy of the immediate jeopardy. Staff were educated on the implemented changes. All 32 resident were assessed for smoking. All residents will be evaluated for smoking upon admission, quarterly, annually and with a change of condition or return from a hospital. The facility implemented system changes that incorporated all smoking residents who use prescribed oxygen have all smoking supplies kept at the nursing office as well as those of the roommates of those residents. Smoking is only allowed in the designated indoor smoking area that is supervised by a staff at the entrance and supervised by a staff via video surveillance during specific designated smoking hours. Residents who smoke are supervised to wear a smoking apron and no oxygen is allowed in the designated smoking room. The facility created a list of of residents who smoke and require supervision. Staff are able to identify resident who require supervision when smoking. Staff were able to identify how to respond to a fire by rescue, alert, confine, extinguish and how to use the fire extinguisher. Staff were educated to seek immediate medical attention for a resident affected by a fire and to notify the physician. Residents were educated on the facility smoking policy that included not to share smoking materials. Noncompliance remained at the lower scope and severity level of isolated actual harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to identify, report and thoroughly investigate allegations of abuse, this resulted in an immediate jeopardy (IJ) for 6 of 12 residents who had allegations of abuse (R118, R183, R1, R12, R260, R80) due to these residents being afraid of unwanted touch and/or threats of physical harm from staff and other residents. In addition to the residents in IJ, the facility failed to identify, report and thoroughly investigate allegations of abuse that were not an IJ for the other 6 of 12 residents (R28, R45, R112, R186, R218, R167). The IJ began on 1/22/17, when R118 notified facility staff that a nursing assistant (NA) had threatened to hurt her and the facility failed to intervene. The IJ was identified on 1/26/17, and the executive director (ED) was notified of the IJ at 4:32 p.m. on 1/26/17. The IJ was removed on 1/30/17, at 3:05 p.m., but non-compliance remained at the lower scope and severity level of E. Findings include: R183 was interviewed on 1/26/17, at 4:00 p.m. and stated she was aware of the reporting process, but felt it was useless to report, because they were blaming, and accusing her of making up stories. R183 stated she had tried to report to the nurse on the night shift about an incident that had occurred this past spring (date unncertain). R183 stated, she (the night nurse) came in and was blaming me, saying '(NA-HH) is just trying to take care of you.' So I told her to get out. I don't trust anyone here. That director of nursing (DNS) came in to talk to me and I told him to get out. I don't trust him. R183 had tears in her eyes and reported that NA-HH had rubbed her arm, and then had moved to her breast area. R183 said she'd yelled at NA-HH, Stop, what the H**l are you doing? She further stated, He then took his finger (demonstrated a circular motion with her index finger) around my anus. I told him to stop, saying 'what the h**l are you doing?', but he didn't stop, so I slapped him (demonstrated a backhanded slapping motion), and he still didn't stop, so I slapped him again. R183 stated NA-HH was still working here, so she had kept a fork on her bedside table for a long time, as defense, but then they took it away with a dinner tray. R183 stated she woke up last week and he (NA-HH) was standing at the end of her bed. She stated, I picked up my bottle (demonstrated picking up a large glass bottle of hot sauce, with a long thin neck) from my bedside table and threatened to hit him with it if he didn't leave. I had to say I will crack your head open to get him to leave. R183 agreed to speak with licensed practical nurse (LPN)-B, because she felt she could trust her, but said she would not speak with the DNS because she did not trust him at all. At 4:34 p.m. on 1/26/17, LPN-B was asked whether she had noted any changes in R183's behavior or if she had heard any report about R183 having threated to hit a NA-HH. After some thought LPN-B stated, About three or four months ago, R183 would not let anyone turn her or touch her on the night shift. I asked her if anything was wrong, but she wouldn't tell me. LPN-B added, I have talked to my nurses, months and months ago, she wouldn't turn in bed, she wouldn't roll over. We have to be careful with her, she makes things up. She has a history of [DIAGNOSES REDACTED], hallucinations and delusions. I had been asking her what's wrong, and she specifically told me it was ok for NA-HH to take care of her. LPN-B went on to say that R183 was 'tough with mental health, and she tries to get people in trouble. A social worker (SW) and I interviewed her, then the DNS comes up and she kicks him out of the room. The surveyor then asked LPN-B whether she'd been awared that R183 had alleged having been touched inappropriately by NA-HH. LPN-B stated she had not be aware, then proceeded to go in to discuss with R183, and following their conversation LPN-B reported the allegation of sexual abuse to the State agency (SA). Acording to her Admission Record, R183 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], indicated R183 was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION] or hallucinations. In addition, the MDS indicated R183 did not reject cares and had demonstrated no verbal or physical behaviors towards others. R183 was totally dependent on two staff and utilized a mechanical lift for transfers, required extensive physical assistance of two staff for bed mobility, dressing and toilet use, and did not have antipsychotic or antidepressant medications ordered. An MDS dated [DATE], also indicated R183 was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION] or hallucinations. However, the MDS indicated R183 had demonstrated physical behaviors directed towards others during one to three days, verbal behaviors directed towards others on four to six days, and had rejected cares one to three days, all days in reference to the MDS look back period. The MDS indicated R183 was totally dependent on two staff and a mechanical lift for transfers, required extensive physical assistance of two staff for bed mobility, dressing and toilet use, and did not have antipsychotic or antidepressant medications ordered. A Care Area Assessment (CAA) dated 6/27/16, indicated R183 had triggered [MEDICAL CONDITION] as an area for assessment. The CAA analysis indicated the [MEDICAL CONDITION] was due to a decrease in her cognitive score and a recent change in mood; sad or anxious (for example crying, social withdrawal). The Care Plan (CP) dated as far back as 11/14/14, indicated R183 had a potential for abuse due to decreased physical ability, need for care and history of allegations towards staff that were found to be unsubstantiated. The CP dated 6/11/15, indicated behaviors which include shouting, crying and stating I am not crazy. I have a history of psychiatric disorders and will often state a complaint but change my story which results in an inconsistent reporting history. I sometimes refuse the bedpan when offered. Potential [DIAGNOSES REDACTED] exhibited by: 1) verbalize I am having health issues that are not present upon examination/tests. I have paranoia related to my [MEDICAL CONDITION] [DIAGNOSES REDACTED]. I often have concerns regarding the delivery of my cares. I meet with staff on a regular basis to discuss my concerns and resolutions. I often state the NAR's (nursing assistants/registered) are not helping me when in fact I have refused cares. Although the care plan indicated R183 had identified behaviors, the facility did not thoroughly investigate her allegations to determine validity of the allegations. An Associated Clinic of Psychology (ACP) note dated 10/11/16, indicated the therapist and R183 had discussed the resident's feelings of anger and distress with staff at the facility, and that R183 had elaborated on three of her concerns regarding staff behavior towards her and how she was not pleased with the follow-up thus far. The ACP note also indicated R183 had reported she had not been sleeping well recently, and that she had been encouraged to watch TV and play games on her phone to keep from being overwhelmed by current situation. The note indicated the resident utilized no known medications (for depression or [MEDICAL CONDITION]). The ACP therapists recommendations included: She had been requesting staff to leave her alone as much as possible while continuing to appropriately address her care needs. She seemed to be in a protective mode at that time and thus staff should be very mindful of their behavior around her which includes the way in which they care for her, what they say to her and their body language in her presence. Ongoing: It may be important for staff to know that she liked people to be straight with her. She reported she will become impatient, and most likely verbally aggressive, if she feels others are not being truthful with her. It is important she feels listened to. Staff trying to make sure she understands what is being asked of her and clarifying information with her will most likely be helpful. A subsequent ACP note dated 10/25/16, included: In wheelchair in depressed mood with distressed affect. She reported sad and tearful due to family issues and grievances with staff at facility which she discussed in detail. Recent events have challenged her beliefs about staff at facility and has continued to find concerns that lead her to question their skills. No known medications (for depression or [MEDICAL CONDITION]). Recommendations: Staff will inquire about her willingness to move to a different unit within the facility as she does not trust her current direct care staff and does not feel that relationships can be healed. She remains in protective mode at this time and thus staff should be very mindful of their behavior around her which includes way in which they care for her. An ACP note dated 11/8/16, In wheelchair in room, dysphoric (state of unease or dissatisfaction) mood and angry affect. Reports progressively becoming more distressed and angry the longer she stays at the facility. She does not trust any staff or their motives. Unable to sleep or eat well because of this. Unrealistic about placement in the community. No known medications (for depression or [MEDICAL CONDITION]). Recommendations: Not open to staff challenging her beliefs regarding her health and perceptions and thus staff should continue to address her care and flow with delusions. She is not open to trying medications that may help to reduce her internal emotional distress as she does not believe that she has any mental health concerns. Staff who interact with her should be mindful to present with a neutral demeanor and facial expression as she does not trust fake smiles, to improve rapport with her. An ACP note dated 11/15/16, In bed in room, incident claimed that direct care staff were rough with her. Dysphoric mood with angry affect. Appears she reacted in way she did due to exacerbation of pain that staff caused her when staff assisted in turning her. Vented frustration, does not trust staff. Not able to consider reconciling differences with staff at this time and shared her belief that only option to improve her situation was to leave facility, even though she has no plans or means to do so. Unit Social worker has initiated process of getting her a relocation worker to help find her appropriate placement in the community. Staff her interact with her should be mindful to present with a neutral demeanor and facial expression as she does not trust fake smiles, to improve rapport with her. The ACP note dated 11/22/16, R183 sitting in a wheelchair in a slightly euthymic (normal) mood with calm affect. She had developed a technique of refraining from interacting with direct care staff so they have nothing to use against her. Recommendations: Had developed a trust with physical therapist, and would like to work with him to assist her doctors with orders for exercise. R183's 11/30/16, CP included: I recently bought a set of ankle weights and have a history of stating that I want to throw things at staff. I will request to have the weights or other objects in my hands while I am worked up. I have a history of swinging out at staff with these objects. Behavior charting for R183 was reviewed from 7/31/16 through 1/27/17: Charting from 9/24/16, at 10:24 a.m. alleged R183 cursed (no further description) at NA-P, a female staff on the day shift. On 10/4/16, at 9:54 p.m. R183 rejected assistance of dressing and personal hygiene (no further description) from male staff NA-JJ. On 10/30/16, at 8:33 p.m. R183 had behaviors not directed towards others (no further description) from male staff NA-LL. On 11/10/16, at 8:34 a.m. R183 rejected care (no further description) from female staff NA-P. On 11/12/16, at 1:12 a.m. R183 had behaviors not directed towards others socially inappropriate behavior, male staff NA-LL. On 11/14/16, at 4:03 p.m. R183 had behavior not directed towards others socially inappropriate behaviors, male staff NA-LL. On 11/26/16, at 12:49 a.m. R183, rejected care by male staff NA-LL. On 12/7/16, at 9:23 p.m. R183 had verbal behaviors directed towards others, male staff NA-LL. On 12/19/16, at 1:58 a.m. rejection of care, assistance dressing and personal hygiene by male staff NA-EE. On 1/26/16, at 12:32 a.m. behaviors not directed towards others (no further description) male staff NA-LL. On 1/27/16, at 1:48 a.m. rejection of care, male staff NA-LL. The facility's Behavior documentation book was reviewed and noted: On 1/13/17, night shift documented episode of resistant to cares, redirected. On 1/14/17, (no shift noted) resistant to cares, redirected no change. On 1/15/17, day shift accusing staff of unsubstantiated things occurred on days, redirected. On 1/18/17, resistant to cares on nights, redirected same. On 1/19/17, resistant to cares on nights redirected same. On 1/20/17, (no shift noted) Resistant to care. On 1/24/17, Resistant to cares on night shift redirected. On 1/26/17, Resistant to cares on night shift. Nursing Progress notes reviewed: On 12/4/16, at 9:16 a.m. R183 requested to speak with licensed practical nurse (LPN)-B I am tired. These damn NAs refuse to take care of me and tell me I am trouble. I fell asleep last evening and woke up at midnight, asked to have my food heated and then be cleaned up. No one helped me. I told them to leave the food tray here so I could show you and you wouldn't think, I was lying. LPN-B documented resident displaying paranoid behaviors, R183 asked the nurse to look into the bathroom to ensure no-one was listening to the conversation. NA-HH (alleged abuser of R183) and NA-LL had worked the night shift prior. On 12/9/16, at 8:00 a.m., LPN-M wrote a nursing note that R183 said both PM (afternoon shift) and night aides did not change me all night, I am completely wet. LPN-M documented that she'd stated to R183, put on your call light when you need help. She further documented that R183 had gotten mad and started to use profanity. Get the F*** out of my room you B****, LPN-B notified. NA-HH (alleged abuser of R183) and NA-LL had worked the night shift prior. On 12/9/16 at 8:48 a.m., LPN-B had gone in to see R183 and two NAs were working with her. LPN-B told R183 she would back to get R183's statement about cares when finished with cares and breakfast trays. R183 noted to be incontinent in her brief at that time. R183 stated you want to see what I'm talking about. LPN-B told R183, she would return when cares were done, and would speak with NA's about what they'd found. Documentation indicated R183 had began yelling and stated Oh never mind, you don't care anyway. Get the F**k out, all of you just leave me alone .leave me the F**k alone. The note indicated R183 was thrashing in bed while hooked up to mechanical lift (Marissa Lift), and when staff had started to unhook the sling, R183 had stated, I didn't tell you to stop, get me up.' R183 asked to speak to ED, said she was wet all night, and she was not going to ring and tell anyone what to do. Get out of my room. The author indicated an unidentified SW had been notified. On 12/9/16 at 12:11 p.m. LPN-B documented she had returned to R183's room with unidentified SW, R183 was quiet at first and did not want to talk to staff, then starting stating. I don't have to put my call light on when I need cares. No one came in to take care of me all night. R183 stated I'm not crazy, I know you all think I am, but I'm not crazy. DNS knocked and entered to respond to request for ED, R183 told DNS to get out of her room, stated I can't stand that SOB (curse word), I ain't talking to him, I don't trust him. R183 remained angry and refusing meals . Placed phone calls to the night shift staff and awaiting call back. On 12/9/16 at 3:23 p.m., documentation indicated LPN-B had interviewed night shift aides who stated they had attempted to provide cares twice for R183, but they stated she was asleep and refused cares. However, during the interview with R183, she stated she stayed awake all night to see if anyone would come into her room. On 12/15/16, at 12:45 p.m. in house LICSW (licensed clinical social worker) met with resident on 12/13/16, R183 was in dysthymic mood with angry affect, less distressed than past sessions. R183 able to vent about staff with whom she does not work well and the coping skill she has developed where she asks people to leave her room as a means to protect herself. Staff should continue to be respectful of R183's right to refuse services and reapproach later. NA-SS and NA-OO worked the night shift prior. NA-P, NA-QQ, NA-YY, and NA-AAA worked the day shift. On 1/11/17, at 8:19 a.m. noted R183 wanting to meet with LPN-B in room, with roommate. Residents are usually conversing and laughing in room. R183 will say to roommate tell her what happened last night, roommate will not remember and R183 tells her what to say. R183 stated I'm telling you girl these aides are worthless, and I am going to report that to the state when they get here. R183 refused to meet with DNS. NA-HH (alleged abuser of R183) and NA-LL worked the night shift prior. On 1/14/17, at 2:02 p.m. R183 had a run in with a NA. Apparently he walked in when she was talking to a different NA, and she felt that was rude. R183 told the unnamed NA to get out. The unnamed NA stated I don't have to. R183 became very angry and cussed NA out. NA left and registered nurse (RN)-O came in and talked with R183, who calmed down. NA-HH (alleged abuser of R183), NA-SS worked the night shift prior. NA-P, NA-QQ, NA-UU, NA-E worked the day shift. There was no facility documentation that the unnamed NA was investigated for the incident. 1/15/17, at 4:27 a.m. RN-K noted R 183 refused cares that shift, NA attempted two times. RN-K went in and R183 attempted to get roommate to tell RN-K what happened. Roommate didn't quiet (sic) know what to say. R183 was upset at NA and yet refused to talk with them or receive help from them. R183 angrily yelled no one is going to touch me, I'll hurt somebody. I will stay like this and I will call the state about it. NA-HH (alleged abuser of R183), NA-VV, and NA-SS worked the night shift. On 1/23/17, at 4:34 p.m. LPN-B noted, early that morning, was notified by NA that R183 asked them to get out of her room when they were attempting to get her up with the Marisa Lift to her chair. NA's reported they did nothing wrong and R183 won't say why she was upset. LPN-B and an unidentified SW talked with R183, Get me up, they don't know what they are doing. They didn't put the sling under me right. NA-HH (alleged abuser of R183), NA-LL, NA-OO worked the night shift prior. NA-F, NA-TT, NA-UU, NA-VV, NA-WW worked the day shift. On 1/24/17, at 11:27 a.m. (unnamed) NA came to SW-D to assist with R183. R183 was in wheelchair (w/c) but was not positioned well. R183 said that one of the NA's helping didn't know what she was doing. SW-D, NA and trainee got resident on lift and repositioned in w/c correctly. Internal investigation began. NA-N, NA-PP, NA-QQ, and NA-RR worked the shift. On 1/26/17, at 6:25 a.m. RN-K noted R183 refused cares that shift, reapproached and continued to refuse. When the day shift NA arrived, R183 allowed cares, was changed and cleaned up. NA-OO and NA-SS worked the night shift. On 1/26/17, at 3:30 p.m. LPN-B stated R183 had been interviewed and NA-HH was going to be suspended. On 1/27/16, at 6:06 a.m. RN-K noted 15 minute safety checks, slept in room all night and was safe. No concerns noted (no documentation why 15 minute safety checks). -At 6:16 R183 refused cares this shift, reapproached three times. Risks and benefits explained. Morning staff updated. NA-HH (alleged abuser of R183), NA-LL, NA-OO worked the night shift. -At 12:00 p.m. LPN-B stated R183 had been put on 15 minute checks, was happy and had no complaints. -At 1:43 p.m. R183 stated the assistant director of nursing (ADNS) had told her NA-HH was gone. During 7 of the 11 behavior episodes, the alleged abuser NA-HH had been working that shift, or the night shift prior. During 9 of 11 behavior episodes, at least one of three NAs consistently working that shift or the prior shift (including NA-HH, NA-LL, and NA-P). The employee files were reviewed and the following was noted: NA-HH, hired 6/6/11, undated training in new hire file for abuse/neglect, patient rights. NA-HH was disciplined on 10/18/11, for poor work quality and productivity for leaving a resident in a bed soaked with urine, changed sheets, but immediately wet again, and NA-HH left for day shift. On 1/8/12, NA-HH had left the floor to buy a can of pop for resident, did not ask nurse if resident could have pop. NA-HH did not tell anyone he was leaving the floor. Notice of 2 week voluntary resignation dated 4/9/15, with last day being 4/21/15. NA-HH was rehired 2/24/16. On 11/18/16, Step 1 discipline notice instructed NA-HH to improve getting to work on time. NA-LL hired 9/12/16, received preventing abuse training on 9/22/16, and Alzheimer's training on 10/26/16. NA-N, hired 3/20/15, received preventing resident abuse training on 4/7/15, and Alzheimer's training on 10/26/17. Discipline notice on 4/7/15, for failure to perform assigned duties in an appropriate manner or at assigned times. Discipline notice dated 9/25/15 indicated, staff is loud and demanding when she approaches them (residents). Makes the resident anxious and sometimes feel intimidated, always provide excellent customer service. Knock before entering and announce self by name and title. Greet all your residents at the beginning of your shift to let them know that you are their aide that day. Utilize words such as please and thank you frequently. Ask for resident preference, do not just tell them what to do. Provide explanations and plan ahead with them for them. Approach with calm, patient tone. Not all residents are deaf and speaking louder does not always help. It may seem intimidating if a resident is having a difficult time understanding, always ask for assistance from another staff member. Resident needs always come first. Ask questions. Discipline notice dated 1/25/17, instructed NA-N customer service: be aware of how you approach a patient, be aware to speak clearly, make sure that if a resident is asking for your help, you are helping them safely. Address all needs while working with a patient. If you feel uncomfortable being the only staff caring for a resident, bring another staff with. The facility failed to fully investigate a change in patient behavior, and rejection of cares. The facility failed to track and trend staffing patterns with R183's behavioral outbursts to identify a potential staff abuse. R118's quarterly MDS dated [DATE], indicated she was cognitively intact and required minimal assistance with activities of daily living (ADLs). During interview with R118 at 8:22 a.m. on 1/24/17, the resident stated she had been threatened by NA-BB the week prior. She said the NA had threatened to knock her head off. R118 further stated she was afraid of NA-BB. R118 stated she had reported the threat to the Alzheimer's Care Director (ACD). R118 stated the ACD had replied, it was just a joke. A facility document titled Verification Of Investigation (VOI) dated 1/22/17, was reviewed. The documentation indicated R118 had been interviewed by facility staff regarding the threat by the NA. The VOI included recommendations taken to prevent reoccurrence which included suspension of the employee, and customer service education having been provided to the employee. The recommendations also included re-directing R118 during episodes of inappropriate behaviors, even though the allegation of inappropriate behavior was made by R118. The facility's VOI document indicated abuse had not been substantiated and further indicated, per investigation there was a misunderstanding by client regarding employee's comment which does not substantiate. R1's quarterly MDS dated [DATE], indicated she was severely cognitively impaired and required extensive assistance with ADLs. The care plan dated 12/26/17, identified R1's potential for abuse. The care plan further identified a physical functioning deficit and directed staff to assist with transfers, toileting and personal hygiene. During interview on 1/23/17, at 5:01 p.m., R1 stated NA-AA had pushed her. R1 stated NA-AA was rough with her. She stated she needed help to get dressed and that she was afraid NA-AA would come to help her and stated, I don't want to get in trouble. R1 stated she had not reported the incident to the facility. On 1/23/17, at 5:21 p.m., the allegation of abuse was reported to the DNS. At 6:28 p.m., the DNS reported to the surveyor that NA-AA had been sent home pending investigation of the abuse allegation and that the allegation had been reported to the State agency. The facility had documented a VOI on 1/24/17 for the allegation R1 had made 1/23/17. The VOI indicated R1 had reported to facility staff that when she requests assistance from NA-AA, the staff member tells her, do it yourself, get into your chair. R1 reported NA-AA is rude to her and always had been. The VOI further identified recommendations/interventions to prevent reoccurrence as follows: NA (AA) suspended pending outcome of investigation, staff encourage R1 to transfer independently which R1 interprets as being rude. Unable to substantiate allegation of abuse as resident does transfer herself and staff encourage her to promote independence. Customer service education will be given to NA-AA upon her return. On 1/25/17, NA-AA was observed working the a.m. shift on the unit where R1 resides. During an interview on 1/25/17, at 10:56 a.m., the social services director (SSD) stated if someone reports an allegation of abuse, she immediately reports it to the DNS and the ED. She stated the DNS and ED make the decision whether or not the allegation gets reported to the State agency. The SSD stated if an allegation is made on the weekend, it's harder because we're (management) not here so it goes on a grievance and staff would notify the building supervisor. The SSD stated LPN-B had told her about the allegation made by R1 and stated LPN-B and SW-C completed the investigation. During an interview on 1/25/17, at 11:07 a.m. with LPN-B and SW-C, LPN-B stated if a resident reports mistreatment by staff she would immediately report to the ADNS, DNS and ED. LPN-B stated the ED and DNS determine if an allegation is reportable to the State agency. SW-B verified she had assisted with the investigation regarding R1's report to the surveyor. SW-C stated she had not followed up with R1 but stated she had reported the allegation to the social worker from the ACP who was scheduled to see R1 on 1/24/17. SW-C stated she was aware the ACP social worker had spoken to R1 about her report however, SW-C stated she had not read the ACP social worker's report after the visit. She further stated she had not been aware R1 had accused NA-AA of pushing her or being rough with her prior to the investigation. At 11:14 a.m., LPN-B stated the DNS had told her R1 had reported to the surveyor that staff had been rude to her. LPN-B stated she was not aware R1 had reported that a staff member had pushed her or been rough with her and stated the DNS had not told her that. LPN-B stated R1 had told her NA-AA refused to help her. Review of the ACP Progress Note dated 1/24/17, indicated a licensed social worker had visited with R1 that day and identified the following: Staff shared R1 had reported abuse from a direct care worker to the State assessor yesterday. Met with R1, she showed no obvious evidence of any current delusions or hallucinations. When asked, she expressed some anxiety about sharing her concerns to the State worker and reassured her that it was her right to do so and important to keep her safe. R1 was unable to identify any clear reasons why she had not brought up her concerns during her care conference the previous week aside from stating she was awoken to attend. She (R1) was unable to confidently state that she would feel comfortable reporting similar concerns to the unit nurse manager (LPN-B) or SW-C in the future. During an interview on 1/25/17, at 11:24 a.m., the DNS stated if the facility received an allegation of abuse he would call the ED and they would report the allegation to the SA. He stated R1's allegation was still being investigated, but stated interviews with staff and other residents had been completed. The DNS stated based on the conclusion of the interview, the facility felt that NA-AA had been trying to promote independence by encouraging R1 to transfer herself and that he interpreted NA-AA's behavior as rude, and had scheduled her for additional customer service training. He verified NA-AA had not completed the training prior to returning to work on the floor because they had call-ins. The DNS further stated he did not interview the resident himself and stated the ADNS had interviewed her. During interview on 1/25/17, at 11:36 a.m., the ADNS stated she had not talked to R1. She stated she talked to the facility's human resource specialist (HRS) who placed modules in NA-AA's bin and stated NA-AA needed to complete them today. During a subsequent interview on 1/25/17, at 11:37 a.m., the DNS acknowledged no one had had followed up with R1 after NA-AA returned to work, nor had anyone asked R1 whether any staff had pushed her or been rough with her. He stated SW-C should have done that. In addition, the DNS stated if an employee needs to be educated, we provide the education. The DNS stated he felt the allegation from R1 was mistaken information or a communication issue. At that time, the ED added, if there was a second incident with an employee the suspension could be longer or the employee could be terminated. The DNS stated NA-AA's employment file was reviewed and contained no previous allegations. The ED stated, because of the clientele, the education had to go into the delusion and hallucination piece. On 1/25/17, at 11:46 a.m., SW-C confirmed she had not followed up with R1 regarding the concerns. On 1/25/17, at 1:15 p.m., the DNS stated he had reviewed R1's care plan to determine if it was appropriate for staff to encourage her to self-transfer and stated, he had taken notes but didn't keep them. LPN-B and the ED were also present during the interview. LPN-B stated, it is not safe for (R1) to self-transfer. During interview on 1/25/17, at 2:36 p.m. the HRS stated no one had reviewed NA-AA's employment file for previous allegations or education. R12's quarterly MDS 12/9/16, identified the resident's [DIAGNOSES REDACTED]. In addition, the MDS indicated R12 had intact cognition and no behavioral symptoms including verbal, physical or refusal/rejection of cares. During interview with R12 on 1/24/17 at 7:59 a.m., when asked whether staff, a resident or anyone else at the facility had abused him, including verbal, physical or sexual abuse, R12 stated, Yes. R12 further explained, Some of them. A few days ago (LPN-E) talked to be like I was her child. She told me I had to go to bed before ten o'clock and I told her I was not going to. She said I had to, and again I told her I was not going to. There was an exchange of words between the two of us and it got verbally abusive from both of us. I told her she was a b***h. I reported it to my social worker (SW-B) and the director came and talked to me and said they were looking into it. I have been abused both verbally and emotionally. I told her (LPN-E) I was old enough to be her father. R12's CP dated 10/15/13, indicated he was at risk for potential abuse due to his [DIAGNOSES REDACTED]. In addition, the care plan indicated the resid

Based on observation, interview and document review, the facility failed to implement their abuse prohibition policies and procedures related to immediate reporting of alleged abuse/neglect to the administrator and State agency (SA), protecting resident/s from ongoing abuse, and completing a thorough investigation following an allegation of abuse/neglect. This resulted in an immediate jeopardy (IJ) for 6 of 12 residents (R183, R118, R1, R12, R260, R80) due to the residents being afraid of unwanted touch and/or threats of physical harm from staff and other residents. In addition to the residents in IJ, the facility failed to identify, report and thoroughly investigate allegations of abuse that were not an IJ for the other 6 of 12 residents (R28, R45, R112, R186, R218, R167). The IJ began on 1/22/17, when R118 notified facility staff that a nursing assistant (NA) had threatened to hurt her and the facility failed to intervene. The IJ was identified on 1/26/17 and the executive director (ED) was notified of the IJ at 4:32 p.m. on 1/26/17. The IJ was removed on 1/30/17, at 3:05 p.m., but non-compliance remained at the lower scope and severity level of E. Findings include: A facility policy titled Golden Living Investigation and Reporting of Alleged Violations of Federal and State Laws involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident' Property, dated 11/18/16, was reviewed. The policy indicated the company would take the following steps to prevent abuse Incidents identified as potential violations shall be reported as stated in the reporting section of this policy and reviewed by the facility's QAPI (quality assurance performance improvement) for detection of patterns or trends. The policy further indicates The ED (executive director) shall notify the appropriate State agency and investigate the allegation. R183 was interviewed on 1/26/17, at 4:00 p.m. and stated she was aware of the reporting process, but felt it was useless to report, because they were blaming, and accusing her of making up stories. R183 stated she had tried to report to the nurse on the night shift about an incident that had occurred this past spring (date unncertain). R183 stated, she (the night nurse) came in and was blaming me, saying '(NA-HH) is just trying to take care of you.' So I told her to get out. I don't trust anyone here. That director of nursing (DNS) came in to talk to me and I told him to get out. I don't trust him. R183 had tears in her eyes and reported that NA-HH had rubbed her arm, and then had moved to her breast area. R183 said she'd yelled at NA-HH, Stop, what the H**l are you doing? She further stated, He then took his finger (demonstrated a circular motion with her index finger) around my anus. I told him to stop, saying 'what the h**l are you doing?', but he didn't stop, so I slapped him (demonstrated a backhanded slapping motion), and he still didn't stop, so I slapped him again. R183 stated NA-HH was still working here, so she had kept a fork on her bedside table for a long time, as defense, but then they took it away with a dinner tray. R183 stated she woke up last week and he (NA-HH) was standing at the end of her bed. She stated, I picked up my bottle (demonstrated picking up a large glass bottle of hot sauce, with a long thin neck) from my bedside table and threatened to hit him with it if he didn't leave. I had to say I will crack your head open to get him to leave. R183 agreed to speak with licensed practical nurse (LPN)-B, because she felt she could trust her, but said she would not speak with the DNS because she did not trust him at all. At 4:34 p.m. on 1/26/17, LPN-B was asked whether she had noted any changes in R183's behavior or if she had heard any report about R183 having threated to hit a NA-HH. After some thought LPN-B stated, About three or four months ago, R183 would not let anyone turn her or touch her on the night shift. I asked her if anything was wrong, but she wouldn't tell me. LPN-B added, I have talked to my nurses, months and months ago, she wouldn't turn in bed, she wouldn't roll over. We have to be careful with her, she makes things up. She has a history of [DIAGNOSES REDACTED], hallucinations and delusions. I had been asking her what's wrong, and she specifically told me it was ok for NA-HH to take care of her. LPN-B went on to say that R183 was 'tough with mental health, and she tries to get people in trouble. A social worker (SW) and I interviewed her, then the DNS comes up and she kicks him out of the room. The surveyor then asked LPN-B whether she'd been awared that R183 had alleged having been touched inappropriately by NA-HH. LPN-B stated she had not be aware, then proceeded to go in to discuss with R183, and following their conversation LPN-B reported the allegation of sexual abuse to the SA. Acording to her Admission Record, R183 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE], indicated R183 was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION] or hallucinations. In addition, the MDS indicated R183 did not reject cares and had demonstrated no verbal or physical behaviors towards others. R183 was totally dependent on two staff and utilized a mechanical lift for transfers, required extensive physical assistance of two staff for bed mobility, dressing and toilet use, and did not have antipsychotic or antidepressant medications ordered. An MDS dated [DATE], also indicated R183 was cognitively intact and had no signs or symptoms of [MEDICAL CONDITION] or hallucinations. However, the MDS indicated R183 had demonstrated physical behaviors directed towards others during one to three days, verbal behaviors directed towards others on four to six days, and had rejected cares one to three days, all days in reference to the MDS look back period. The MDS indicated R183 was totally dependent on two staff and a mechanical lift for transfers, required extensive physical assistance of two staff for bed mobility, dressing and toilet use, and did not have antipsychotic or antidepressant medications ordered. A Care Area Assessment (CAA) dated 6/27/16, indicated R183 had triggered [MEDICAL CONDITION] as an area for assessment. The CAA analysis indicated the [MEDICAL CONDITION] was due to a decrease in her cognitive score and a recent change in mood; sad or anxious (for example crying, social withdrawal). The Care Plan (CP) dated as far back as 11/14/14, indicated R183 had a potential for abuse due to decreased physical ability, need for care and history of allegations towards staff that were found to be unsubstantiated. The CP dated 6/11/15, indicated behaviors which include shouting, crying and stating I am not crazy. I have a history of psychiatric disorders and will often state a complaint but change my story which results in an inconsistent reporting history. I sometimes refuse the bedpan when offered. Potential [DIAGNOSES REDACTED] exhibited by: 1) verbalize I am having health issues that are not present upon examination/tests. I have paranoia related to my [MEDICAL CONDITION] [DIAGNOSES REDACTED]. I often have concerns regarding the delivery of my cares. I meet with staff on a regular basis to discuss my concerns and resolutions. I often state the NAR's (nursing assistants/registered) are not helping me when in fact I have refused cares. Although the care plan indicated R183 had identified behaviors, the facility did not thoroughly investigate her allegations to determine validity of the allegations. An Associated Clinic of Psychology (ACP) note dated 10/11/16, indicated the therapist and R183 had discussed the resident's feelings of anger and distress with staff at the facility, and that R183 had elaborated on three of her concerns regarding staff behavior towards her and how she was not pleased with the follow-up thus far. The ACP note also indicated R183 had reported she had not been sleeping well recently, and that she had been encouraged to watch TV and play games on her phone to keep from being overwhelmed by current situation. The note indicated the resident utilized no known medications (for depression or [MEDICAL CONDITION]). The ACP therapists recommendations included: She had been requesting staff to leave her alone as much as possible while continuing to appropriately address her care needs. She seemed to be in a protective mode at that time and thus staff should be very mindful of their behavior around her which includes the way in which they care for her, what they say to her and their body language in her presence. Ongoing: It may be important for staff to know that she liked people to be straight with her. She reported she will become impatient, and most likely verbally aggressive, if she feels others are not being truthful with her. It is important she feels listened to. Staff trying to make sure she understands what is being asked of her and clarifying information with her will most likely be helpful. A subsequent ACP note dated 10/25/16, included: In wheelchair in depressed mood with distressed affect. She reported sad and tearful due to family issues and grievances with staff at facility which she discussed in detail. Recent events have challenged her beliefs about staff at facility and has continued to find concerns that lead her to question their skills. No known medications (for depression or [MEDICAL CONDITION]). Recommendations: Staff will inquire about her willingness to move to a different unit within the facility as she does not trust her current direct care staff and does not feel that relationships can be healed. She remains in protective mode at this time and thus staff should be very mindful of their behavior around her which includes way in which they care for her. An ACP note dated 11/8/16, In wheelchair in room, dysphoric (state of unease or dissatisfaction) mood and angry affect. Reports progressively becoming more distressed and angry the longer she stays at the facility. She does not trust any staff or their motives. Unable to sleep or eat well because of this. Unrealistic about placement in the community. No known medications (for depression or [MEDICAL CONDITION]). Recommendations: Not open to staff challenging her beliefs regarding her health and perceptions and thus staff should continue to address her care and flow with delusions. She is not open to trying medications that may help to reduce her internal emotional distress as she does not believe that she has any mental health concerns. Staff who interact with her should be mindful to present with a neutral demeanor and facial expression as she does not trust fake smiles, to improve rapport with her. An ACP note dated 11/15/16, In bed in room, incident claimed that direct care staff were rough with her. Dysphoric mood with angry affect. Appears she reacted in way she did due to exacerbation of pain that staff caused her when staff assisted in turning her. Vented frustration, does not trust staff. Not able to consider reconciling differences with staff at this time and shared her belief that only option to improve her situation was to leave facility, even though she has no plans or means to do so. Unit Social worker has initiated process of getting her a relocation worker to help find her appropriate placement in the community. Staff her interact with her should be mindful to present with a neutral demeanor and facial expression as she does not trust fake smiles, to improve rapport with her. The ACP note dated 11/22/16, R183 sitting in a wheelchair in a slightly euthymic (normal) mood with calm affect. She had developed a technique of refraining from interacting with direct care staff so they have nothing to use against her. Recommendations: Had developed a trust with physical therapist, and would like to work with him to assist her doctors with orders for exercise. R183's 11/30/16, CP included: I recently bought a set of ankle weights and have a history of stating that I want to throw things at staff. I will request to have the weights or other objects in my hands while I am worked up. I have a history of swinging out at staff with these objects. Behavior charting for R183 was reviewed from 7/31/16 through 1/27/17: Charting from 9/24/16, at 10:24 a.m. alleged R183 cursed (no further description) at NA-P, a female staff on the day shift. On 10/4/16, at 9:54 p.m. R183 rejected assistance of dressing and personal hygiene (no further description) from male staff NA-JJ. On 10/30/16, at 8:33 p.m. R183 had behaviors not directed towards others (no further description) from male staff NA-LL. On 11/10/16, at 8:34 a.m. R183 rejected care (no further description) from female staff NA-P. On 11/12/16, at 1:12 a.m. R183 had behaviors not directed towards others socially inappropriate behavior, male staff NA-LL. On 11/14/16, at 4:03 p.m. R183 had behavior not directed towards others socially inappropriate behaviors, male staff NA-LL. On 11/26/16, at 12:49 a.m. R183, rejected care by male staff NA-LL. On 12/7/16, at 9:23 p.m. R183 had verbal behaviors directed towards others, male staff NA-LL. On 12/19/16, at 1:58 a.m. rejection of care, assistance dressing and personal hygiene by male staff NA-EE. On 1/26/16, at 12:32 a.m. behaviors not directed towards others (no further description) male staff NA-LL. On 1/27/16, at 1:48 a.m. rejection of care, male staff NA-LL. The facility's Behavior documentation book was reviewed and noted: On 1/13/17, night shift documented episode of resistant to cares, redirected. On 1/14/17, (no shift noted) resistant to cares, redirected no change. On 1/15/17, day shift accusing staff of unsubstantiated things occurred on days, redirected. On 1/18/17, resistant to cares on nights, redirected same. On 1/19/17, resistant to cares on nights redirected same. On 1/20/17, (no shift noted) Resistant to care. On 1/24/17, Resistant to cares on night shift redirected. On 1/26/17, Resistant to cares on night shift. Nursing Progress notes reviewed: On 12/4/16, at 9:16 a.m. R183 requested to speak with LPN-B I am tired. These damn NAs refuse to take care of me and tell me I am trouble. I fell asleep last evening and woke up at midnight, asked to have my food heated and then be cleaned up. No one helped me. I told them to leave the food tray here so I could show you and you wouldn't think, I was lying. LPN-B documented resident displaying paranoid behaviors, R183 asked the nurse to look into the bathroom to ensure no-one was listening to the conversation. NA-HH (alleged abuser of R183) and NA-LL had worked the night shift prior. On 12/9/16, at 8:00 a.m., LPN-M wrote a nursing note that R183 said both PM (afternoon shift) and night aides did not change me all night, I am completely wet. LPN-M documented that she'd stated to R183, put on your call light when you need help. She further documented that R183 had gotten mad and started to use profanity. Get the F*** out of my room you B****, LPN-B notified. NA-HH (alleged abuser of R183) and NA-LL had worked the night shift prior. On 12/9/16 at 8:48 a.m., LPN-B had gone in to see R183 and two NAs were working with her. LPN-B told R183 she would back to get R183's statement about cares when finished with cares and breakfast trays. R183 noted to be incontinent in her brief at that time. R183 stated you want to see what I'm talking about. LPN-B told R183, she would return when cares were done, and would speak with NA's about what they'd found. Documentation indicated R183 had began yelling and stated Oh never mind, you don't care anyway. Get the F**k out, all of you just leave me alone .leave me the F**k alone. The note indicated R183 was thrashing in bed while hooked up to mechanical lift (Marissa Lift), and when staff had started to unhook the sling, R183 had stated, I didn't tell you to stop, get me up.' R183 asked to speak to ED, said she was wet all night, and she was not going to ring and tell anyone what to do. Get out of my room. The author indicated an unidentified SW had been notified. On 12/9/16 at 12:11 p.m. LPN-B documented she had returned to R183's room with unidentified SW, R183 was quiet at first and did not want to talk to staff, then starting stating. I don't have to put my call light on when I need cares. No one came in to take care of me all night. R183 stated I'm not crazy, I know you all think I am, but I'm not crazy. DNS knocked and entered to respond to request for ED, R183 told DNS to get out of her room, stated I can't stand that SOB (curse word), I ain't talking to him, I don't trust him. R183 remained angry and refusing meals . Placed phone calls to the night shift staff and awaiting call back. On 12/9/16 at 3:23 p.m., documentation indicated LPN-B had interviewed night shift aides who stated they had attempted to provide cares twice for R183, but they stated she was asleep and refused cares. However, during the interview with R183, she stated she stayed awake all night to see if anyone would come into her room. On 12/15/16, at 12:45 p.m. in house LICSW (licensed clinical social worker) met with resident on 12/13/16, R183 was in dysthymic mood with angry affect, less distressed than past sessions. R183 able to vent about staff with whom she does not work well and the coping skill she has developed where she asks people to leave her room as a means to protect herself. Staff should continue to be respectful of R183's right to refuse services and reapproach later. NA-SS and NA-OO worked the night shift prior. NA-P, NA-QQ, NA-YY, and NA-AAA worked the day shift. On 1/11/17, at 8:19 a.m. noted R183 wanting to meet with LPN-B in room, with roommate. Residents are usually conversing and laughing in room. R183 will say to roommate tell her what happened last night, roommate will not remember and R183 tells her what to say. R183 stated I'm telling you girl these aides are worthless, and I am going to report that to the state when they get here. R183 refused to meet with DNS. NA-HH (alleged abuser of R183) and NA-LL worked the night shift prior. On 1/14/17, at 2:02 p.m. R183 had a run in with a NA. Apparently he walked in when she was talking to a different NA, and she felt that was rude. R183 told the unnamed NA to get out. The unnamed NA stated I don't have to. R183 became very angry and cussed NA out. NA left and registered nurse (RN)-O came in and talked with R183, who calmed down. NA-HH (alleged abuser of R183), NA-SS worked the night shift prior. NA-P, NA-QQ, NA-UU, NA-E worked the day shift. There was no facility documentation that the unnamed NA was investigated for the incident. 1/15/17, at 4:27 a.m. RN-K noted R 183 refused cares that shift, NA attempted two times. RN-K went in and R183 attempted to get roommate to tell RN-K what happened. Roommate didn't quiet (sic) know what to say. R183 was upset at NA and yet refused to talk with them or receive help from them. R183 angrily yelled no one is going to touch me, I'll hurt somebody. I will stay like this and I will call the state about it. NA-HH (alleged abuser of R183), NA-VV, and NA-SS worked the night shift. On 1/23/17, at 4:34 p.m. LPN-B noted, early that morning, was notified by NA that R183 asked them to get out of her room when they were attempting to get her up with the Marisa Lift to her chair. NA's reported they did nothing wrong and R183 won't say why she was upset. LPN-B and an unidentified SW talked with R183, Get me up, they don't know what they are doing. They didn't put the sling under me right. NA-HH (alleged abuser of R183), NA-LL, NA-OO worked the night shift prior. NA-F, NA-TT, NA-UU, NA-VV, NA-WW worked the day shift. On 1/24/17, at 11:27 a.m. (unnamed) NA came to SW-D to assist with R183. R183 was in wheelchair (w/c) but was not positioned well. R183 said that one of the NA's helping didn't know what she was doing. SW-D, NA and trainee got resident on lift and repositioned in w/c correctly. Internal investigation began. NA-N, NA-PP, NA-QQ, and NA-RR worked the shift. On 1/26/17, at 6:25 a.m. RN-K noted R183 refused cares that shift, reapproached and continued to refuse. When the day shift NA arrived, R183 allowed cares, was changed and cleaned up. NA-OO and NA-SS worked the night shift. On 1/26/17, at 3:30 p.m. LPN-B stated R183 had been interviewed and NA-HH was going to be suspended. On 1/27/16, at 6:06 a.m. RN-K noted 15 minute safety checks, slept in room all night and was safe. No concerns noted (no documentation why 15 minute safety checks). -At 6:16 R183 refused cares this shift, reapproached three times. Risks and benefits explained. Morning staff updated. NA-HH (alleged abuser of R183), NA-LL, NA-OO worked the night shift. -At 12:00 p.m. LPN-B stated R183 had been put on 15 minute checks, was happy and had no complaints. -At 1:43 p.m. R183 stated the assistant director of nursing (ADNS) had told her NA-HH was gone. During seven of the 11 behavior episodes, the alleged abuser NA-HH had been working that shift, or the night shift prior. During 9 of 11 behavior episodes, at least one of three NAs consistently working that shift or the prior shift (including NA-HH, NA-LL, and NA-P). The employee files were reviewed and the following was noted: NA-HH, hired 6/6/11, undated training in new hire file for abuse/neglect, patient rights. NA-HH was disciplined on 10/18/11, for poor work quality and productivity for leaving a resident in a bed soaked with urine, changed sheets, but immediately wet again, and NA-HH left for day shift. On 1/8/12, NA-HH had left the floor to buy a can of pop for resident, did not ask nurse if resident could have pop. NA-HH did not tell anyone he was leaving the floor. Notice of 2 week voluntary resignation dated 4/9/15, with last day being 4/21/15. NA-HH was rehired 2/24/16. On 11/18/16, Step 1 discipline notice instructed NA-HH to improve getting to work on time. NA-LL hired 9/12/16, received preventing abuse training on 9/22/16, and Alzheimer's training on 10/26/16. NA-N, hired 3/20/15, received preventing resident abuse training on 4/7/15, and Alzheimer's training on 10/26/17. Discipline notice on 4/7/15, for failure to perform assigned duties in an appropriate manner or at assigned times. Discipline notice dated 9/25/15 indicated, staff is loud and demanding when she approaches them (residents). Makes the resident anxious and sometimes feel intimidated, always provide excellent customer service. Knock before entering and announce self by name and title. Greet all your residents at the beginning of your shift to let them know that you are their aide that day. Utilize words such as please and thank you frequently. Ask for resident preference, do not just tell them what to do. Provide explanations and plan ahead with them for them. Approach with calm, patient tone. Not all residents are deaf and speaking louder does not always help. It may seem intimidating if a resident is having a difficult time understanding, always ask for assistance from another staff member. Resident needs always come first. Ask questions. Discipline notice dated 1/25/17, instructed NA-N customer service: be aware of how you approach a patient, be aware to speak clearly, make sure that if a resident is asking for your help, you are helping them safely. Address all needs while working with a patient. If you feel uncomfortable being the only staff caring for a resident, bring another staff with. The facility failed to fully investigate a change in patient behavior, and rejection of cares. The facility failed to track and trend staffing patterns with R183's behavioral outbursts to identify a potential staff abuse. R118's quarterly MDS dated [DATE], indicated she was cognitively intact and required minimal assistance with activities of daily living (ADLs). During interview with R118 at 8:22 a.m. on 1/24/17, the resident stated she had been threatened by NA-BB the week prior. She said the NA had threatened to knock her head off. R118 further stated she was afraid of NA-BB. R118 stated she had reported the threat to the Alzheimer's Care Director (ACD). R118 stated the ACD had replied, it was just a joke. A facility document titled Verification Of Investigation (VOI) dated 1/22/17, was reviewed. The documentation indicated R118 had been interviewed by facility staff regarding the threat by the NA. The VOI included recommendations taken to prevent reoccurrence which included suspension of the employee, and customer service education having been provided to the employee. The recommendations also included re-directing R118 during episodes of inappropriate behaviors, even though the allegation of inappropriate behavior was made by R118. The facility's VOI document indicated abuse had not been substantiated and further indicated, per investigation there was a misunderstanding by client regarding employee's comment which does not substantiate. R1's quarterly MDS dated [DATE], indicated she was severely cognitively impaired and required extensive assistance with ADLs. The care plan dated 12/26/17, identified R1's potential for abuse. The care plan further identified a physical functioning deficit and directed staff to assist with transfers, toileting and personal hygiene. During interview on 1/23/17, at 5:01 p.m., R1 stated NA-AA had pushed her. R1 stated NA-AA was rough with her. She stated she needed help to get dressed and that she was afraid NA-AA would come to help her and stated, I don't want to get in trouble. R1 stated she had not reported the incident to the facility. On 1/23/17, at 5:21 p.m., the allegation of abuse was reported to the DNS. At 6:28 p.m., the DNS reported to the surveyor that NA-AA had been sent home pending investigation of the abuse allegation and that the allegation had been reported to the State agency. The facility had documented a VOI on 1/24/17 for the allegation R1 had made 1/23/17. The VOI indicated R1 had reported to facility staff that when she requests assistance from NA-AA, the staff member tells her, do it yourself, get into your chair. R1 reported NA-AA is rude to her and always had been. The VOI further identified recommendations/interventions to prevent reoccurrence as follows: NA (AA) suspended pending outcome of investigation, staff encourage R1 to transfer independently which R1 interprets as being rude. Unable to substantiate allegation of abuse as resident does transfer herself and staff encourage her to promote independence. Customer service education will be given to NA-AA upon her return. On 1/25/17, NA-AA was observed working the a.m. shift on the unit where R1 resides. During an interview on 1/25/17, at 10:56 a.m., the social services director (SSD) stated if someone reports an allegation of abuse, she immediately reports it to the DNS and the ED. She stated the DNS and ED make the decision whether or not the allegation gets reported to the State agency. The SSD stated if an allegation is made on the weekend, it's harder because we're (management) not here so it goes on a grievance and staff would notify the building supervisor. The SSD stated LPN-B had told her about the allegation made by R1 and stated LPN-B and SW-C completed the investigation. During an interview on 1/25/17, at 11:07 a.m. with LPN-B and SW-C, LPN-B stated if a resident reports mistreatment by staff she would immediately report to the ADNS, DNS and ED. LPN-B stated the ED and DNS determine if an allegation is reportable to the State agency. SW-B verified she had assisted with the investigation regarding R1's report to the surveyor. SW-C stated she had not followed up with R1 but stated she had reported the allegation to the social worker from the ACP who was scheduled to see R1 on 1/24/17. SW-C stated she was aware the ACP social worker had spoken to R1 about her report however, SW-C stated she had not read the ACP social worker's report after the visit. She further stated she had not been aware R1 had accused NA-AA of pushing her or being rough with her prior to the investigation. At 11:14 a.m., LPN-B stated the DNS had told her R1 had reported to the surveyor that staff had been rude to her. LPN-B stated she was not aware R1 had reported that a staff member had pushed her or been rough with her and stated the DNS had not told her that. LPN-B stated R1 had told her NA-AA refused to help her. Review of the ACP Progress Note dated 1/24/17, indicated a licensed social worker had visited with R1 that day and identified the following: Staff shared R1 had reported abuse from a direct care worker to the State assessor yesterday. Met with R1, she showed no obvious evidence of any current delusions or hallucinations. When asked, she expressed some anxiety about sharing her concerns to the State worker and reassured her that it was her right to do so and important to keep her safe. R1 was unable to identify any clear reasons why she had not brought up her concerns during her care conference the previous week aside from stating she was awoken to attend. She (R1) was unable to confidently state that she would feel comfortable reporting similar concerns to the unit nurse manager (LPN-B) or SW-C in the future. During an interview on 1/25/17, at 11:24 a.m., the DNS stated if the facility received an allegation of abuse he would call the ED and they would report the allegation to the SA. He stated R1's allegation was still being investigated, but stated interviews with staff and other residents had been completed. The DNS stated based on the conclusion of the interview, the facility felt that NA-AA had been trying to promote independence by encouraging R1 to transfer herself and that he interpreted NA-AA's behavior as rude, and had scheduled her for additional customer service training. He verified NA-AA had not completed the training prior to returning to work on the floor because they had call-ins. The DNS further stated he did not interview the resident himself and stated the ADNS had interviewed her. During interview on 1/25/17, at 11:36 a.m., the ADNS stated she had not talked to R1. She stated she talked to the facility's human resource specialist (HRS) who placed modules in NA-AA's bin and stated NA-AA needed to complete them today. During a subsequent interview on 1/25/17, at 11:37 a.m., the DNS acknowledged no one had had followed up with R1 after NA-AA returned to work, nor had anyone asked R1 whether any staff had pushed her or been rough with her. He stated SW-C should have done that. In addition, the DNS stated if an employee needs to be educated, we provide the education. The DNS stated he felt the allegation from R1 was mistaken information or a communication issue. At that time, the ED added, if there was a second incident with an employee the suspension could be longer or the employee could be terminated. The DNS stated NA-AA's employment file was reviewed and contained no previous allegations. The ED stated, because of the clientele, the education had to go into the delusion and hallucination piece. On 1/25/17, at 11:46 a.m., SW-C confirmed she had not followed up with R1 regarding the concerns. On 1/25/17, at 1:15 p.m., the DNS stated he had reviewed R1's care plan to determine if it was appropriate for staff to encourage her to self-transfer and stated, he had taken notes but didn't keep them. LPN-B and the ED were also present during the interview. LPN-B stated, it is not safe for (R1) to self-transfer. During interview on 1/25/17, at 2:36 p.m. the HRS stated no one had reviewed NA-AA's employment file for previous allegations or education. R12's CP dated 10/15/13, indicated he was at risk for potential abuse due to his [DIAGNOSES REDACTED]. In addition, the care plan indicated the resident had a history of [REDACTED]. The CP directed staff to explain what they were going to do before providing care. On 1/25/17, at 11:01 a.m. SW-B stated R12 had

Based on observation, interview and document review, the facility failed to ensure 3 of 3 residents (R26, R80, R165) was treated in a dignified manner during personal cares. R26 sustained emotional harm when the facility failed to provide assistance with care resulting in R26 having fecal incontinence. Findings include: R26, on 1/23/17, at 5:13 p.m. was asked whether she felt staff treated her with respect and dignity. R26 stated, I just think some of the staff are lazy and I don't want to work with lazy people. On 1/27/17, at 8:17 a.m. R26 was observed to be in her room and was overheard yelling in a loud tone of voice, I need to go to bed just do it. Why couldn't you transfer me when I asked you to. Now I am covered in s**t! You keep saying you need two people but you don't do it that way when the State is not here. I told you I needed to go to the bathroom and you know I can't wait. How many times do I have to ask three, four, five? Maybe you should try this. Certified medication technician (CMT)-C came out of R26's room. At 8:19 a.m. CMT-C was standing at the medication cart. When interviewed CMT-C stated, She (R26) is mad because she wanted to lay down and asked how come I did not do it without a second person. She put her light on again and complained about stomach pain. She said something about going to the bathroom at that point. I cannot do it, she needs a Hoyer (mechanical lift) and staff are in the dining room. The rule is you can not use the Hoyer by yourself. She put her light on again. I told her we would get to her as soon as possible. (Nursing assistant (NA)-E) and I put her in the sling. He put her in bed and he is cleaning her up now. I can't do anything without help to transfer her but she yelled at me. On 1/27/17, at 8:20 a.m. R26 was observed to be lying on her right side crying. Her shoulders were moving up and down and her upper body was shaking due to her crying. R26's pants were observed to be covered with feces. On 1/27/17, at 8:31 a.m. when NA-E left the room, R26 stated to the surveyor, They just f*****g made me like this! At 8:33 a.m. NA-E returned to the room NA-F and hygiene supplies. The nursing assistants proceeded to assist R26 with toileting hygiene. On 1/27/17, at 9:02 a.m. R26 was interviewed and stated, I was crying because I was upset. I was in my wheelchair and he (CMT-C) came in. I told him my stomach hurt and I need to go to the bathroom almost before 8 a.m. (CMT-C) did not say anything about needing two people but turned the call light off. I was leaning over and was screaming. He (CMT-C) left and then came back 10-15 minutes and said you need to stop screaming. There is a sick lady out there. Then he left and shut the door. I asked to be put to bed at that time and he said is it because you need to go to the bathroom? I said yes, I've got to go, I need to lay down. He told me the staff were doing breakfast so I'd have to wait until they were done. After 10 minutes I went over to the bed and pushed the button. Because I got tired of waiting and was going in my pants. (CMT-C) then came in with (NA-E). They transferred me to bed. I had soiled myself. (CMT-C) asked me, 'Why must you yell at me? Look I don't want to hear you. You don't know what it is like.' He kept blabbing on and I told him to leave. (NA-E) put me in bed after (CMT-C) left. R26 stated this experience made her feel very upset and embarrassed. It made me hurt and I felt hurt by what he (CMT-C) said. It all depends on how fast I go I could not hold this long. R26 further commented, This happens all the time, every time I ask to lay down they give me excuses about not having enough staff, or that I need to wait till someone is free. I get frustrated. I have told people I am tired of talking, they don't listen and they don't care. On 1/30/17, at 10:29 a.m. a follow up interview was conducted with R26. The resident stated, I was crying and I felt that only happened one time and that was Friday when I asked to go to bed to have a BM (bowel movement) and didn't get there in time. I use the bedpan here, so they have to transfer me. When I am at home I use the toilet. I don't have that long from the time I feel the urge, maybe 5 minutes. I have had incontinence episodes where I have not been able to ask staff before it happens. It was very upsetting, my feelings got hurt. It made me mad because (CMT-C) knew I had to go, but he shut the call light off and then shut the door. To get some attention, I started yelling. I started yelling before I lost control. When they started the transfer I had already lost control. (NA-E) is fine, he is a good person. If I tell him I need to go to the bathroom he changes what he is doing and takes care of me then. According the hospital's History and Physical dated 12/11/16, R26 had a [DIAGNOSES REDACTED]. R26 was admitted to the facility on [DATE], to the according to the Admission Face Sheet. A Bowel assessment dated [DATE], indicated R26 was currently incontinent of bowel and that the resident recognized the appropriate time/place to defecate. The resident was able to feel the urge and sensation for bowel movement, but was unable to participate in a program due to functional disability and was dependent on staff. R26's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident was cognitively intact. The MDS also indicated R26 was dependent upon two staff for transfers, bed mobility, dressing, toileting, hygiene and did not ambulate. The corresponding Care Area Assessment (CAA) for Activities of Daily Living dated 12/29/16, further verified the resident needed extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene and did not ambulate at that time. R26's care plan dated 12/29/16, identified a problem area of UTI's (urinary tract infections) and incontinence. Interventions directed staff to assist with incontinence care as needed. However, the care plan lacked evidence of any interventions for the [DIAGNOSES REDACTED]. On 1/27/17, at 9:18 a.m. NA-E was interviewed and stated, She (R26) was yelling when I came into the room, (CMT-C) was in the room. She was in the chair. I think she was upset and wanted to go to bed, she was upset because she was sitting in BM. (CMT-C) stayed in the room for the transfer. We put the sling on her together and then (CMT-C) stood there and I did the transfer. I went back to the dining room passing breakfast trays. I finished passing the trays then I went back to the room. It took probably 15 minutes. Even though the bowel assessment indicated R26 was incontinent, it also revealed that R26 felt the urge to go and knew when she had use the bedpan for defecation. Staff did not provide her with dignity for toileting. On 1/27/17, at 1:36 p.m. the facility's executive director (ED) was interviewed and verified when a resident needed to use the bathroom there can be urgency in the request. She stated R26 had not been treated with dignity because she had informed the staff she needed to defecate, and because staff did not respond to the request R26 defecated all over herself, which made her emotionally and visibly upset. R80 was observed on 1/23/17, at 7:56 p.m. NA-A was observed to enter R80's room where R80 laying in bed asleep. NA-A grabbed the blanket and pulled it down and off R80 in a quick manner. NA-A stated they had to provide pericare, because R80 was always digging in the rectal area and R80 had bowel movement material under nails. R80 asked, What the h**l are you doing, leave me alone. NA-A did not provide R80 with any explanation of what they were doing in the room prior to the start of cares. On 1/23/17, at 8:30 p.m. surveyor(s) informed the director of nursing services (DNS) observations of cares provided by NA-A. R80's annual MDS dated [DATE], indicated R80 was moderately cognitively impaired. R80's MDS indicated R80 had verbal and physical behaviors toward others on to three times in the seven days prior to the MDS. R80's MDS indicated R80 required assistance with all activities of daily living (ADL) except eating and had [DIAGNOSES REDACTED]. R80's Cognitive Loss/Dementia CAA Worksheet dated 11/14/16, R80 had [DIAGNOSES REDACTED]. R80 was at risk for unmet needs and safety deficits. ADL CAA Worksheet dated 11/14/16, indicated R80 required staff assistance with some ADL and cognitive skills. Behavioral Symptoms CAA Worksheet dated 11/14/16, indicated CAA was triggered due to R80 scratching a staff member during cares one day. Care plan considerations instructed staff to monitor for signs and symptoms of depression and to make sure R80 was not in pain or uncomfortable. Neither cognition or behavioral CAA indicated R80 was an inaccurate reporter or made false allegations against staff. The Physical Functioning Deficit care plan revised 11/16/16, indicated R80 had a history of [REDACTED]. Bed mobility, personal hygiene, toileting, oral care and locomotion were to be assist of one staff member. Alteration in mood or behavior care plan revised 11/16/16, did not identify false allegations or inaccurate reporting as a problem but did instruct staff using 2 persons during care may be needed due to potential for allegations date initiated 6/21/16. Undated, unlabeled nursing assistant assignment sheet instructed staff R80 was frequently incontinent of both bowel and bladder and to not apply two incontinence briefs at the same time. No skin issues were identified on the assignment sheet and staff were instructed to have 2 person care givers at all times. R165 was sitting in bed in a hospital gown on 1/23/17, at 4:29 p.m. R165 showed copies of grievances filed with the facility, and showed phone where R165 was documenting stay at facility. R165 said, I try to journal daily to help me deal with depression. I don't always if I am too angry. I have done so for years. LTC Professionals Progress Note date 1/2/17, indicated R165 had undergone an anterior fusion (abdominal surgery joining of two or more vertebrae together so motion did not occur) of L5-S1 (Lumber 5-last vertebrae in lower back and sacral 1-first vertebrae at the top of the sacrum on 12/23/16, with resulting retroperitoneal (the space between the back and the lining around the organs of the abdomen) hemorrhage (bleeding) and had ongoing abdominal and back pain. R165's admission MDS dated [DATE], indicated R165 was cognitively intact with signs of depression but no hallucinations, delusions or behaviors. The MDS further indicated R165 required assistance with bed mobility, dressing, toileting, personal hygiene and walking in room or on the unit, and indicated R165 was occasionally incontinent of bladder, had constant pain at 8/10, and had impairment in range of motion for one side upper and lower body. In addition, the MDS indicated R165 had [DIAGNOSES REDACTED]. R165's ADL Functional /Rehabilitation Potential CAA Worksheet dated 1/10/17, indicated R165 required extensive assistance with ADL's with goals minimizing risks and avoiding complications. Urinary Incontinence and Indwelling Catheter CAA Worksheet Dated 1/10/17, indicated R165 was occasionally incontinent of urine. Urinary CAA indicated contributing factors included pain, restricted mobility and urinary urgency. Urinary CAA care plan considerations indicated R165 was frequently incontinent of urine and required assistance of staff with cares. Falls CAA worksheet dated 1/10/17, indicated R165 was at risk for falls and overall decline with difficulty maintaining seated balance and impaired balance when changing positions. Pain CAA worksheet dated 1/10/17, indicated R165 was having pain that put R165 at risk for immobility depression and functional decline. R165's care plan dated 12/30/16, instructed staff R165 preferred to wear hospital gowns for comfort. R165's pain management care plain instructed staff to implement R165's preferred non-pharmacological pain relief strategies of offering cold pack and to encourage independence with repositioning. R165's care plan lacked specific interventions for ADLs or urinary incontinence. An undated Subacute NA Assignment Sheet 2, indicated R165 required minimal assist of one with mobility, was independent to assist of one at times for toileting, and had pain in back and leg. The assignment sheet instructed staff to have two staff present with cares and interactions. A facility document titled Grievance Form, dated 1/11/17, indicated R165 had reported a concern on 1/10/16, that on 1/9/17, staff did not answer her call light for 25 minutes, beginning at 10:30 p.m. Thus, R165 reported having been incontinent of urine from having to wait. According to the grievance, R165 reported going to the hallway for help and registered nurtde (RN)-N laughed at her and said, 'she just needs a [MEDICATION NAME]'. R165 reported feeling so upset R165 wanted to go home. The findings section on the Grievance Form, indicated the allegations were not confirmed and indicated R165 put the call light on and one minute later came out of room yelling at staff to 'give a [MEDICATION NAME] now'. The resolution on the grievance form indicated: Reviewed with staff -prompt responding to call lights and requests and respectful interactions. It also indicated a meeting had been scheduled with the long-term-care Ombudsman for 1/16/17, to discuss concerns and care for R165. The investigation lacked indication of interview with nursing assistants working the unit at time of allegation, but included interviews completed 1/21/17 and 1/22/17, with staff who had not been working the unit at the time of the allegation. This allegation of neglect and verbal/emotional abuse was not reported to the State agency. The grievance form was documented as having been received by the Grievance Official on 1/24/17. Review of R165's Progress Notes from 1/2/17 through 1/26/17 revealed: Progress Note charted 1/9/17, at 11:39 p.m. R165 had call light on one minute and came out screaming, I need my pain bill (sic) now. Progress Note dated 1/10/17, indicated, Res (resident) reported last night that she had her call light on 'a long time and nobody was answering it' and 'didn't make it to the bathroom on time.' The Progress Note also indicated R165 told RN-F, She wanted to leave last night because of 'how I felt I was treated.' but ended up deciding to stay. The Progress Note further included: her report is different than staff report on her behavior. A Review of R165's Medication Administration Record [REDACTED]=no pain 1-4=mild pain 5-7=moderate pain 8-10= excruciating pain. If Pain assessed at moderate to excruciating=document interventions. Level of on 1/9/17 was documented as 8 on the day shift, 7 on evening shift 9 on the night shift. Review of Progress Notes for 1/9/17 did not indicate usage of any nonpharmacological interventions. Review of MMedication Administration Record [REDACTED]. R165 received [MEDICATION NAME] 4 mg at 3:25 a.m., 11:00 a.m., and 5:37 p.m. and 11:27 p.m. During interview on 1/26/17, at 12:20 p.m. R165 said, I don't have the exact time, I was so upset that I did not make notes. I was in so much pain, I needed help to get to the bathroom. I put on my call light and when no one came I got myself to the bathroom. I had wet on myself. I put the bathroom call light on. It took me 20-25 minutes to clean up. I turned the call light off. I went out into the hall and (RN-N) said hi, what can I do for you? I told her I wanted [MEDICATION NAME] and she turned to her coworker and said all she wants is her [MEDICATION NAME] and laughed. I was so humiliated and came back in my room and started packing. I was so upset and angry, I could not respond. (RN-N) tried to talk me into staying. If I had gone out there and yelled not saying that I did I would have said please. During interview on 1/28/17, at 2:32 p.m. NA-EE said, Sometimes (R165) gets upset at me but she does not yell. (R165) uses the call light. A call light is a means of communication that we answer normally as soon as able. NA-EE stated call lights have two different sounds one for the room and one for the bathroom. NA-EE said, Someone has to respond immediately to the bathroom call light, it is an emergency call light. Everyone is responsible to answer call lights. During interview on 1/28/17 at 3:32 p.m. NA-O verified worked the evening shift. NA-O said, We can have two or three lights going at the same time. The patients do not complain. If there are more than three call lights on we try to let the patients know that if it is not urgent they need to wait. Bathroom lights are very dangerous so we must answer them first. If a patient asks to go to the bathroom that needs to be first priority because if not they will be incontinent and feel so bad it could be humiliating. On 1/27/17, at 1:36 p.m. the facility's ED was interviewed and stated all residents are to be treated with respect and dignity. Dignity policy effective date 2/26/15, instructed staff, All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observation, interview and document review, the facility failed to thoroughly assess residents at risk for falls, and failed to develop and/or implement interventions to prevent further falls for 2 of 3 residents (R118, R119) reviewed. This resulted in actual harm for R118 who sustained a laceration to her arm which required medical intervention. In addition the facility failed to ensure 1 of 3 residents (R151) was safe in bed with rails on the bed and the facility failed to ensure 1 of 1 resident (R260) had appropriate supervision during smoking. Findings include: According to R118's record, she sustained 17 falls in the facility, one of which required an emergency room visit related to a laceration. However, there was no evidence the facility consistently reviewed R118's falls in an effort to determine causal factors and/or prevent further injury. Further, the staff indicated R118's falls were all related to non-compliance with the use of her walker, however, at least three of R118's falls indicated she was using her walker and there was no evidence these falls were investigated. R118's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact and required limited assistance with activities of daily living. The MDS indicated she was occasionally incontinent of bladder. R118's care plan dated 12/14/16, indicated the resident had a risk for falls related to a history of falls in the facility. Care plan interventions included: assess for pain, call light in reach, observe for side effects of medications, therapy referral and use mechanical lift (Hoyer) if unable to get up off floor independently. A facility document untitled and undated, (nursing assistant care sheet) identified the following fall intervention: Sling Size: large sling if falls and unable to self transfer from floor. No other interventions were indicated. R118's Progress Notes and corresponding Incident Reports were reviewed from 5/5/16 through 1/27/17. The following fall history was identified: 5/5/16 - R118 had an unwitnessed fall in her bathroom. Staff entered room and found her sitting on the floor. At that time the resident stated she had slipped because her socks were slippery. Although staff provided R118 with non-slip socks, there was no evidence an incident/investigative report had been completed. 5/9/16 - R118 was found on the floor leaning against her walker. She sustained an abrasion to her right foot. There was no evidence an incident/investigative report had been completed. 6/30/16 - R118 was heard calling for help at 6:00 p.m. staff responded to find her sitting on the floor in the doorway of her bathroom. At that time, the resident stated she'd slid to the floor and crawled to the bathroom. A subsequent Progress Note dated 7/5/16, indicated R118 had sustained a bruise to her right knee related to the 6/30/16 fall. A facility document titled Post Fall Analysis/Plan dated 7/7/16, indicated the interdisciplinary team (IDT) had reviewed the fall and recommended R118 be reminded to use her walker. 7/20/16 - R118 reported she lost her balance and fell in her room and hit her head. The resident sustained [REDACTED]. A facility document titled Post Fall Analysis/Plan dated 7/21/16, indicated the IDT had reviewed the fall and recommended staff encourage R118 to call for assistance, and for staff to offer assistance. 8/5/16 - R118 was found lying on the floor by her bathroom doorway. There was no evidence an incident/investigative report had been completed. 9/2/16 - R118 stated she was trying to find the bathroom and could not find the grab bar. She told staff she had lost her balance and fallen. There was no evidence an incident/investigative report had been completed. 10/7/16 -Staff heard R118 calling for help and found her sitting on the floor with her walker next to her. The resident told staff she had tripped on her walker. Although R118 sustained three skin tears to her right forearm, there was no evidence an incident/investigative report had been completed. 10/12/16 - Staff responded to R118's bathroom light to find her lying on the floor. R118 stated she'd fallen and crawled to the bathroom to call for help. There was no evidence an incident/investigative report had been completed. 10/20/16 - Staff heard a loud noise coming from the craft room and responded to find R118 sitting on the floor beside the toilet in the craft room bathroom. There was no evidence an incident/investigative report had been completed. 11/2/16 - A housekeeper called nursing staff to report R118 had fallen. The housekeeper had reported R118 had been standing at the door and putting on her sweater when she'd lost her balance and fallen backwards. The resident sustained [REDACTED]. A facility document titled Post Fall Analysis/Plan dated 11/3/16, indicated the IDT had reviewed the fall and that R118 was working with physical therapy to increase/improve use of walker. 11/5/16 - R118 was found lying on the floor calling for help. She was on her right side lying across her doorway. The documentation indicated R118 had stated she'd been coming from the bathroom, had lost her balance and had fallen. There was no evidence of any further investigation related to the incident. 11/15/16 - Staff responded to R118's call light to find her sitting on the floor in the middle of her room. R118 had sustained a deep laceration to the elbow. Documentation indicated the laceration measured 4 cm x 2 cm and that R118 went to the emergency room for treatment, returning with staples in her arm to close the wound. Although R118 sustained an injury requiring medical care, there was no evidence of any further investigation related to the fall. 12/14/16 - R118 was found sitting on the floor and stated she'd fallen after tripping on her walker. An Incident Report dated 12/17/16, indicated R118 had a scratch to her left leg and a bruise measuring 6 cm x 3 cm to her right side below her shoulder blade as a result of the 12/14/16 fall. However, there was no evidence the incident was investigated or reviewed by the IDT. 1/2/17 - R118 was found lying on the floor at 7:00 p.m. Documentation indicated she'd reported to staff that she'd hit her head. A facility document titled Post Fall Analysis/Plan dated 1/3/17, indicated the IDT had reviewed the fall and that R118 continued with physical therapy and refused to use the walker. No other recommendations were identified. 1/12/17 - R118 fell in the dining room and was lying on her back. Staff indicated she was ambulating while eating ice cream, lost her balance and fell . A facility document titled Post Fall Analysis/Plan, dated 1/13/17, indicated the IDT reviewed the fall and recommended staff try to decorate R118's walker to encourage use. 1/14/17 - R118 was found lying on the floor next to her bed by staff. Documentation indicated R118 had reported to staff she'd slid out of her bed and landed on her bottom. A facility document titled Post Fall Analysis/Plan, dated 1/23/17, indicated the IDT reviewed the fall and recommended continued reminders to use her walker. 1/27/17 - R118 fell while ambulating in the hallway at 3:00 p.m. Documentation indicated she'd reported she'd pivoted too quickly and lost her balance. There was no evidence the IDT reviewed the fall as of 1/30/17, at 4:30 p.m. During observation on 1/27/17 at 9:25 a.m., R118 was ambulating independently throughout the unit. She was not using her walker. Staff on the unit did not approach R118 with reminders to use her walker. During interview on 1/26/17 at 3:56 p.m., nursing assistant (NA)-S stated she was unaware of any fall interventions for R118. NA-S reviewed her care sheet and indicated the only intervention was to use a sling if R118 falls and cannot get up. During an interview on 1/26/17 at 3:59 p.m., licensed practical nurse (LPN)-G stated R118 experiences a lot of jerking she is unable to control due to her medical [DIAGNOSES REDACTED]. LPN-G indicated fall interventions for R118 include: encourage her, offer assistance, and to make sure to give R118's meds on time. During an interview on 1/26/17 at 4:30 p.m., the assistant director of nursing services (ADNS) stated R118 needs a weighted walker due to impaired balance. She stated R118 will not use the walker even though staff encourage her. The ADNS stated when a fall was reported the nurse was supposed to complete an incident report and that falls are discussed at the IDT meetings. The ADNS stated the facility had attempted physical therapy for R118, however R118 had complained of increased shoulder pain with use of her walker. The ADNS then stated most recently the IDT had discussed decorating R118's walker to promote use. During an interview on 1/30/17 at 9:55 a.m., the director of nursing services (DNS) stated an incident report should be completed for each fall. He stated the IDT reviews each fall and discusses potential interventions to prevent future falls. In addition, the DNS stated R118's falls were due to non-compliance with the use of her walker. He stated R118 does not always remember her walker and that staff will regularly educate and remind her to use it. He stated R118 has balance problems and has been referred to physical therapy. He stated when she uses her walker she's fine, even though she had her walker with her during many of her falls. The DNS verified other than the physical therapy referral and reminders to use the walker, they had not implemented any other interventions. He acknowledged, We should have looked at other options instead of just what we did.We should have looked at her more closely, and we didn't. A facility policy titled Golden Living post Fall Analysis Summary and Guidelines for Completion, dated 10/11/16, was reviewed and indicated the following: It is the policy of the living center to complete the Post fall Analysis Summary after every known fall. The IDT team will complete a review of the post fall Analysis within 72 hours. Recommendations implemented shall be recorded on the report and plan of care revised as necessary. A facility Falls Management Guideline, undated, indicated following a resident's fall, appropriate interventions to prevent falls will be implemented. R119's falls were not thoroughly investigated to identify the root cause. R119's falls CAA dated 4/20/16, indicated resident was at risk for falls related to weakness and balance instability. In addition the care indicated resident was at risk for fall with potential for fracture and/or serious injury and further debilitation. R119's [DIAGNOSES REDACTED]. In addition, the MDS indicated resident required extensive physical assistance of one staff with transfers, used a wheelchair for locomotion and was not steady and required human assistance to stabilize when moving from seated to standing position. R119's Clinical Health Status dated 12/21/16, indicated resident had been identified at a high risk for falls. R119's care plan dated 1/24/17, indicated resident was at risk for falls related to history of falls, balance impairments, weakness/deconditioning, history of high blood pressures history of low blood sugar. On 1/24/17, 10:15 a.m. when asked how many falls had resident had in the last 30 days LPN-I stated resident had a fall on 1/1/17, and had no injuries. On 1/28/17, at 4:20 p.m. to 4:50 p.m. resident was observed wheel self in the first floor of the facility by the subacute unit. Resident was observed wearing a pair of blue gripper socks. When asked about her transfers and the assistance she received, resident stated the staff was supposed to help her however when she needed the assistance it was a while before someone came. When asked about her gait the resident stated sometimes am just tired like after dialysis. When asked about the falls, the resident stated they happened so fast. During review of the medical record, both electronic and paper, the following was revealed about the resident falls in the Progress Note: -6/2/16, at 10:45 p.m. indicated a NA had reported to the writer the resident was on the floor. The writer went into the resident room and found the resident on the floor between the wheelchair and bed crying. When asked what had happened, the resident stated I was trying to get my chips from the floor and the resident slip off the wheelchair and had hit her left arm and was complaining of pain. The resident was assessed and transferred using a Hoyer with two staff and vital signs were noted to be within normal limits. -8/10/16, at 10:20 p.m. the writer indicated the resident had been found on the floor, sitting on her bottom, denied hitting head and denied pain and had no injuries noted. -12/23/16, at 8:00 p.m. the resident was found sitting by the bedside. The resident stated she had slid to the floor when trying to transfer self. Denied hitting head. Transferred and denied pain. The note indicated the resident had been asked to use the call light when trying to transfer to avoid falls. During review of the Post Fall Analysis/Plan 12/23/16, it was revealed the interdisciplinary team (IDT) review and recommendation had been made for resident to be referred to physical/occupational/speech therapy for evaluation. -1/1/17, at 6:56 a.m. note indicated the resident had a fall at 6:20 a.m. and resident had stated I was grabbing a candy, and fell . The note indicated the resident was assessed, denied, vital signs were obtained, denied hitting her head and no injuries noted. During further document review, it was revealed there were no Post Fall Analysis/Plan reports were completed for R119 for falls dated 6/2/16, 8/10/16, and 1/1/17. In addition it was revealed even though the IDT had recommended therapies the recommendation had not been followed on. On 1/26/17, at 3:01 p.m. the director of nursing services (DNS) stated he was not able to pull the actual incident reports and Post Fall Analysis/Plan for R119's falls for the dates 6/2/16, 8/10/16, and 1/1/17. When asked the facility policy for investigating falls aftermath, DNS stated the nurses were supposed to complete both as that was how the IDT followed up all incidences and if there was no incident the falls were not reviewed as they did not generate Total Events log for resident. On 1/30/17, at 9:25 a.m. a therapy staff reviewed the therapy notes and all the episodes R119 stated the last time resident had been seen by physical, occupational and speech therapies was 6/28/16, 9/19/16, and 11/24/16, respectfully. She verified resident had not been seen by either of the therapies even though it had been recommended by the IDT team to be seen following the fall on 12/23/16. On 1/30/17, at 11:30 a.m. DNS stated the staff was still looking for the Incident reports and would provide them. At 12:54 p.m. DNS approached stated he was not able to find the incident reports for the 6/2/16. He indicated the staff was supposed to fill the incident reports as the IDT team would follow up and identified the root cause of the fall or incident. R151 was observed on 1/24/17, at 9:47 a.m. R151 was sitting in wheel chair and gave permission to check side rail. The right half side rail was in the down position in middle of the bed and the rail was tight as it did not move from side to side. The left half side rail was in the up position. The left side rail moved side to side. During observation on 1/25/17, at 6:39 a.m. R151 lying in bed with call light on, both half side rails were down in the middle of the bed. During observation of morning cares on 1/25/17, at 7:18 a.m. R151 was sitting on edge of the bed. The right half rail was in the down position and left side rail was in the up position. NA-E assisted R151 to stand up. R151 used left side to stand up and the side rail moved. NA-E did a pivot transfer with R151. R151 sat down on wheelchair arm rest. NA-E helped R151 stand back up and sat R151 down in wheelchair. R151 said, They usually use the EZ (mechanical lift) lift. It is easier, I get stuck on the wheel (wheelchair). R151's initial care plan dated 12/31/16, did not address side rail usage until after surveyor asked LPN-B about R151's activity of daily living (ADL) care plan. Nor did the temporary plan of care address R151 mobility status, transfer status, and recent stroke. R151's admission comprehensive assessment dated [DATE], indicated the resident was a fall risk. The physician admission orders [REDACTED]. R151's physical therapy (PT) evaluation dated 1/2/17, did not address side rails or grab bars. PT was working with R151 for bed mobility including side to side turning using minimal assistance and transfers using moderate assistance. R151's admission MDS dated [DATE], indicated R151 was cognitively intact with no behaviors and required assistance with ADL including bed mobility and transfers. R151's MDS indicated R151's [DIAGNOSES REDACTED]. The MDS indicated the resident did not use bedrails or restraints and had not fallen since admit. R151's Falls CAA Worksheet dated 1/10/17, indicated R151 was at risk for falls with injury related to recent stroke with left sided weakness. The Subacute NA Assignment Sheet undated did not address side rails or positioning bars use. On 1/25/17, at 7:25 a.m. NA-E was interviewed. NA-E indicated R151 was a pivot transfer and that R151 used the rails for transferring. NA-E verified the left grab bar could be moved approximately 1.5 inches in either direction. On 1/26/17, at 7:35 a.m. R151's bed rails were observed with the maintenance director. The right side rail was in the down position and did not deviate from side to side. The left side rail was in the up grab bar position. The left side rail moved back and forth approximately 1.5 inches. The maintenance director looked at side rail and verified the left grab bar was loose. The maintenance director stated that side rails were on for preventative maintenance that month and that he would fix the rail. When asked what the process was for preventative maintenance the maintenance director stated he looked at all the bed rails on a weekly basis. He indicated he did not document the rooms as he did all of the rooms. The preventative maintenance was reviewed in the electronic record. The electronic record read check and adjust all side rails set up weekly as preventative maintenance task. It was not room specific which would instruct staff to tighten or replace side rails if not tight or functioning correctly. It was marked as being completed every Thursday. On 1/27/17, at 8:02 a.m. LPN-D verified the medical record lacked evidence of an assessment for side rails, risk versus benefits explanation, lacked consent, lacked a physician's orders [REDACTED]. LPN-D also verified when R151 was in bed, the 1/2 rails are to be in the down position. LPN-D Verified that the left rail was loose and could be moved approximately 1.5 inches in either direction which made the rail wobbly. On 1/27/17, at 11:23 a.m. RN-E stated, I do not think he could get himself up without assist (of the bedrails) but he could go to the bottom of the bed if the bedrail is in the down position. During interview on 1/27/17, at 1:01 p.m. DNS said, We do not have side rails on the beds, we have railings on bed that are used as assist with bed mobility and turning and repositioning. DNS said, We do not obtain a consent, because we don't use restraints in the facility. DNS said, We assess patients upon admission and provide them with the necessary equipment. We do risk and benefits if it is appropriate. During interview on 1/30/17, at 12:10 p.m. DNS indicated the side rails were on the bed when the bed was delivered to the unit. The bed was in the room when resident was admitted and no interventions were documented prior to using the railings. DNS stated the staff were to follow the care plan. The Restraint Evaluation and Utilization Guideline dated 2/4/16, instructed staff. The need for the use of restraint will be discussed with the resident and/ or family. The risks and benefits will be explained to the resident and /or family. The facility will obtain a signed consent for the use of the restraint. The center will obtain a physician order [REDACTED]. The Physician order [REDACTED]. No consent could located in R151's medical record. In addition, the medical record lacked evidence any interventions tried before applying the bed rails. R260 was observed on 1/24/17, at 9:55 a.m. R260 was observed to put a cigarette out on the sidewalk of the court yard, leaving the smoldering tip of cigarette on the sidewalk. R260 walked into the facility. There were no facility staff observed in the area. Surveyor continued to observe to ensure tip stopped smoldering. During a random observation on 1/25/17, at 9:39 a.m. R260 was smoking in the outside courtyard R260 threw cigarette into the garden without putting it out. There were no facility staff in the common area leading to the outside court yard. During continuous observation on 1/25/17, from 11:42 a.m. until 12:43 p.m. - At 11:43 a.m. R260 came walking into common area with a cigarette dangling out of her mouth. R260 went out to the courtyard and said to another resident no one is in the lunch room so I decided to have a cigarette. R260 lit cigarette with lighter and then put the lighter back in her coat pocket. -At 11:46 a.m. R260 reentered building with cigarette in hand. R260 put cigarette in the left coat pocket. R260 verified she had put cigarette in her pocket and showed surveyor that she had knocked the end off of it and the cigarette was not smoldering. R260 had a pack of Smoky Joe's cigarettes that had 15 cigarettes in it. -At 12:23 p.m. R260 entered the common area with a cigarette hanging out of her mouth and went out to the courtyard to smoke. -At 12:25 p.m. R260 went out to the courtyard and lit cigarette then sat on bench. R260 tapped the ash off of the cigarette onto the ground. R260 was holding cigarette in right hand that had a splint and gauze wraps on it. -At 12:29 p.m. R260 put cigarette out on ground by bench. During a random observation on 1/28/17, at 2:44 p.m. R260 was outside wearing a white tee shirt and gray sweat pants and boots. R260 was passing a cigarette back and forth with sharing a cigarette with unidentified resident. Temperature at that time was 23 degrees with a wind chill of 11 degrees Fahrenheit. The Clinical Health Status Form dated 1/12/17, indicated R260 was at risk for elopement due to being cognitively impaired with impaired decision. The Smoking Assessment section indicated on 1/12/17, R260 did not have any cigarettes and the smoking policy was explained. On 1/30/17, the Smoking Assessment was updated and indicated R260 did not have cognitive or physical impairment preventing from safely containing ash and extinguishing cigarette after the surveyor brought it to the attention of the facility. The Immediate Plan of Care Smoking dated 1/12/17, revealed R260 had impaired cognition, hand tremors and was not following smoking policy. The care plan instructed staff, supervision per policy while resident is smoking. The Smoking Care Plan dated 1/13/17, indicated R260 was at risk for smoking related injury related to: Smokes independently Non-compliant with facility smoking policy. Smokes in undesignated areas at undesignated times, and does not keep smoking materials in locked cart. R260's smoking care plan instructed staff to, Assure smoking material is extinguished prior to patient leaving smoking area, Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, immediately inform facility management. Patient not to have cigarettes or smoking material on person Place patient in position to assure visualization of ashtray, Provide smoking apron while smoking, Storage of smoking materials per Living Center policy. The Comprehensive assessment dated [DATE], indicated R260 had [DIAGNOSES REDACTED]. The Assessment section indicated, Res. (resident) reported to be a smoker but did not bring in any cigarettes. 2 hours later noted res. To have a cigarette hanging out of her mouth and was asked where she found a cig (cigarette) and res. Stated, 'I found a friend'. Informed of smoking policy and designated times to smoke, place to smoke, and also requiring a smoke eval (evaluation) and supervision. Res agrees with everything staff tell her but then does something different. Was noted to be smoking outdoors with redirection given and res stood and looked at staff and cont. (continues) to smoke. ETOH (alcohol) policy reviewed also. During interview on 1/26/17, at 7:11 a.m. LPN-B said, When she first came she did not have cigarettes but she made friends easily. All of our residents who smoke are to go up to second floor. All people there are supervised. There is supposed to be no smoking outside. When asked what you do to keep residents who smoke in the court yard safe, LPN-B said, Most of the people who smoke outside are pretty safe. They know the policy and choose to smoke outside. It has been a battle. Residents are not compliant with the smoking policy. When told of observations made of R260 smoking outside, LPN-B said, If someone were to not ash in the receptacle or put their butts into the receptacle that would be unsafe behavior. I have seen her (R260) yesterday up in the smoke room. During interview on 1/27/17, at 6:50 a.m. housekeeping -A verified there were 32 cigarette butts on the ground of the courtyard. Housekeeping-A said, I clean the butts up two times a day in the morning and again right before two p.m. Housekeeping-A verified there was a cigarette box in the butt can and verified there was no way to call for help if someone started a fire. Housekeeping-A said we have had no fires out here. Housekeeping-A was unable to say where nearest fire extinguisher was. During interview on 1/27/17, at 11:23 a.m. registered nurse (RN)-E reviewed R260's smoking assessment dated [DATE], and said, Social Service (SS)-A did the assessment. We have non complaint patients and we care plan noncompliance. Per care plan she (260) is independent with smoking and is also identified as non-compliant. RN-E said, I will let (SS-A) know, she will care plan and do the education. When asked, do you notify management every time there is unsafe behavior or a resident borrows smoking materials or other violations of your policy, RN-E said, It would be daily. We talk about people at morning meetings. We do not have anyone patrolling the court yard. RN-E verified there was no call light in the courtyard or common area to be used in case of an emergency. RN-E verified the closest fire extinguisher was in the hallway on the other side of the common area from the entrance to the courtyard. During interview on 1/27/17, at 11:44 a.m. SS-A said the supervisor who was here on the day a resident is admitted , watches the resident smoking and writes it down in the nursing packet. SS-A said, basically it was very difficult to tell the independent people what to do. We cannot force them to come in because they do not listen. We cannot force them to come inside and take their cigarettes because that would be abuse. All we can do is educate and hope, especially when it is really cold outside. I have never seen it. We are working on coming up with a plan to make the smoking policy work for the independent people. We are waiting to see what the Monarch policy is. SS-A verified R260 was at the facility under a provisional discharge which included a Provisional Discharge Contract dated 1/12/17, that indicated, I (R260) will maintain my safety and well-being. This involves not doing to harm or threaten others or myself including use of illicit drugs and alcohol. During interview on 1/27/17 at 11:57 a.m. RN-E said, It is impossible to keep the residents who smoke in the courtyard supervised. They do what they want to. We try to keep them in when it is cold but that does not work. She (R260) is not safe to smoke in the court yard but insists. RN-E verified putting a used cigarette in pocket would be unsafe, knocking the tip off a cigarette would be unsafe, and not putting a cigarette in the trash bin would be unsafe behavior. During interview on 1/27/17, at 1:10 p.m. DNS said, We do a smoking assessment upon admission. If they wish to smoke and do not have the cigarette we reach out to guardian and POA (power of attorney) as we know resident is going to smoke. All residents smoking in the courtyard are people who have been assessed per facility policy and they go out and smoke. We can take the cigarettes and they have family bring more. When asked, how do you ensure they are safely smoking, the DNS said The residents are the ones who feel they are independent and ambulate on their own. They say 'no you are not going to supervise me. We pick our battles. DNS verified the throwing a cigarette was a risky behavior. When asked, how can a resident notify staff if there was a concern, DNS did not answer. DNS said, We have not had any accidents. During interview on 1/28/17, at 4:50 p.m. DNS verified there were 78 cigarette butts on the ground in the courtyard. DNS verified there was a folded long section of toilet paper in the butt can that had a cigarette burn through several layers. DNS verified the outside weather was 23 degrees and the wind chill was 11 degrees Fahrenheit. During interview on 1/30/17 at 8:36 a.m. Executive Director said, How do we keep them safe as they will go outside in spite of what we say. They will go out other doors not dressed appropriate for the weather. Smoking and Tobacco Use Guideline dated 9/14/15, indicated Patients and Residents of Golden Living are permitted to smoke in the designated area only. Each LivingCenter will specify the smoking area. Smoking outside the LivingCenter designated smoking area is strictly prohibited. Patient/Residents may only smoke at the designated times. Each LivingCenter will develop and specify the smoking times. Smoking will be supervised by a staff member. Smoking garments/aprons will be worn by all residents while smoking for safety. The designated smoking area will be equipped with smoking aprons, fire-proof furniture, Fire-proof receptacles and a fire extinguisher. Smoking is not permitted in any other area of the property.

Based on observation, interview, and document review, the facility failed to ensure individual resident dignity was maintained for 7 of 31 residents (R154, R257, R1, R55, R96, R193, R135) interviewed regarding dignified treatment. This deficient practice resulted in harm for R154 and R257 who experienced harm and felt disrepected due to lack of provision of incontinence cares and privacy. Findings include: R154's quarterly Minimum Data Set ((MDS) dated [DATE], indicated cognition was intact, required extensive physical assistance of one staff with bed mobility, dressing, toilet use and supervision oversight of one staff with personal hygiene and used walker and wheelchair for mobility. On 5/5/15, at 3:05 p.m. when asked if she felt there was enough staff available to make sure she got the care and assistance she needed without having to wait for a long time R154 stated "I have waited for hours and even had accidents when waiting for them to come. I use my call light and they don't come at all. Someone said they were going to have three aides and they have had only two and I have to wait until the second shift comes to be changed I should not wait to go the bathroom. I have had UTI's (urinary tract infections) twice and been put on antibiotics and now on cranberry juice. They say I refuse cares but when I am alert, am able to tell them my needs and I have the right to refuse cares but when I need the help and I put the call light I need them to help me." When asked if staff treated her with respect and dignity R154 stated "Some don't you tell them to slow down or be soft when providing cares and they just don't." R154 was crying the whole time when explaining to surveyor with tears rolling down her checks as her body was shaking. On 5/7/15, at 3:57 p.m. when approached R154 indicated some of the staff were indicating she was refusing cares, yet on some nights she was not able to sleep well or had little sleep due to the noise and during the day that was when she was finally falling asleep. As R154 was talking to surveyor she broke down looked to the other side of the room facing the window crying and tears were observed rolling down her cheeks. R154 further indicated in the last two days during the evening and night shifts the staff had taken over one hour to answer her call light and she had accidents as a result of waiting for the staff to answer the call light which is a problem and the staff knows about it. When asked how it made her feel when she soiled herself she indicated it made her feel helpless as tears rolling down her cheeks as she stated "I want to go to a different place." R154's [DIAGNOSES REDACTED]. The MDS also indicated R154 had rejected cares one to three days during the assessment period, was occasionally incontinent of urine, had no urinary program and was always continent bowel. During review of the Progress Notes dated 4/1/15, through 5/8/15, it had been documented mostly at the end of the shifts 13 times R154 had refused cares and getting out of bed. Although refusal of care was documented R154 had expressed to staff she did not want to get up and would let staff know but this was considered refusal of care. In addition the Progress Notes revealed R154 had complained of burning with urination and upon a urinary analysis and culture R154 was found to have urinary tract infection which she was treated for [REDACTED]. R257 was interviewed on 5/6/15, at 8:06 a.m. R257, who was assessed as cognitively intact according to the CAA dated 11/17/14, expressed concern and stated, "Some of the staff here don't listen and they just don't care enough to do the job right. I will refuse cares from the staff who do not perform my cares the right way. They don't understand my arthritis and some of them don't have the patience and they push me. Some of the staff are nasty and I have said to them, I don't know what your problem is but you need to leave it outside this door, don't come in to help." Furthermore, R257 expressed sometimes she felt like they are against her that she complains, but they do not understand the arthritis and the problems developing from the arthritis. R257 validated she had refused cares and transfers because the staff are hurting her and they are not listening to what was best for her condition. R257 said staff have told her so many times to just urinate in her brief so that she does. R257 said when she lived on first floor they used the bedpan. R257 boldly stated' "I am not incontinent, I have never been incontinent." R257 did not know why a commode or toilet had not been an option. R257 expressed "feeling sad" that the staff do not understand her pain and condition and was "afraid" they would retaliate against her for complaining and move her to third floor. R257 felt like the staff treat her as if she had a "mental" condition/problem so they do not listen to her. R257 stated, "I am not treated with dignity and respect, the staff listen in on my personal conversations and turn everything against me, I feel like I am worth nothing." During our interview an activity person came into the room without waiting for permission and preceded to sit on the roommates bed when the roommate was not there. Surveyor asked the activity person for privacy so they left the room. R257 said, "See, they were coming in to find out what was being said so they could hold it against me. Watch the bathroom next, they will be in there trying to listen to our conversation." According to a care area assessment dated [DATE], R1 had been assessed as cognitively intact. R1 was interviewed on 5/8/15, at 7:19 a.m. R1 expressed concerns regarding dignity and respect. He said some of the staff come into his room without knocking on the door or waiting for a response. R1 also stated the majority of staff do not say who they are or what they are going to do for you. R1 stated sometimes the staff do not speak in English and expressed "frustration" with not knowing what was being said. R1 said sometimes he would get "angry" because the nursing assistants (NA) would tell the nurse he refused to do something, like get up when they wanted him to. R1 said it wasn't true and that he thought the staff were saying more to the nurses about him refusing so they would not have to do the work of getting him up or taking him to the bathroom when he requested. R1 expressed not knowing who the staff are, even the regulars, and said he sometimes forgot who they were and wished out of dignity and respect, they would tell him who they were each time they entered his room. R1 talked about several of the residents talking about dignity at the facility when cares were not provided according to their (resident) wishes. R1 stated, "I am not important enough for them to care about me. I just want to give up, but I think of the people who can't speak up for themselves. I am afraid of retaliation by them telling me to move out." R1 said he had told "several in management" about his concerns without a resolution to his satisfaction. During the interview at about 7:30 a.m. 5/8/15, licensed practical nurse (LPN)-D was observed to enter R1's room without knocking and/or waiting for an invitation to come in. LPN-D did not tell R1 who they were and donning a pair of gloves preceded to do a blood glucose check without informing R1 what they were going to do. The surveyor asked the LPN-D what they were going to do for R1. During the observation another staff member, nursing assistant (NA)-G, also entered the room without knocking or seeking R1's permission. R55 was interviewed on 5/5/15, at 2:57 p.m. R55, who was assessed as cognitively intact according to the CAA dated 11/21/14, reported the majority of the NAs are very disrespectful and implied they think they have rights above and beyond what we the residents have. An example according to R55 would be while talking to a nurse, the NAs would interrupt and actually talk above what R55 was reporting. According to R55 meals are sometimes missed because the staff forget about (R1) because he was out and about in the facility. R55 feels not getting the meals may be retaliation for concerns expressed to management but has no proof of retaliation. R55 expressed staff have actually walked away from him when they have been asked to do something regarding cares. R55 said the staff have told him to urinate in his brief rather than taking him to the bathroom or offering a urinal. R55 said "It seems petty, but the aides don't introduce themselves or let me know who is my aide for the shift, I think when they come in my room they should tell me who they are." R55 had a note posted on the door of the room informing staff and visitors to knock and wait for permission before entering the room. R55 expressed fear of retaliation because he speaks up about concerns in the facility, R55 stated, "I am afraid I will lose my room and they will make me move." R96 was interviewed on 5/7/15, at 7:53 a.m. R96, who was assessed as cognitively intact according to the Care Area Assessment (CAA) dated 3/7/15, complained that staff do not wait for her response before coming into the room and thought that was a dignity concern. R96 expressed relaying concerns to the nurses regarding concerns "many times." R96 said LPN-E barged into the room all the time and when she was told "No, she barges in anyway, looks at me, laughs at me and proceeds to tell the nursing assistants about someone else that needs help. That's a breach of confidentiality." R96 expressed getting "angry and frustrated" that all the interruptions distract the staff who are taking care of her at the time. R96 talked about NA-L and stated, "She is rude, she just comes in without knocking, and doesn't talk to you, doesn't say anything to you, pushes you around like a piece of meat, you ask her to do something and she just looks at you. Everybody know that she is that way and no one gets her straightened out to not be rude." Furthermore R96 talked about dignity and staff telling her to urinate in her brief rather than use the bedpan or commode or toilet. R96 stated, "I demanded to be toileted after lunch, before supper and before bed, I wasn't going to tolerate them telling me to just go in my brief." During the interview on 5/7/15, about 8:00 a.m., NA-B opened the door without knocking to see who was in the room. R96 validated and stated, "That happens all the time, no knocking and no saying who they are. I once heard that nursing assistant tell a resident she was too busy to take care of them." R193 was interviewed on 5/7/15, at 9:55 a.m. R193, who was assessed as cognitively intact according to the CAA dated 5/20/14, expressed dissatisfaction with the "room needing paint and the registers falling apart." R193 stated, "Does that look like they care about me, that is not respect to have my room be like this for so long, they know it is like this." R193 said he had spoken to the ombudsman because of staff coming into his room without knocking and he did not know who they are. R193 expressed concern because staff would say he was sleeping and then they would skip his shower which frustrated him because then they say he was argumentative when the staff are the ones who frustrate him. During the interview on 5/7/15, at 9:55 a.m. the oxygen person knocked on the door and came through the door without waiting for R193 to say come in. The oxygen person did not say their name, did not smile and preceded to move to the oxygen tank. R193 told the oxygen person you did not wait for my response. The oxygen person started to become defensive with the resident. The surveyor intervened and reported the incident to the director of social services. When interviewed on 5/8/15, at 9:18 a.m. the administrator validated the facility had meetings with the residents, but due to the changing of the social services department they have not had an advocate and have lost the trust which needed to be regained with the resident's. The administrator verified the facility did not have a specific policy for dignity, but staff are educated with the Residents Rights information. R135 was interviewed on 5/7/15, at 10:12 a.m. resident stated "sometimes it takes an hour for aides to come to my room." The most recent happened on 5/5/15, before lunch when R135 turned on the call light. R135 was sitting in her wheelchair at that time and was waiting to go to lunch. R135 verbalized she waited an hour before staff came to get her for lunch. On 5/7/15, at 1:01 p.m. R135 was interviewed again and further stated she had turned on her call light because she had to use the bathroom (referring back to 5/5/15). At that time, her incontinent pad was not wet. She stated her pad was wet of urine, when staff came into the room to answer the call light (which was one hour later). When R135 retold the surveyor the information, R135's tone of voice was slightly high pitched and R135's shoulders were slumped in a downward position as if R135 was disgusted. R135 was admitted to the facility on [DATE], per the Admission Record. R135's [DIAGNOSES REDACTED]. Care plan dated 6/23/14, indicated: "alteration in elimination of bowel and bladder function, functional incontinence of bowel and bladder related to bilateral cerebral infarction, diabetic ketoacidosis, [MEDICAL CONDITION] disorder with personality disorder and history of UTI's. Refused to be checked and changed every two hours, with goal to be free of UTI. Intervention was to check, change or toilet every two hours and as needed (prn). Monitor and report signs and symptoms of UTI. Risks/benefits had been explained of not following toileting plan. Used briefs/pads for incontinence protection." The quarterly MDS dated [DATE], indicated R135 was cognitively intact, and the MDS indicated moderate depression. Bowel and bladder assessment indicated frequently incontinent of urine, always incontinent of bowels, and was not on a toileting program. Functional status indicated bed mobility was one person assist; transfers were two person assist, dressing was one person assist, toileting was two person assist and hygiene was one person assist. R137 used a wheelchair for mobility. On 5/7/15, at 1:10 p.m. registered nurse (RN)-B stated sometimes residents think time has gone by longer than they realize when they wait for a call light to be answered. She provided a copy of call light log from 3/18/15, and indicated they do not do call light logs daily. RN-B further stated if a resident has a call light concern they will then do a random audit. She did not have a call light audit for 5/5/15. On 5/8/15, at 8:34 a.m. R135 was eating breakfast. When asked if she had concerns with her call light not being answered today, stated "no." Facility did not provide call light or a dignity policy.

Based on observation, interview and document review, the facility failed to ensure 2 of 3 residents (R257, R200) identified as incontinent of urine, received the necessary care and services to meet their toileting needs. This deficient practice resulted in harm for R257 who experienced an increase in urinary incontinence. Findings include: R257 was interviewed on 5/6/15, at 8:06 a.m. R257, who was assessed as cognitively intact according to the care area assessment (CAA) dated 11/17/14, expressed concern and stated, "Some of the staff here don't listen and they just don't care enough to do the job right. I will refuse cares from the staff who do not perform my cares the right way. They don't understand my arthritis and some of them don't have the patience and they push me. "The only reason I have briefs on is because I cannot get up and go to the bathroom, it is for staff convenience. I am not incontinent of urine but have been told to just go in my brief. I wait until I can get the staff to help me and then I go in my brief because it is easier for the staff." Furthermore R257 expressed there were not enough staff to get her up because a mechanical lift was used for transfers because of her weight and arthritis and the process takes too long so it was easier to "just go" in the brief. R257 said staff had told her so many times to just urinate in her brief so that she does so without asking to be toileted. R257 said when she lived on first floor they used the bedpan. R257 boldly stated "I am not incontinent, I have never been incontinent." R257 did not know why a commode or toilet had not been an option. R257 expressed "feeling sad" that the staff do not understand her pain and condition and was "afraid" they would retaliate against her for complaining and move her to third floor. R257 talked about when she was on first floor the staff offered to toilet her but since moving up to second floor there were no more offers. R257 felt like the staff treat her as if she had a "mental" condition/problem so they don't listen to her. R257 stated, "I am not treated with dignity and respect, the staff listen in on my personal conversations and turn everything against me, I feel like I am worth nothing." R257 became teary eyed when talking about arthritis pain and being a "bother" to the staff. During observation on 5/6/15 and 5/7/15, throughout various times of the day from 8:00 a.m. until 2:00 p.m., R257 was not offered a bedpan or a commode and the staff revealed they did not know R257 was to be offered toileting assistance. R257's 14 day scheduled Minimum Data Set ((MDS) dated [DATE], indicated R257 was occasionally incontinent of urine, less than seven episodes of incontinence in the week of observation. R257's MDS noted R257 was not on a toileting program. The quarterly MDS dated [DATE], indicated R257 was cognitively intact and was always incontinent of urine with no episodes of continent voiding in the one week observation period. R257 had a decline in bladder function in the last three months and was not on any toileting program to potentially restore bladder function as much as possible. R257's plan of care dated 11/10/14, directed staff, "Toileting assistance of 1-2 staff." In addition care plan dated 11/14/14, indicated "I sometimes have behaviors which include crying stating I am not crazy." The care plan did not indicate R257 had behaviors with care refusal. Although the MDS dated [DATE], had indicated R257 had rejection of care for one to three days during the assessment period the care plan did not have the care rejection. The undated aide assignment sheet directed staff, incontinent of urine and "Check and change every 2 hours." On 5/6/15, at 1:46 p.m. the full time licensed practical nurse (LPN)-D did not know about any toileting plan for R257 and implied R257 was always incontinent and wore a brief. LPN-D was not aware of offering a bedpan or commode for R257. When interviewed on 5/7/15, at 1:54 p.m. the full time nursing assistant (NA)-A referred to R257 as continent sometimes and sometimes used the bedpan and stated, "We are to offer the bedpan." When interviewed on 5/7/15, at 1:55 p.m. NA-D stated, "I have never offered to toilet (R257) because (R257) just uses the brief, I never knew about offering a bedpan or commode." When interviewed on 5/7/15, at 2:03 p.m. NA-K who worked full-time on the evening shift verified NA-K had never offered a bedpan or commode to R257 and stated, "We just change her brief. " When interviewed on 5/7/15, at 2:46 p.m. nurse manager RN-A referred to R257 as someone who just stopped doing everything because of her arthritis and many times she would not talk to staff and would just pull the covers up over her head. RN-A verified efforts were not pursued to restore or improve R257 bladder continence. R200 was observed on 5/6/15, at 7:28 a.m. in the wheelchair dressed and watching television (TV). Stated he got ready that morning. - At 2:14 p.m. R200 returned from therapy. R200 was observed on 5/8/15, at 7:26 a.m. and was groomed and dressed in clean clothing. Toileting was not observed as the resident was up already. The Minimum Data Set ((MDS) dated [DATE], identified R200 had moderate cognitive impairment, no mood indicators, no behaviors, and identified R200's behaviors had "improved;" MDS identified R200 required extensive assistance with bed mobility, transferring, dressing, personal hygiene and toilet use; and was non-ambulatory. The MDS identified used a wheelchair and had a limb prosthesis. The MDS identified R200 was "frequently" incontinent of urine. The Cognitive Loss Care Area Assessment (CAA) dated 10/24/14, indicated, "CAA triggered for cognitive Loss/Dementia. Resident appears to be alert and oriented to self, place and time. He does however have a lot (sic) of anxiety and that seems to affect his judgement/insight. Has Dx (diagnoses): [MEDICAL CONDITION], Mild Cognitive impairment, Cognitive and neurobehavioral dysfunction. At risk for neglect, falls, behaviors and mood changes secondary to safety deficits and cognitive deficits. Currently working with PT (physical therapy). Proceed to care plan." The CAA for ADL Functional/Rehabilitation Potential dated 10/24/14, indicated, "CAA triggered for ADLs (Activities of Daily Living) secondary to patient requiring assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Has a right BKA ([MEDICAL CONDITION]) and uses w/c (wheelchair) as primary mode of locomotion." The CAA identified R200 was, "At risk for isolation, falls, and behaviors causing further debilitation and discomfort." R200's MDS dated [DATE], depicted R200 as being frequently incontinent of urine (bladder). The MDS noted R200 was not on a toileting program to potentially restore bladder and/or bowel function. The MDS dated [DATE], depicted R200 as being frequently incontinent of urine and always incontinent of bowel. The MDS identified R200 had a decline in bladder function as R200 went from being frequently incontinent of bladder to always incontinent of bladder; the MDS identified R200 was not on toileting program to restore function. The Comprehensive Assessment (narrative summary) dated 2/19/15, identified R200 required extensive assist of one with transfers and assist of two with bed mobility. Did not ambulate and was working with physical therapy for to work towards being independent to limited assist of one off unit for locomotion, was frequently incontinence of bladder. The assessment did not identify if R200 was on a toileting program, lacked identification if R200 was a candidate for bladder retraining. R200's MDS dated [DATE], depicted R200 had no behaviors, had one mood indicator of feeling tired/having little energy; the MDS depicted R200 as "always" incontinent of urine. Although the assessment on 2/19/15, identified R200 was "frequently" incontinent of bowel, the care plan identified R200 was "always" incontinent of bowel. The MDS indicated R200 needed assistance from two staff for dressing, grooming, transfers, bed mobility, toileting. Although R200 had a [MEDICAL CONDITION], the MDS identified R200 had no functional limitations with range of motion (ROM). The MDS noted R200 was able to speak clearly, had no hearing difficulties, was able to make needs known, and was able to comprehend others. The MDS noted R200 had moderately impaired cognition as he did not know the year or month. The MDS indicated R200 sustained a decline in bladder function, as R200 went from being frequently incontinent of bladder to always incontinent of bladder. R200 sustained a decline in bladder and bowel function in the last six months and was not on toileting program to potentially restore bladder and bowel function as much as possible. The care plan did not identify a toileting program to potentially address R200's change in bladder continence status. The care plan did not identify R200 was not a candidate for bladder retraining. The plan of care dated as reviewed on 7/24/15, identified the facility had identified R200 was at risk for abuse due to a [DIAGNOSES REDACTED]. The care plan identified the facility was aware R200 had a history of [REDACTED]." The care plan indicated the facility had identified R200 made statements of "they hurt me," of being witnessed to have a "Hx (History) of lacking impulse control as evidenced by nursing watching (R200's name) lower self to floor to meet immediate need, i e (in example) bathroom, eating." The care plan identified the facility was aware of R200's making statements of feeling "Balled out" when staff explained safety concerns/redirection to R200. Although the care plan directed, "Let my physician know if I (sic) my behaviors are interfering with my daily living (such as bladder and/or bowel continence changes, or changes in toileting function)." The clinical record lacked evidence R200's behaviors interfered with continence or toileting function. The care plan further revealed R200 had a physical functioning deficit related to self-care impairment, mobility impairment, ROM (range of motion) limitations secondary to right below the knee [MEDICAL CONDITION]. The care plan also noted R200 needed toileting and transferring assistance of "1 to 2 persons as needed." On 5/4/15, at 5:54 p.m. during interview when asked if he felt there was enough staff available to make sure you get the care and assistance you need without having to wait a long time R200 Stated had to wait for an "Hour" or "Two hours" and "they come in here all pissed at me!" as he described being incontinent of bowel and bladder and waiting to be changed and denied being able to use toilet, urinal, or bed pan; R200 further stated he felt "dirty" and grew teary eyed and began to cry. A policy to re-approach residents after refusal of care was asked for, but not received at the time of the exit. A review of the facility policy titled, Bowel and Bladder Review dated 12/2/14, read, "To ensure that the Medical Record includes documentation that incontinent Residents are receiving care and services to restore or improve bowel and bladder functioning."