Every finding on record at The Villas at Osseo LLC

Based on observation, interview, and document review, the facility failed to ensure staff had access to a resident's locked door for 1 of 1 resident (R85) reviewed for accidents and hazards.Findings include:R85's quarterly Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment, no behaviors, was independent with walking and personal cares. Diagnoses include schizoaffective disorder and major depressive disorder.R85's care plan dated 7/7/26, included R85's behavior of locking herself in her room and self-isolating; care plan failed to include how staff would access her room in case of emergency when the door was locked.On 8/31/26 at 3:20 p.m., nursing assistant (NA)-A confirmed R85's door was always locked whether in or out of her room. NA-A shrugged her shoulders when asked how staff would access R85's room in the event of an emergency. NA-A stated staff would just knock and R85 would open the door.On 8/31/26 at 3:25 p.m., NA-B stated R85 had her own key to lock and unlock her door. When asked how staff would access the locked door, NA-B stated he would get the key from the nurse's desk.On 8/31/26 at 3:30 p.m., R85 returned to her room and used a key to unlock her door.On 9/1/26 at 9:30 a.m., nurse manager registered nurse (RN)-A, stated staff should knock twice on R85's door and R85 would unlock it. In addition, RN-A stated maintenance, nurse managers and director of nursing (DON) had a key to access R85's room. RN-A further stated there was a locked box outside of the administrator and DON offices that could be accessed in case of emergency. RN-A confirmed the code to lock box was not readily available and staff would have to call the on-call administrator to receive the code.On 9/1/26 at 9:36 a.m., licensed practical nurse (LPN)-A stated a spare key was located in the maintenance department on the lower level. LPN-B was also present and stated there was no spare key near the nurse's desk and had only been aware a key was located in the maintenance department. LPN-B confirmed this would be a concern in an emergency as the maintenance department was located on the lower level of the building.On 9/1/26 at 11:13 a.m., NA-B retrieved a key to R85's door from his personal backpack at the nurse's desk. NA-B stated he had been provided a key by maintenance when he started working at the facility.On 9/1/26 at 11:23 a.m., DON stated he had been aware R85 kept her door locked. DON stated the triple zero ( 000) key would open R85's door and was located on a key ring for each medication cart and also at the nurse's desk. DON had retrieved LPN-B's key ring and verified the 000 key was present. DON had been unable to locate the key that should have been located at the nurse's desk. DON stated he was surprised staff were unaware of the location of the keys and expected they knew. DON expected this information was included on R85's care plan.On 9/1/26 at 12:27 p.m., corporate nurse consultant (RN-B) stated she placed a key for R85's door handle lock in a drawer at the nurse's desk today. The key was observed in a drawer and had been wrapped in paper that was taped and stapled shut and was identified as key room [ROOM NUMBER] in red ink. RN-B stated an order had been placed in the electronic health record (EMR) indicating nursing staff were to check the nurse's desk for the location of 000 key each shift.On 9/1/26 at 12:32 p.m., RN-A had been aware R85 kept door locked. RN-A had been unaware staff did not know where to find the key to open R85's door. RN-A stated staff could call maintenance to open the door, however, was unaware if maintenance was in the building 24/7. RN-A confirmed the order had been placed in the EMR by RN-B because everyone needs reminders. RN-A stated she was not aware of any training provided to new staff or agency staff regarding unlocking R85s door in an emergency.On 9/2/26 at 10:14 a.m., administrator confirmed staff should have been aware of the location of keys, adding that information had been added to the care plan 9/1/26. Administrator stated this should have been covered during new employee orientation and would now be added to the checklist. Administrator confirmed it was a concern staff did not know where the key was located to access R85's room in case of an emergency.Facility Locks on Resident Room Doors policy dated 9/1/26, included the facility permits the use of privacy locks on resident room doors provided they comply with federal regulations. Under no circumstances may a lock require a key, tool, passcode, or complex combination to unlock from the inside. Master keys capable of unlocking all resident rooms must be stored at the nurse's desk at all times and the charge nurse must carry a key to ensure immediate emergency entry. Residents are to be assessed for cognitive status, safety awareness and physical capabilities and it must be explicitly documented in the care plan.No policy had been available prior to State surveyor identifying the concern.

Based on interview, and record review the facility failed to ensure residents were free from resident to resident abuse for 5 of 5 residents (R3, R5, R6, R7, & R8) reviewed when R1 had physically assaulted R3 and R5 and verbally assaulted all five residents resulting mental anguish and multiple police visits.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 14 indicating R1 was cognitively intact. R1 did not exhibit any behaviors and did not refuse cares. R1 used a walker and/or a cane for ambulation. He was independent with eating, putting on and taking off footwear, personal hygiene, rolling in bed, sitting to lying and lying to sitting. He required set-up assistance with sitting to standing, dressing and toileting. R1's pertinent diagnoses were metabolic encephalopathy (the brain does not function normally because of a medical condition), hypokalemia (low potassium levels), alcohol dependence, nicotine dependence, personality disorder and altered mental status. R3's annual MDS dated [DATE] indicated R3 spoke Ukrainian and required an interpreter. R3's BIMS score was 15 indicating no cognitive impairment. R3 had no behaviors identified. R3 used a wheelchair for ambulation. She required moderate assistance with toileting hygiene, upper body dressing and transferring. She required maximum assistance with lower body dressing. R3's pertinent diagnoses were paraplegia (paralysis of legs and lower body), anxiety, psychotic disorder, and post-traumatic stress disorder. R5's quarterly MDS dated [DATE] indicated R5 had a BIMS score of 15 indicating she was cognitively intact. R5 used a wheelchair for ambulation. No behaviors were identified. R5 was independent with hygiene, upper body dressing and transferring. Her pertinent diagnoses were depression, wedge compression fracture of her T5-T6 vertebrae (the front of the bone collapse and causes a wedge shape), chronic pain and alcohol abuse. R6's quarterly MDS dated [DATE] indicated R6 had a BIMS score of 15 indicating she was cognitively intact. No behaviors were identified. R6 was independent with dressing, personal hygiene, and transferring. She was dependent on toileting hygiene. Her pertinent diagnoses were depression, encounter for surgical aftercare following surgery of the digestive system, irritability and anger, impulsiveness and other symptoms and signs with cognitive functions and awareness. R7's quarterly MDS dated [DATE] indicated R6 had a BIMS score of 12 indicating she had moderate cognitive impairment. No behaviors were identified. R7 used a wheelchair for ambulation. R7 required maximum assistance with dressing and toileting hygiene and moderate assistance with transferring. Her pertinent diagnoses were depression, anxiety, displacement fracture of the right lower leg, nicotine dependent, and borderline personality disorder (severe emotional instability). R8's quarterly MDS dated [DATE] indicated R8 had a BIMS score of 15 indicating she was cognitively intact. No behaviors were identified. She used a wheelchair for ambulation. R3 required moderate assistance with upper body dressing, maximum assistance with lower body dressing and personal hygiene and transfers. Her pertinent diagnoses were depression, multiple sclerosis, insomnia, and muscle weakness. A police report dated [DATE] at 5:22 p.m. indicated two officers were dispatched to the facility for a disturbance between two residents. Call notes indicated in the smoking lounge back patio a male and a woman fighting and yelling at each other. Officers arrived on scene and spoke with R1, who was very uncooperative when trying to get information about what happened. He stated a female had hit his hat off and he became upset because it was a hat from a Reservation and they started arguing, He stated he never hit anyone and was just minding his own business. An officer spoke with a staff member, the business officer manager who was able to interview R3 in Russian. She stated R1 had been swearing at R3 and staff along with other residents at the facility. R3 stated R1 pulled her hair, and she would have hit him because every day he said profanities to everyone. Officers told both parties involved to stay away from each other and informed staff to keep them separated. The police supplemental report dated [DATE] at 6:15 a.m. indicated on [DATE] at approximately 5:22 p.m. two officers were dispatched to the facility due to a fight that was occurring in the back smoking patio. Upon arrival, R1 was in a wheelchair and across the street from the patio where the alleged fight happened. Officers tried talking to R1, but he appeared to be intoxicated by the smell of the odor of consumed alcoholic beverages, and he had red blood shot eyes. R1 was very uncooperative with officers and made several comments about this being his land and that he could go anywhere he wanted to. He also told officers that his hat was knocked off his head and that no one disrespects a Reservation hat like that. At this point another officer went to speak to the other party involved (R3). R1 later said that R3 was a white Bitch and that she had told him to get his black ass out of this country and that he told her he was not black and was red. This was when R3 walked up to him and slapped his hat off his head. A short time later, the officers were advised that R3 did not speak English and that things never got physical, but she did intend to pull R1's hair and that is when his hat fell off. R1 was told R3 did not speak English and asked why he told me she had said those things to the officer. R1 stated that he does not need to understand anyone's language to know what they are saying to him. At that point officers advised both parties to stay away from each other, which they agreed. A facility investigation document, undated, by the business office manager indicated on [DATE], around 5:30 p.m. the admission coordinator, the culinary director, and the business office manager were called up to the patio due to a resident altercation. They walked out to the smoking patio and in the far corner saw R1. R1 stated R3 grabbed his hat and threw it down on the floor. He stated she did this because she was racist against Native Americans. He continued to swear throughout the conversation, stating that he was here before all of them. They went back inside to meet with R3 and found her coming out of the elevator. She stated that R1 had been verbally abusing all the women at the facility, residents and staff included. She stated she did not touch his hat; it flew off because she pulled his hair and slapped him. She then followed the staff outside, where they saw two police officers speaking to R1 by the next to the assisted living door. One officer walked over and took R3's statement with the business office manager translating. R3 told the officer that she pulled R1's hair and slapped him, and that if staff had not intervened, she would have punched him as well. R5 told the officer that she would be calling the police until they did something about R1. The officer who was talking to R1 walked over to the smoking patio door, discussed the situation with the other officer. They came to the staff to say that their hands were tied because R1 was in their custody. Police officer report dated [DATE] at 6:51 p.m. indicated an officer was dispatched to a disturbance at the facility. R11 reported that a native man in the wheelchair, referring to R1, had been out on the smoking patio harassing the other residents, calling them bitches, [NAME] and cunts. He also stated that he went over to the assisted living behind the facility to hang out with a resident over there and she provided alcohol to him. The officer went over to the smoking patio where he was given the following information from the following residents: -R5 stated to the officer that R1 had been hostile to the residents and staff at the facility by yelling at everyone, calling them Fucking Cunts. R5 stated R1 was trying to kick her from his wheelchair. R5 was standing behind her wheelchair when R1 kicked her wheelchair causing it to jam her into the stomach. R5 then stated that R1 fell over from all the kicking. R5 stated that this all happened 1 hour before the officer arrived.-R6 stated to the officer that R1 had been verbally threatening her and calling her a Cunt. R6 stated that on [DATE] R1 had told her I am going to kill you, you fucking cunt he also told her that he had people in the city that will take care of her. R6 stated that she had been worried that R1 would act on those threats and had trouble sleeping that night.-R7 stated to the officer that R2 had been cursing everyone out the last couple of days and called her a Bitch, Cunt and whore. R7 stated R1 was going to try and shove her wheelchair but ended up kicking R5's wheelchair to the point that the wheelchair went into R5's stomach.-R11 stated to the officer that R1 has been very hostile and threatening. He stated that R1 told him to get away from him or he would beat him up when he was not near him. R11 stated R1 called him white boy and all sorts of other derogatory names and told him to get off his land. R1 had threatened to beat him up and kill him multiple times.-All the residents then stated R1 had been telling everyone that all the land because he was native, they needed to get off his land, and he could do whatever he wanted.-R8 stated to the office that R1 threatened to beat up R11 and has been calling everyone derogatory names.-The officers requested an emergency medical hold for a mental health evaluation due to the recent involvements of combative and disruptive assaultive conduct causing fear of death and bodily harm to other residents resident in the facility. Dispatch requested an ambulance to the facility. An Officer arrived on scene and completed the Emergency Medical Hospitalization form. R1's nursing note dated [DATE] at 6:40 p.m. indicated today at around 5:30 pm, writer was called and informed that there is an outburst between two residents. As reported by resident from room R3 and translated by the Business Manager. R3. stated that while attempting to access the elevator, resident R1 repeatedly blocked her path while yelling insults, cursing, and using profane language including multiple F words. Resident R3 further reported that the verbal confrontation escalated into a physical altercation which continued to the smoking zone, during which both residents pulled each other's hair and slapped one another. R3 continued to report that the same happened yesterday in the smoking zone with the same resident but did not generate to physical outbursts, At the time this note was entered, R1 did not provide his version of events and continued yelling and using inappropriate language toward staff and others present. Due to the escalation and aggressive behavior displayed, police were contacted by one of the residents who had witnessed and responded to the facility. The social worker, business manager, and dietary director were present and witnessed the collection of statements from involved parties and witnesses. R3 was able to be separated for safety. R1 was very aggressive and could not agree to go to his room to calm the situation. The situation was reported to the on-call nurse manager, and monitoring will continue. Further follow-up and assessment will be completed as needed. R1's nursing note dated [DATE] at 8:43 p.m. indicated from around 4:00 p.m. R1 exhibited combative and disruptive behavior, this included yelling profanities, making both verbal and physical threats toward staff and other residents. R1 was noted using abusive language in the hallway and in the smoking zone area, he was more verbally aggressive when approached regarding facility rules and safety measures. Multiple attempts were made to redirect and de-escalate the situation were not effective. Resident remains noncompliant with the required supervised smoking and any attempts to remind him about them were futile, he repeatedly went out to smoke without staff supervision. Staff continued to monitor residents closely, provided verbal redirection, and reinforced facility expectations. Manager on duty was notified, On-call provider was updated via vital care, and she ordered 1-time 50 mg trazadone. R1's nursing note dated [DATE] at 8:57 p.m. indicated the writer was called to the smoking area, upon getting there, writer noted the R1 seated on the ground, residents (witnesses) who were smoking reported that he was trying to charge at one of them but slipped off his wheelchair, R1 was verbally aggressive, yelling at staff and refusing assistance. A skin tear was noted on the right shin, bleeding present. Staff attempted multiple times to assess the injury, provide first aid, and assist R1 from the ground; however, R1 repeatedly refused all attempts and continued to use hostile language toward staff. Charge nurse and provider updated. R1's nursing note dated [DATE] at 9:09 p.m. indicated at around 8:20 pm, writer was notified that one of the residents had contacted law enforcement with concerns of the R1's behaviors towards them. Police responded to the facility and assessed the situation, took statements from both staffs and residents, the police contacted emergency medical services and R1 was evaluated on-site, due to aggressive behavior and safety concerns, R1 was transported for further psychiatric and medical evaluation. R1's family did not answer when contacted. R1's nursing note dated [DATE] at 9:31 p.m. indicated staff was called to the smoking area, upon getting there, writer noted R1 on the ground, residents (witnesses) who were smoking reported R1 was trying to charge at one of them but slipped off his wheelchair, resident was noted to be verbally aggressive, yelling at staff and refusing assistance. A skin tear was bleeding on the right shin. Staff attempted multiple times to assess the injury, provide first aid, and assist the resident from the ground; however, R1 repeatedly refused all attempts and continued to use hostile language toward staff. The charge nurse and the provider were updated. R1's hospital note dated [DATE] at 1:59 a.m. indicated R1 arrived at the emergency department at 8:47 p.m. related to a fall from a wheelchair. R1 had a history of alcohol dependence, major depression, and personality disorder, cerebrovascular accident with residual deficits and hypertension. R1 reported he ran over a rock and fell backwards in his wheelchair striking the wall, hitting his head, his shine and lost consciousness. An x-ray was taken of his leg, and a head scan was completed with no concerns for injury. R1 was discharged back to the facility. R1's nursing note dated [DATE] at 10:12 p.m. indicated hourly safety checks were completed. R1 spent most of the evening outside in the smoking area. R1's nursing note dated [DATE] indicated the interdisciplinary team (IDT) met to discuss R1's behavior and recent police report received. R1 was placed on 1:1 staff/resident supervision for behavior management and safety. The DON notified the provider. The facility investigation on [DATE] documented by the culinary director indicated an unidentified culinary aide called the culinary director to come out to the patio as two residents were having an altercation. All three members in the business office reported to the scene. R3 had already left the patio area and was back upstairs. R1 remained on the patio. He was very agitated about the situation. R1 claimed that R3 grabbed his hat off his head and threw it to the ground. He stated R3 was racist against Native Americans. He stated his people fought and died on this land; they were here first. He continued to speak with many obscenities, calling R3 a bitch and a cunt. He even threw his own hat on the floor numerous times in demonstration for the event that occurred. The three staff members all tried to deescalate the situation. R1's obscenities turned towards the three of them. Telling them that we do not belong here. His people were here first. The staff attempted to ask the residents on the patio about the incident, but they were too afraid to comment on the situation. Staff went inside the facility as R1 had settled down a bit. He remained on the patio, and R3 was on her way back out to the patio. R3 spoke with the business office manager who spoke Russian about the situation. They all headed back out to the patio when staff noticed the police were present. The social worker (SW)-A joined them to gather information on the situation. The business office manager translated R3's statement to the police officer. The other officer was meeting with R1 across the parking lot. R5 stated that she would continue calling the police on R1 until he was taken away. The officer suggested they try to keep the residents separated. The staff had a quick team call in the social worker's office to discuss interventions involving R1's guardian. A facility investigation report documented on [DATE] by the admission coordinator indicated on [DATE] at approximately 5:20 pm, the Culinary Director received a call from one of her staff members requesting immediate assistance for a resident altercation that was taking place on the smoking patio. The director asked for assistance go with her as they did not know the severity of the situation. When the three staff arrived at the patio other staff had already intervened. R1 was still on the smoking patio, visibly upset. When trying to get R1's statement of the incident, he was rambling about being a Native American and being here first. He stated that R3 ripped his hat off and threw it on the ground calling her a cunt and fucking bitch. He continued to use offensive language throughout the conversation, avoiding direct answers to the questions he was being asked about the incident, continuously calling R3 a cunt and fucking bitch and repeating I'm Native American and was here first! Staff told R1 that she wanted to listen and get his story but requested that he speak respectfully. R1 responded by telling them to shut the fuck up and called them fucking cunts. The three staff then went to exit that patio and asked other residents that were on the patio if they saw what happened. They stated yes but were scared to speak with R1 on the patio. They went inside to speak with R3, meeting her at the back entrance as she was exiting the elevator. The business office manager translated for (SW)-A. During their conversation she saw two police officers pull into the back parking lot, speaking to R1 in the courtyard of the assisted living. R5's social service note dated [DATE] at 8:23 p.m. indicated Social Services (SS) followed up with the resident regarding a police report involving R1. R5 confirmed the report and answered yes/no when asked whether she felt safe at the facility, because of R1. She stated that the involved resident did not personally threaten her. R5 denied emotional distress or suicidal thoughts but reported feeling mentally stressed. SS reassured R5 and informed her of current interventions, which she indicated were helpful. TR5 declined psychological services. BIMS score: 15/15, indicating intact cognition. PHQ-9 score: 2/27-indicating minimal depression. SS will continue to support R5. R6's SS note dated [DATE] at 8:20 p.m. indicated Social Services followed up with R6 due to a police report involving R1. R6 confirmed the report, stating, he's all talk, but added, I think he could hurt me, but not my family. R6 reported feeling afraid of R1 when alone with him on the smoking patio. R6 denied emotional distress, stated she feels safe at the facility, and is doing well, but became teary when asked for consent to notify her daughter (POA). R6 declined to notify any of her family members, stating, I trust you people at the facility that you will take care of things. The SS provided reassurance and reviewed current interventions, which the resident appreciated and noted helped her a lot. R6 utilizes psych services with ACP. BIMS score: 15/15, indicating intact cognition. PHQ-9 score: 0/27, indicating no depression. R1's nursing progress note dated [DATE] at 1:59 a.m. indicated R1 was physically very aggressive, hit staff twice, smoked in his room and was exit seeking when told doors were locked at 11:00 p.m. Cigarette butts were removed from his room. He was loud and aggressive to the point disturbing other residents. A virtual call was placed to on call Medical Doctor (M.D.) to request a transfer order. The order was received and R1 was sent to the hospital for behavioral disturbance. Upon interview on [DATE] at 9:40 a.m. the culinary director stated one of her staff called her on [DATE] to ask for her assistance as there was a resident-to-resident altercation on the patio. She stated R3 left the area and R1 was still on the patio upset. The other residents stayed very quiet. She did not interview any of the residents. She stated she was aware that R1 was put on 15-minute staff checks for a day, then 30-minute staff checks for a day, and the hourly staff checks for a day. She stated she was not aware of R1's altercation on [DATE]. Upon interview on [DATE] at 11:17 a.m. via professional Russian interpreter R3 stated R1 assaulted all the woman with very rude and cursing American words. She stated staff did follow-up with her and told her R1 would have staff with him all day, but that had not stop him for still cursing at the staff and residents. In a subsequent interview on [DATE] at 9:30 a.m. she stated the following evening R1 threw a chair outside. She was not certain which resident it was meant to hit but it was thrown in the direction where the residents were sitting. In addition, R1 disturbed her sleep as he is up all hours of the night going down the hallway, cussing loudly at the staff who are following him. R3 felt safe at the facility but stated her anger had worsened when R1 started with his abusive actions. Upon interview on [DATE] at 11:37 a.m. R5 stated she called the police when R1 and R3 were fighting and would continue to call the police even though staff had asked her to notify them. She stated the facility plans did not work as R1 still cussed at residents and residents did not feel safe. He attempted to kick her and her wheelchair got pushed into her stomach. She did not have any pain and stated no bruise occurred. In a subsequent interview on [DATE] at 11:22 a.m. she stated R1 threw a chair and yelled at her on the evening of [DATE]. R1 was upset because he thought she was calling the police on him trespassing on the assisted living property. R5 stated R1 would sit on the facilities edge of the property and get alcohol from his girlfriend at the assisted living and the 1:1 staff would not intervene. She stated she would feel safer if R1 was gone. R5 and her friends make sure they use the buddy system when going to smoke in case R1 showed up. Upon interview on [DATE] at 12:10 p.m. nursing assistant (NA)-A stated she had worked as the 1:1 staff with R1 and it is difficult to tell if he is cussing and screaming at staff or residents because he yells at everyone in his vicinity. Upon interview on [DATE] at 12:30 p.m. R6 stated about two weeks ago R1 got right in her face and yelled he was going to kill her and her family. R6 stated she has had trouble sleeping. She was concerned about her family because she felt R1 had people who could kill them, but she told herself over-and-over that he did not know her family to calm herself down and attempt to sleep, but he could have someone hurt her. He is threatening. Upon interview on [DATE] at 12:44 p.m. R1 stated he had been uptight and frustrated because he wanted to move. He stated he was confused and denied anyone bothering him. R6 stated his mind spins, and he did not know what to do. The woman is probably scared of him. He never used to be like that. He never treated girlfriends the way he treated the women at the facility. R6 stated his reason was [NAME]-up frustration. He had been in jail and prison, and nobody followed him around 24 hours a day. If staff continued to follow him, he would lash out and fight someone even worse than he had already. He stated his frustrations come from the Native American people being ridiculed for 300 years. Upon interview on [DATE] at 1:35 p.m. R7 stated she has been assaulted and harassed by R1 multiple times. Just yesterday she mentioned to R1 that his girlfriend was not allowed on the facilities property anymore and R1 got right up in her face and called her a fucking cunt, that he was going to kill her and to stop calling police on him because he owned the land. R7 stated she feared R1. Upon interview on [DATE] at 8:45 a.m. the business office manager stated she did not know R3 well but had interpreted for her a few times. She stated R3 was a very angry woman due to her injury and past history . R3 stated to her that the situation with R1 exacerbated her anger and she wanted to protect the older women at the facility because they were vulnerable and like mothers to her. Upon interview on [DATE] at 11:19 a.m. SW-A stated the facility was trying to relocate R1. She stated R3 had anger issues, and she had calmed down, however she had been more frustrated with incidents involving R1. R5 had increased anxiety after the incident as she was the other one physically assaulted by R1. SW-A is continuing to give her support. R6 told the SW that everyone wants R1 out of the facility, she felt safe, but not alone with him. She felt R1 might do something, but killing was a bluff. (SW)-A did not speak with R7 that the Administrator summer intern did. R8 was just hospitalized for her own drinking so it was hard to identify her thoughts following the verbal abuse and witnessing abuse by R1. Upon interview on [DATE] at 1:32 p.m. R1's Nurse Practitioner stated she had attempted to put a 72-hour hold on R1 at the hospital, but the hospital sent him back each time within hours. She asked what the state of Minnesota was doing with residents like R1 who have disruptive behaviors and the facility had exhausted all efforts. Who was to take care of this type of individual, shouldn't the state have facilities for them? Upon interview on [DATE] at 2:55 p.m. NA-B stated he had worked with R1 on [DATE] and witnessed him throwing a chair, which was toward the residents, but he was not able to indicate who it was directly meant for; however, he felt it was to R5 because R1 then shouted and cussed at her on the outside patio. R1 continued to yell at staff and residents even with his 1:1 in place. Upon interview on [DATE] at 3:10 p.m. the director of nursing (DON) stated the first incident with R1 the facility put him on 15-minute staff checks for 24 hours, then 30-minute staff checks for 24 hours, and finally hourly staff checks for 24 hours. Upon his second incident the staff placed him on 1:1 staff supervision. He was aware that R1 continued to be aggressive with hitting and cussing at staff but was denied any knowledge of continued aggression with the residents. A facility policy titled Abuse Vulnerable Adult Policy with a revision date of 11/2025 indicated the purpose was to protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse. To promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. To promptly investigate, report and determine probable cause of unknown origin injuries. To identify and remedy any potentially abusive situations.

Based on interview and record review the facility failed to develop the care plan for 1 of 1 resident (R1) review for care plan. R1 was placed on 1:1 staff supervision with specific interventions that were not on added to his care plan.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 14 indicating R1 was cognitively intact. R1 did not exhibit any behaviors and did not refuse cares. R1 used a walker and/or a cane for ambulation. He was independent with eating, putting on and taking off footwear, personal hygiene, rolling in bed, sitting to lying and lying to sitting. He required set-up assistance with sitting to standing, dressing and toileting. R1's pertinent diagnoses were metabolic encephalopathy (the brain does not function normally because of a medical condition), hypokalemia (low potassium levels), alcohol dependence, nicotine dependence, personality disorder and altered mental status. R1's care plan dated 6/9/26 indicated R1 was At risk for alteration in mood and behavior r/t dx including Metabolic Encephalopathy, Alcohol Dependence, Depression, Personality Disorder Unspecified. Behaviors: -resident, at times, prefers to eat meals in his room. -like to take longer naps. -history of refusing care. -frequently ruminates on leaving the facility -mood disturbance is characterized by irritability and agitation consistent with his personality d/o and depression symptoms. -occasional verbal outburst -potential for physical aggression. -denial of his current health condition and need for a structured facility. Staff was encouraged to use a patient-centered, non-confrontational approach, collaborative language, validation of the resident's perspective, participation in decision-making, and reinforcement of his progress toward independence. R1's interventions were: MDS section D/PHQ 9 (depression screening) will be conducted per regulation and PRN.Monitor and document mood state/behaviors upon occurrence.Praise positive behaviors [All]Approach in a calm manner and provide resident with choices as appropriateRedirect as needed (prn).If resident becomes anxious, remove from crowded area.utilization of social supports.Staff to visit with resident one on one during cares and prn.Provide emotional support, validation, and comfort measures prn.Monitor Target Behaviors per protocol.PSYCHOSOCIAL WELL-BEING CARE PLAN: Alteration in psychosocial well-being r/t adjustment to placement and current health condition. Resident is Native American, Red Lake Nation. The resident has a supportive and involved family; the guardian recommended an ALF closer to the family. The resident has a strong desire for independence. Autonomy is a central value and motivating factor in recovery. Emphasize autonomy by offering choice whenever possible (e.g., scheduling daily activities and aspects of care) to promote a sense of control. Will monitor safety concerns and evaluate PRN: smoking, elopement, suicide riskIntroduce resident to staff and residents.Encourage resident to attend activities of interest for socialization and enjoyment.Will provide 1:1 visits to encourage verbalization of feelings, offering support and reassurance, PRN.Will invite resident and family to care conferences quarterly.Will monitor and respond to unmet needsEncourage utilization of social supports.Will monitor mood state, refer PRNWill monitor adjustment and relationship issues in facilityR1's care plan did not indicate R1 was receiving around the clock 1:1 staff supervision or specific interventions regarding the supervision. A facility investigation report dated 5/29/26 indicated 1:1 staff supervision was initiated on R1 upon the Administrator receipt of the police report. The intradisciplinary team (IDT) would re-assess and titrate. On interview on 6/10/25 at 3:38 p.m. the director of nursing (DON) stated after R1's first physical and verbal altercation he was placed on 15-minute staff checks for 24 hours, then 30 minute checks for 24 hours and finally hourly checks for 24 hours. When R1 had his second altercation he was placed on 1:1 staff supervision around the clock. R1 was upset with the supervision, so staff was to sit outside of his door and go with him wherever he went throughout the facility and outside. A facility policy regarding care planning was not obtained.

Based on observation, interview, and record review the facility failed to maintain a clean comfortable homelike environment for 1 of 3 residents (R4) reviewed for home like environment.Findings include: R4's admission Minimum Data Set (MDS) dated [DATE] was not completed as R4 was only at the facility for approximately 24 hours. R4's nursing progress note dated 6/4/25 at 5:55 p.m. R4 was admitted from the hospital via emergency medical services accompanied by family member (FM)-A. R4 required assistance of one staff member for mobility and daily care needs. R4 was nonverbal. A video uploaded date of 6/5/26 at 10:30 a.m. revealed R4's window with two black ants crawling along the windowsill. A facility grievance form dated 6/8/26 indicated the date of Incident: 6/4/2026. Specific Location Where Incident Occurred: Resident room, entrance. Incident Description: Resident admitted to facility 6/4/26. Family members had complaints alleging that there was no staff to greet them immediately upon arrival. They expressed concern that there was not an air conditioner (AC) unit in the room. They expressed that the resident often swung his legs out of bed, and it is enough force to cause him to fall out of bed. They were concerned that he would not be offered thicken fluids as often as he should be. They were concerned that the staff would not keep the head of his bed elevated. Family alleged that he was not served breakfast. They had had other miscellaneous complaints such as the paint chipping in the drawers, broken nightstand drawer, smell of bathroom, etc. Family alleged to the director of nursing (DON) that there were ants in the room and questioned mouse droppings in wardrobe drawer. Upon observation on 6/8/26 at 11:15 a.m. the room R4 was in had two beds and two bedside tables. The bed closest to the door had rust on the bed frame. The bedside table next to the bed R4 used had paint peeling in the top drawer. The bottom panel in the middle drawer was detached from one of the sides. The middle drawer also had visible stains and peeled paint. The bottom drawer did not have a bottom panel attached anymore. R4's wardrobe drawer was covered with small black dry flakes and chunks of irregular shapes and sizes, with the largest approximately 2 millimeters x 2 millimeters, they crumbled upon wiping a few with a Kleenex. There was no odor in the drawer. R4's bathroom, a shared bathroom with two male residents in the next room had a strong stale urine odor. The interior windowsill had dirt along the length of the windowsill. It appeared to be dirt as upon wiping a small area with a Kleenex the color was dark grey; it wiped away easily and left a clean surface underneath. Upon interview on 6/8/28 at 1:18 p.m. FM-A stated R4 was on hospice with only a short time of life remaining and the room he was admitted to was unlivable. She stated she saw ants crawling on the windowsill, the room was hot, but the staff brought a fan. She could not put R4's clothing items away in the drawers because the bedside table was broken, dirty, and had chipped paint. The wardrobe drawer was full of mouse droppings. The odor coming from the bathroom was so strong she kept the door shut however she still could not dismiss the odor. Due to no other option she had to leave R4 there overnight but had him discharged the following day due to her environmental concerns. She stated she had other care concerns, but she felt those could have been taken care of once the staff got to know R4. Upon observation and interview on 6/8/26 at 3:18 p.m. licensed practical nurse (LPN)-A the assistant director of nursing observed R4's where she witnessed the broken drawers, the peeled paint and debris in the drawers, rust on the bed frame, the dirty windowsills, and the odor. She stated she did receive a grievance from R4's family about the environment of the room and stated rooms are supposed to be checked prior to admission. Upon interview on 6/8/26 at 4:33 p.m. registered nurse (RN)-A, a hospice nurse stated she did not go into any of the drawers in R4's room so she did not have any knowledge of those conditions. She did notice the room was warm and there was a heavy urine odor permeating. Upon observation and interview on 6/9/26 at 9:15 a.m. the Administrator observed the bathroom and agreed there was a urine odor. Upon interview on 6/10/26 at 9:18 a.m. R9 the resident who had a shared bathroom with R4 stated he did not need to use the bathroom notice. He did notice an odor when his roommate used the bathroom or when the door was open. Upon interview on 6/10/26 at 9:25 a.m. R10 the resident who also shared the bathroom with R4 stated he did use the bathroom and noticed an increase in odor over the past weeks as the weather got hotter. Upon observation on 6/10/26 at 9:35 a.m. the bathroom had a lemon cleansing odor along with the stale urine odor. Upon observation and interview on 6/10/26 at 9:46 a.m. the Administrator agreed the urine odor still existed and stated the facility would need to use a deodorizer in the bathroom. A policy for safety and homelike environment was requested; however, none were provided.

Based on interview and document review the facility failed to provide pain management in accordance with the resident's new physician's orders to a resident experiencing pain for 1 of 3 residents (R1) reviewed for medication administration. Findings include:R1's hospital Discharge summary dated [DATE], identified R1's primary diagnoses included type two diabetes mellitus, acquired absence of right leg below knee (BKA), acute on chronic left lower extremity (LLE), rheumatoid arthritis with rheumatoid factor, and peripheral vascular disease.R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment and was receiving pain medications.R1's care plan dated 5/8/26 identified a focus of alteration in comfort related to left lower extremity pain with staff interventions included providing non-medicinal forms of pain relief such as positioning, rest, massage, etc; administering pain medication as ordered by the provider, and documenting the effectiveness of the pain medication.R1's physician order dated 5/20/26 instructed:- to discontinue oxycodone 10 mg.- to administer hydromorphone (use to manage moderate to severe pain) 4mg per mouth (po) one time only for left foot pain.-to start hydromorphone 4 mg po every 4 hours as needed for left foot pain.Review of May 2026 medication administration record (MAR) showed R1 did not receive any doses of hydromorphone 4 mg from 5/20/26 through 5/21/26.R1's medication incident report dated 5/21/26 at 11:45 a.m., indicated the facility failed to timely transcribe the hydromorphone 4 mg every four hours as needed order and failed to transcribe the hydromorphone 4 mg one-time order as per physician's order on 5/20/26.R1's progress note dated 5/21/26 at 6:55 a.m., indicated R1 had complained of pain and was administered oxycodone 10 mg as needed (PRN) along with acetaminophen (Tylenol). The note further indicated R1 was transferred to the hospital per family request for pain control. However, review of R1's clinical record did not evidence whether the administered pain interventions were effective or whether R1's response to the medications was assessed and documented prior to transfer.During an interview on 06/03/26 at 11:19 a.m., Registered Nurse (RN-A) stated she was not aware of R1's hydromorphone 4 mg one-time order. RN-A reported R1 was frustrated regarding her wound and was consistently experiencing pain. RN-A further stated she was uncertain whether the previously ordered oxycodone 10 mg should have been discontinued and whether hydromorphone 4 mg every four hours was intended to replace it.During an interview conducted on 6/3/26 at 1:49 p.m., RN-C stated when a resident reports pain, nursing staff should assess the location of the pain and determine the severity using a 0 (no pain) to 10 (severe pain) scale. RN-C further stated non-pharmacological interventions should be offered prior to administering pain medication. She added the nurse should reassess the resident at a later time to evaluate the effectiveness of the intervention. RN-C explained she was unable to locate documentation indicating why hydromorphone 4 mg was not administered to R1 as ordered. RN-C confirmed failure to administer hydromorphone 4 mg to R1 as prescribed constituted a medication error.During an interview on 6/3/26 at 10:39 a.m., Nurse Practitioner (NP-A) stated she expected the nurse to administer the one-time dose order immediately as prescribed. NP-A explained R1 was experiencing severe pain in the left lower extremity (LLE) and the treatment plan was to transition from oxycodone 10 mg to hydromorphone 4 mg every four hours to achieve improved pain control. NP-A further stated she faxed the new order to the pharmacy and confirmed the facility was aware of the change. However, NP-A indicated she was unable to locate documentation in R1's medical record confirming hydromorphone 4 mg had been administered as ordered.During an interview on 6/4/26 at 4:04 p.m., the Director of Nursing (DON) stated he expected nurses to follow physician orders. The DON confirmed the hydromorphone 4 mg one-time dose, as well as the hydromorphone 4 mg every four hours, were not administered as ordered on 5/20/26. The DON further stated RN-A did not return his call for interview.The Pain Management Protocol dated 3/23/2025 directed the provider to order appropriate medication interventions to address individuals' pain and for the staff to evaluate and report how much and how often the resident utilizes PRN pain medication. It also directed staff to notify the provider if the prescribed medications are not available or there is a delay in obtaining the medication.

Based on interview and record review, the facility failed to timely transcribe the physician's new orders to initiate a pain management therapy for 1 of 3 residents (R1) reviewed for medication administration. Findings include:R1's hospital Discharge summary dated [DATE], identified R1's primary diagnoses included type two diabetes mellitus, right leg below knee amputation (BKA), acute on chronic left lower extremity (LLE), rheumatoid arthritis with rheumatoid factor, and peripheral vascular disease.R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment and was receiving a pain medication.R1's physician order dated 5/20/26 instructed:- to discontinue oxycodone 10 mg.- to administer hydromorphone (use to manage moderate to severe pain) 4mg per mouth (po) one time only for left foot pain.-to start hydromorphone 4 mg po every 4 hours as needed for left foot pain.R1's facility physician orders that were transcribed into electronic health record (EHR) did not include orders for hydromorphone 4 mg one time only or hydromorphone 4 mg every 4 hours as needed per physician order dated 5/20/26.Review of R1's physician orders dated 5/20/26 revealed that orders for hydromorphone 4 mg one-time dose and hydromorphone 4 mg every 4 hours as needed (PRN) were not transcribed into the facility's EHR, resulting in the EHR not accurately reflecting the physician's prescribed medication orders.Review of May 2026 medication administration record (MAR) showed R1 did not receive any doses of hydromorphone 4 mg as prescribed from 5/20/26 through 5/21/26.Review of R1's medication incident report dated on 5/21/26 at 11:45 a.m. revealed the facility failed to accurately and timely transcribe physician orders for hydromorphone. Specifically, a physician order dated 5/20/26 for hydromorphone 4 mg every four hours as needed (PRN) was not transcribed in a timely manner, and a separate one-time order for hydromorphone 4 mg was not transcribed as ordered. As a result, the facility failed to ensure physician medication orders were implemented according to prescribed directions.R1's progress note dated 5/21/26 at 6:55 a.m., indicated R1 had complained of pain, she was administered oxycodone as needed, Tylenol, and was transferred to the hospital per family request for pain control.During an interview on 6/3/26 at 9:31 a.m., pharmacy technician (pharm tech)-A stated R1's hydromorphone 4 mg was delivered to the facility on 5/20/26 at 6:00 p.m. Pharm Tech-A explained a registered nurse (RN)-A signed for receipt of the medication at the time of delivery.During an interview on 6/3/26 at 11:19 a.m., RN-A stated medications were administered per physician orders. RN-A recalled receiving R1's hydromorphone 4 mg delivery on 5/20/26 and securing it in the narcotic book. However, she did not recall receiving the one-time physician order for the medication. RN-A explained she did not transcribe the hydromorphone 4 mg order into the EHR and did not co-sign the order for R1 on 5/20/26.During an interview on 6/3/26 at 4:44 p.m., RN-B explained new physician orders must be transcribed into the EHR and cosigned by a second nurse before becoming available in the MAR for administration. RN-B further stated medications will populate in the MAR for administration based on the documented start date entered during transcription.During an interview on 6/3/26 at 9:08 a.m., a nurse practitioner (NP)-A stated one-time dose medications are expected to begin on the day they are ordered. NP-A reported she was at the facility on 5/20/26 when she found R1 crying in pain. After assessing R1, NP-A issued new orders for a one-time dose of hydromorphone 4 mg, discontinued oxycodone 10 mg, and initiated hydromorphone 4 mg every four hours for left leg pain. NP-A further stated on 5/21/26, the director of nursing (DON) informed her that the 5/20/26 orders had not been transcribed into the EHR, and R1 had been sent to the hospital at the family's request for pain management.During an interview conducted on 6/4/26 at 4:04 p.m., the DON confirmed R1's new physician orders dated 5/20/26 were not entered into the EHR until 5/21/26. This delay occurred after R1 had already been transferred to the hospital for pain management. The order for hydromorphone, which was scheduled to begin on 5/20/26 at 6:00 p.m., was not initiated as ordered. As a result, R1 experienced a delay in receiving the prescribed medication, resulting in missed doses.The Medication and Treatment Orders policy dated 2/2024 instructed orders for medications and treatment will be transcribed accurately and in a timely manner. Orders must include:Name and strength of the drug.Number of doses, start and stop date, and/or specific duration of therapy.Dosage and frequency of administration.Route of administration.Clinical condition or symptoms for which the medication is prescribed; andAny interim follow-up requirements.

Based on interview and document review, the facility failed to notify the physician and or the resident representative timely for 2 of 3 residents (R1,R4) reviewed for change in condition. Findings include:R1's hospital Discharge summary dated [DATE], identified R1's primary diagnoses included type two diabetes mellitus, acquired absence of right leg below knee (BKA), acute on chronic left lower extremity (LLE), rheumatoid arthritis with rheumatoid factor, and peripheral vascular disease.R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had no cognitive impairment and was receiving a pain medication.R1's care plan dated 5/8/26 identified a focus of alteration in comfort related to left lower extremity pain with staff interventions included providing non-medicinal forms of pain relief such as positioning, rest, massage, etc; administering pain medication as ordered by the provider, and documenting the effectiveness of the pain medication.On 5/21/26 at 6:55 a.m., R1's progress note indicated the resident complained of pain and was administered oxycodone 10 mg as needed (PRN) along with acetaminophen (Tylenol). The documentation further indicated R1 was transferred to the hospital per family request for pain control. However, review of the clinical record did not evidence whether the administered pain interventions were effective or whether R1's response to the medications was assessed and communicated to the provider timely prior to transfer.Review of the provider call logs dated 5/20/26 through 5/21/26 showed no evidence the provider was notified regarding R1's missed doses of ordered hydromorphone, reports of unmanaged pain, and transfer to the hospital for pain control.R4's hospital Discharge summary dated [DATE], identified R4's primary diagnoses included confusion, frequent falls, dementia, chronic low back pain, and generalized weakness.R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment and required partial/moderate assistance for toileting and transfers.R4's care plan dated 10/6/25 identified a focus of alteration in mood and behavior, resident expresses agitation during cares. Staff interventions included monitor and document mood state/behaviors upon occurrence, if resident becomes anxious, remove from crowed area, reorientation, and supervision as needed. Keep MD or PA informed of changes.R4's x-ray results right wrist, two views dated 10/19/25 at 7:14 p.m., identified R4 had a distal ulnar fracture.R4's incident review and analysis, dated 10/20/25, indicated that on 5/18/25 at approximately 12:00 p.m., R4 attempted to stand and ambulate without assistance. Staff instructed the resident to sit down for safety; however, R4 became agitated and forcefully slammed her right hand/arm onto a chair in the lunchroom, resulting in a major injury. The injury was characterized by redness and swelling of the right hand. Although the incident resulted in a major injury, the record did not indicate whether the resident's representative was notified at the time of the incident.On 10/18/2025 at 10:39 p.m., a progress note documented that R4 was observed to have swelling and redness in the right wrist area. The note indicated the provider was notified. However, a review of R4's medical record did not contain documentation demonstrating that the resident's representative was notified of the change in condition or the incident. During an interview on 6/3/26 at 10:39 a.m., Nurse Practitioner (NP-A) stated R1 was experiencing severe pain in the left lower extremity (LLE). NP-A explained, on 5/20/26, the treatment plan was revised to transition R1 from oxycodone 10 mg to hydromorphone 4 mg every four hours in an effort to achieve better pain control. NP-A further stated she faxed the new medication order to the pharmacy and confirmed the facility had been notified of the change. NP-A indicated she was unable to locate documentation in R1's medical record verifying hydromorphone 4 mg had been administered as ordered. Additionally, NP-A stated she could not confirm whether the on-call provider had been notified when R1 experienced a change in condition.During an interview on 6/2/26 at 2:25 p.m., Family Member (FM)-A stated she had never received a phone call or any update from the facility regarding R1's change in condition.During an interview on 6/2/26 at 2:43 p.m., FM-B stated R1 called him at approximately 4:00 a.m. on 5/21/26. According to FM-B, R1 was crying in pain, appeared to be in poor condition, and begged him to come get her and take her to the hospital.During an interview conducted on June 2, 2026, at 4:04 p.m., FM-C stated she arrived at the facility at approximately 5:00 a.m. on May 21, 2026, and found R1 lying in a fetal position in bed, crying and complaining of pain. FM-C reported she requested staff send R1 to the hospital for evaluation. FM-C stated, after waiting approximately 45 minutes without any action being taken, she called 911 to have R1 transported to the hospital.During an interview conducted on 6/4/26 at 11:01 a.m., FM-D stated he did not recall receiving a call from the facility regarding R4's 5/18/25 incident involving a right wrist injury. FM-D further stated he was not informed of R4's increased agitation or resistance to care on 5/18/25.During an interview on 06/03/26 at 11:19 a.m., Registered Nurse (RN-A) stated she was not aware of R1's hydromorphone 4 mg one-time order. RN-A confirmed R1 was experiencing ongoing pain related to her wound and expressed frustration. RN-A stated she was unclear whether the existing oxycodone 10 mg order should have been discontinued and whether the hydromorphone 4 mg every 4 hours was intended to replace the oxycodone order. RN-A explained she did not notify the provider regarding R1's ongoing pain or whether oxycodone 10 mg was not effective and to request further directions.During an interview on 6/4/26 at 4:04 p.m., the Director of Nursing (DON) stated staff were expected to immediately report any change in condition or resident concern to the provider. The DON stated that he could not locate documentation indicating whether R4's representative had been notified. The DON further explained that when the incident occurred, the nurse should have timely assessed R4, administered pain medication, notified the provider, and contacted the resident's family. The DON confirmed also the provider was not notified when R1 experienced a change in condition.Notification of Changes Policy dated 3/2024 directed the facility staff to make appropriate and timely notification to the physician and delegated non-physician practitioner and notification to the resident representative when there is a change in the resident's condition that may require physician intervention.

Based on interview and document review the facility failed to ensure non-pharmacological (non-pharm) interventions were attempted/offered and documented prior to the administration of as needed (PRN) narcotic medications for 1 of 3 residents (R3) reviewed for pain. Findings include: R3's diagnoses list dated 2/6/26 included fracture of right femur (upper leg bone), hypotension (low blood pressure), and low back pain. R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 did not have cognitive impairment. R3 had occasional pain that interfered with day-to-day activities, therapy, and sleep.R3's care plan dated 1/30/26 indicated a focus of alteration in comfort related to right femur fracture and low back pain with interventions included provide non-medicinal forms of pain relief such as positioning, rest, massage, etcetera (etc.).R3's provider order dated 1/30/26 instructed oxycodone-acetaminophen (a combination pain relieving medication) tablet 10-325 milligrams (mg). Give 1 tablet every 6 hours as needed for chronic pain (the order did not specify the location of the chronic pain). R3's medication administration record (MAR) for February 2026 indicated R3 received oxycodone-acetaminophen 17 times. The MAR also included a task for non-pharmacological pain interventions: no intervention needed, ice, heated blankets, massage repositioning, music, essential oils, food or drink, relaxation breathing; document interventions every shift. The corresponding recorded entries were once per shift versus prior to administration of the PRN Oxycodone. Documented non-pharmacological pain interventions indicated R2 was offered food 20 times and repositioning one time. No other information was included on the MAR. R3's record between 1/30/26 through 2/6/26 did not include comprehensive pain assessments that would include location and pain characteristics. Further, although R3's nursing notes identified the date and time the medication was administered they did not include what, if any, non-pharm interventions had been attempted or offered prior to the narcotic being administered. Additionally, when non-pharmacological interventions were documented R3's record did not identify the effectiveness of the interventions attempted/offered. During an interview on 2/6/2026 at 9:51a.m., R3 stated ice and repositioning help with managing the pain to her leg. Staff will bring her ice if she asks for it, but they do not offer it before a pain pill. During an interview on 2/6/2026 at 11:15 a.m., registered nurse (RN)-A stated when a resident reported pain the nurse should assess location of pain, ask the resident to rate their pain on a scale of 0 (no pain) to 10 (worst pain ever) and offer non-pharm interventions like repositioning. If the non-pharm interventions did not help with the pain or the resident refused, the nurse should offer ordered PRN medication based on the stated pain scale number. A nurse should document administration of the medication, all interventions offered/refused and follow-up information if the medication was effective or not. During an interview on 2/6/2026 at 12:40 p.m., RN-B stated when a nurse assessed a resident for pain, the nurse should ask when the pain started, where is it located, rate the pain on a scale from 1-10, and what has worked in the past to relieve pain. The nurse should offer non-pharm before offering medication. A nurse should document in the PRN medication note where the pain was located, the pain rating and what was offered. The nurse should go back to the resident later to see if the medication was effective. During an interview on 2/6/26 at 3:13 p.m., nurse practitioner (NP)-A stated when a resident has pain, the nurse should start with conservative treatment like repositioning, ice, heat, and topical medication. If conservative treatments were not effective in relieving pain, then the nurse should offer PRN medication based on the resident's pain scale. Documentation of all interventions is important so nurses and providers can look back to see what had been effective in managing the resident's pain. During an interview on 2/6/26 at 5:26 p.m., director of nursing (DON) stated when a resident was experiencing pain, a nurse should ask the resident to describe the pain, where the pain is located, and what had relieved their pain in the past. The nurse could use non-pharm interventions like ice or a warm pack. Non-pharm interventions and the resident's pain rating should be included in the PRN medication administration note. The non-pharm documentation completed one time per shift was not directly tied to a PRN medication administration. DON reviewed R3's medical record and confirmed there were no indications of non-pharm interventions offered, attempted or refused prior to PRN narcotic administration. The Pain Management Protocol dated 12/2025 instructed staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain.

Based on interview and document review, the facility failed to accurately transcribed a physician order with a start date for 1 of 3 (R2) residents reviewed for medication administration. Findings include: R2's diagnoses list dated 2/6/26 included gas gangrene (a bacterial infection) and foot ulcer (an open sore on the foot). R2's hospital discharge order dated 1/25/26 instructed new medication: amoxicillin-pot clavulanate (an antibiotic) 875-125 milligrams (mg). Give 1 tablet two times a day. Stop taking on 2/3/26. R2's physician order dated 1/25/26 was consistent with the hospital discharge order; amoxicillin-pot clavulanate 875-125 milligrams (mg). Give 1 tablet two times a day, stop taking on 2/3/26. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 did not have cognitive impairment. The MDS identified R2 was administered an antibiotic. R2's January and February medication administration records (MAR) identified the physician order for Amoxicillin however; the MARs identified a start date of 1/26/26 with an evening shift administration time. Further identifying R2 missed the evening dose on 1/25/26 and the morning dose on 1/26/26 which was not consistent with the physician order that directed to start the medication on 1/25/26. During an interview on 2/6/26 at 2:11 p.m., pharmacist (pharm) stated R2's amoxicillin-pot clavulanate was delivered on 1/25/26. A resident's medication should start on day of admission unless there is a provider order with a specific start date. During an interview on 2/6/26 at 2:42 p.m., registered nurse (RN)-C stated medications are administered according to the medication administration record. Any medications that are due on a specific shift will be listed under the resident name. A medication will not populate to be administered until after the transcribed start date. During an interview on 2/6/26 at 12:40 p.m., RN-B stated the first time R2 received amoxicillin-pot clavulanate was on 1/26/26 in the evening. RN-B confirmed R2's amoxicillin-pot clavulanate should have started on 1/25/26. During an interview on 2/6/26 at 3:13 p.m., nurse practitioner (NP)-A stated medications should start on day of admission unless the order indicated a specific start date. The provider should be notified of any missed doses so the order can be extended if necessary. NP-A did not recall being notified of the two missed doses. During an interview on 2/6/26 at 5:26 p.m., director of nursing (DON) stated R2's order for amoxicillin-pot clavulanate was not transcribed accurately. The order should have started on 1/25/26 not 1/26/26 which resulted in two missing doses. The Medication and Treatment Orders policy dated 2/2024 instructed orders for medications and treatments will be transcribed accurately and in a timely manner. Orders must include: a. Name and strength of the drug. b. Number of doses, start and stop date, and/or specific duration of therapy. c. Dosage and frequency of administration. d. Route of administration. e. Clinical condition or symptoms for which the medication is prescribed; and f. Any interim follow-up requirements

Based on record review and interview the facility failed to conduct care conferences on a quarterly basis for 6 of 6 residents (R12, R14, R26, R27, R56, R70) reviewed for care planning. Additionally, the facility failed to update the care plan for 1 of 6 residents (R70) reviewed for communication and language preferences. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was admitted on [DATE], moderately cognitively impaired, able to communicate clearly, and understand others, R12 had the following diagnoses: heart failure (HF) (heart pumps ineffectively), hypertension (HTN) (high blood pressure), renal failure, neurogenic bladder (inability to control ones' bladder), and Alzheimer's. R12's care conference form dated 11/13/24, indicated a care conference took place one day after R12's admission, however, there was no other evidence of any other care conferences having been conducted. On 6/9/25 at 1:46 p.m , R12 reported they did not remember ever having a care conference, nor their family being contacted about one either. R14's quarterly MDS dated [DATE], included R14 had an admission date of 12/31/22 and was cognitively intact. R14 utilized a wheelchair for mobility and required partial to moderate assistance for personal hygiene. R14 had diagnoses of arthritis, diabetes, abnormalities of the gait or mobility, and essential tremor. R14's last provided care conference form indicated the date of the most recent care conference was 5/16/25. However, no care conferences noted in chart for previous three quarters. R26's quarterly minimum data set (MDS) dated [DATE], indicated R26 was admitted on [DATE], moderately cognitively impaired, able to communicate and understood others. R26 had the following diagnoses: multiple sclerosis, paraplegia, anxiety and depression. R26's medical record indicated one care conference note dated 9/30/24. However, the record lacked any evidence of any other care conferences taking place. The record also revealed R26 had quarterly MDS assessments on 4/8/25, 1/9/25, and 8/29/24. R27's quarterly MDS date 3/31/25, indicated R27 was admitted on [DATE], severely cognitively impaired, able to communicate and understood others. R27 had the following diagnoses: hypertension, renal failure, diabetes and history of a stroke. R27's medical record indicated care conference note dated 12/17/24. However the record lacked any evidence of any other care conferences taking place. The record also revealed R27 had quarterly MDS assessments on 3/31/25, 3/1/25, re-admission assessment on 2/6/25, and 1/28/25. R56 quarterly MDS dated [DATE], included admission date of 1/9/25 and was cognitively intact. R56 had diagnoses of anxiety, hypertension (high blood pressure), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). R56's last provided care conference form indicated the date of the most recent care conference was 1/10/25. No care conferences were noted for most recent quarter nor previous two quarters before last care conference. R70's annual MDS dated [DATE], indicated admission on [DATE]. R70 was cognitively intact, preferred language was documented as English, and had the following diagnoses: wound infection, fracture, paraplegia, (inability to moves some or all of ones appendages), cerebrovascular accident (CVA) /transient Ischemic attack) (TIA), or stroke, malnutrition, psychotic disorder, and post-traumatic stress disorder (PTSD). R70's care conference dated 4/4/25, indicated it was the most recent care conference conducted. Prior to 4/4/25, no other care conferences had been conducted since 5/31/24. On 6/9/25 at 5:43 p.m., R70 was unable to communicate in English, and when offered translations services, R70's preferred language was Ukrainian. R70 stated frustration, and felt the facility did not care about them or what happened because they were Ukrainian. R70 stated they could not remember ever having a care conference, and they had no idea what was happening with their discharge plan. R70 stated no one communicated with them, and had no idea how the planning was going or if it was occurring at all. On 6/12/25 at 8:49 a.m., the social services director (SS)-A stated the social services department was responsible for conducting care conferences. SS-A confirmed both R12 and R70 were overdue for care conferences, and they should have been conducted quarterly and annually. R70's care plan dated 4/9/25, indicated R70's primary language was Russian, and required translation to communicate with staff members. R70's Associated Clinic of Psychology (ACP) note dated 10/3/23, indicated R70 was born and raised in Ukraine. R70 came to the united stated as a refugee in 2022, fleeing the war between Russia and Ukraine. The provider indicated in the ACP note their concern for possible isolation because of the R70's language barrier, and their need for an interpreter in R70's primary language of Ukrainian, as they know/understand very little English. On 6/9/25 at 5:43 p.m., R70 indicated they spoke Ukrainian. On 6/12/25 at 11:48 a.m., licensed practical nurse (LPN)-A stated the nurse managers were responsible for updating care plans, and they were unaware of what language R70 spoke, however they believed it was Ukrainian. During interview on 6/11/25 at 10:48 a.m., and 6/12/25 at 10:10 a.m., director of nursing (DON) stated an initial care conference was held within three days of admission, and a quarterly care conference was 90 days later. The DON confirmed both R12, and R70 had not had care conferences conducted quarterly per regulations and the DON stated that was unacceptable DON confirmed R26 had only one documented care conference and was overdue for 3 if not 4 others, and R27 had only one documented care conference. DON stated he expected the care conferences to be scheduled following the quarterly MDS assessments and these should be set up with social service director and nurse managers. DON stated it was important to hold care conferences, so all parties were aware of status and contribute to resident care planning. Care conferences were important to keep everyone formally informed of how the resident was doing and their discharge plans. Furthermore, the DON stated they believed R70 was Ukrainian, and their native language was Russian, however they were unsure. The DON confirmed R70's care plan listed Russian as their primary language. The DON was unaware R70 had indicated they spoke Ukrainian. It was important residents were able to communicate in their native language in order to communicate with them appropriately. On 6/12/25 at 12:40 p.m , the administrator stated the social services department was responsible for conducting care conferences, and confirmed both R12 and R70's care conferences had not been completed and were important to ensure collaboration of care with department heads, the resident, and their family's in order for them to be involved in their care. Furthermore, the administrator stated the nurse managers were responsible for updating the care plans of residents. The administrator stated they believed R70 spoke Russian, and they had provided R70 with Berg translations services, and placed communication cards, in Russian, which R70 could use to communicate. The administrator stated R70 had laughed and did not want them. The administration stated they would have noted R70's primary language based on referral information upon admission. The administrator then confirmed R70's care plan stated their primary language was Russian. However, the administrator reviewed R70's orders, and indicated R70's spoke Ukrainian. The administrator stated the importance of using R70's native language because it represents their culture and allows them that right, and for the facility to be aware of the care they need and provide what they need based on their preferences. An email from the administrator dated 6/12/25 at 1:16 p.m., indicated R70's current order started 7/31/24, stating Berg Interpreter Services with a phone number, and speaks Ukraine language/prn communication needs. The facility's Care Planning Policy last revised 11/24, indicated the resident has the right and is encouraged to participate in the development of his or her care. The care plan shall be used in developing the residents daily care routines and will be utilized by staff personnel for the purposes of providing care and services to the resident A care conference policy was requested, and none was provided.

Based on observation and interview, the facility failed to complete proper hand hygiene during 2 of 3 dining observations. This had the potential to affect all 85 residents. Findings include: During dining observation on 6/10/25 at 8:16 a.m., director of nutrition (DN) completed hand hygiene with soap and water for about 5 seconds in the dining room serving area. During interview at 6/10/25 at 8:20 a.m., DN stated she washed her hands for approximately 10 seconds. DN stated she believed proper hand hygiene should take 15 seconds, but felt it was not an issue because she was not touching food, only checking temperatures and adjusting serving dishes in the steam table. During food prep observation on 6/12/25 at 10:05 a.m., dietary aide (DA)-A checked the chemical level on the dishwasher, washed hands with soap and water for 6 seconds, dried hands and replaced gloves. During observation and interview on 6/12/25 at 10:21 a.m., DA-B entered the kitchen, washed hands with soap and water for 7 seconds, put on gloves and started moving clean dishes to storage area. DA-B stated she should have washed her hands for 20 seconds and would just know how long 20 seconds was. During interview on 6/12/25 at 10:29 a.m., director of dietary (DOD) stated it was expected that all staff wash their hands upon entry to the kitchen, between tasks and any time hands were soiled. Staff should wash their hands for at least 20 seconds. DOD stated hand hygiene audits were regularly completed and that one was just completed the previous day. Undated facility handwashing policy included proper hand washing techniques should be used before, during and after preparing food. Hand washing technique included scrubbing hands vigorously for at least 20 seconds prior to rinsing under water and drying with paper towel.

Based on observation, interview, and document review the facility failed to provide assistance with grooming for 1 of 2 resident (R145) reviewed for activities of daily living (ADL's). Findings include: R145's admission Minimum Data Set (MDS) dated [DATE], indicated R145 was cognitively intact and required assistance with ADL's. R145 had diagnosis of acute kidney failure and moderate protein calorie malnutrition. R145's care plan dated 5/27/25, indicated. R145 required assistance with personal hygiene preferences. The care plan revealed R145 would be dressed and groomed per his preferences. During an observation on 6/9/25 at 3:02 p.m., R145 was lying in bed watching television. R145's beard and mustache were approximately one inch long. R145 stated the beard and mustache were long for him. R145 stated he would like it to be clean shaven, he would look better. An interview on 6/10/25 at 1:29 p.m., nursing assistant (NA)-A stated it was part of resident care to offer shaving. NA-A stated she did not offer R145 to be shaved because it was not his shower day. An interview on 6/10/25 at 1:55 p.m. registered nurse (RN)-A stated she was not aware R145 wanted to be clean shaven. An interview on 6/10/25 at 2:31 p.m., nurse manager (NM)-A stated R145 had no documented refusals of personal hygiene which included shaving. NM-A stated R145 required assist of one staff for personal hygiene. An interview on 6/11/25 at 8:03 a.m., R145 stated he looked better and felt better after being shaved. An interview on 6/12/25 at 12:45 p.m., director of nursing (DON) stated shaving for the resident should be offered if the resident wanted to be shaved. The DON stated it is important to complete grooming so residents can look how they want to look, have control over their image, and feel good about themselves. A facility policy Activities of Daily Living (ADLs) Maintain Abilities Policy dated 6/2025 revealed based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following activities of daily living: a. hygiene-bathing, dressing, grooming, and oral care, b. mobility-transfer and ambulation, including walking, c. elimination-toileting, d. dining-eating, including meals and snacks, e. communication, including i. speech, ii. language, and iii. other functional communication systems.

Based on observation and interview the facility failed to ensure medications were secured in resident accessible areas. In addition, the facility failed to ensure medications were labeled with current physician-ordered administration instructions including medication name, and resident name. This unsafe practice had the potential to impact residents who received medications from the 100-unit medication cart. Findings include: During an observation on 6/11/25 at 8:22 a.m., licensed practical nurse (LPN)A administered medications from the 100-unit medication cart to R26. LPN-A placed a blue cup with an unlabeled, undated medication syringe containing a clear liquid and an unlabeled, undated clear medication cup with a round tablet on R26's bedside table while LPN-A administered crushed medications. After R26 took the crushed medications she asked LPN-A what the medications on the bedside table were. LPN-A stated the syringe in the blue cup contained liquid methadone for pain and the pill was lorazepam. R26 shook her head no, and stated she did not want them. LPN-A then picked up the unlabeled, undated blue cup containing the syringe of clear liquid she had identified as methadone, and the unlabeled, undated medication cup with the pill she had identified as lorazepam and exited the room. Upon returning to the medication cart LPN-A unlocked the cart and unlocked the narcotic drawer and immediately placed the blue cup with the syringe, and the medication cup inside the narcotic drawer and closed the lid, pushed the drawer in and locked the cart. LPN-A did not label the syringe with R26's name, date or medication names and/or doses. During continuous observation of 100-unit medication cart and interview on 6/11/25 at 9:23 a.m. through 10:04 a.m., registered nurse case manager (CM)-C stated staff should make two to three attempts to get residents to take medications and if after multiple attempts have been made medications should be destroyed. CM-C stated all narcotic medications require two nurses to destroy. CM-C confirmed the medication in the syringe in the blue cup and the pill in the medication cup located in the narcotic drawer of the 100-unit medication cart were unlabeled and would be difficult to identify. LPN-A and CM-C documented the destruction of the medications and walked away from the 100-unit medication cart. During this observation an insulin pen with the administration needle loaded on the end was noted on top of the medication cart. Numerous residents and staff passed by the medication cart during observation. CM-C returned to cart and confirmed the insulin pen was left on top of the cart unattended by facility staff with multiple staff, residents and guests passing by the cart. CM-C stated anyone could walk by and grab the pen and administer insulin to themselves. During interview on 6/11/25 at 10:48 a.m., director of nursing (DON) stated he expected staff to ensure all medications were properly labeled with resident's name, physician name, medication name and current physician order for administration. He went on to state staff should make at least three attempts to administer medications to a resident who was refusing medications. DON stated if a resident continued to refuse, and the medication was a narcotic it should be immediately destroyed by two nurses and document the destruction. He went on to medications refused by residents should never be returned to the medication cart and stated this was important as this can lead to potential medication errors or drug diversion. DON stated all insulin pens should be stored in the medication cart drawers until ready to be dispensed. DON stated he expected staff to get medications ready at time of administration and never 'set them up' in advance to avoid any potential medication errors, or a resident gaining access to unattended medications. A copy of the medication administration and storage policy was requested but not given.

Based on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding dignity, which was also identified during this survey. This had the potential to affect all 85 residents in the facility. Finding include: Review of the [NAME] Report 0003D Provider History Profile Report dated 5/16/25, indicated the facility was cited for F550 for dignity during the survey exited 9/24/24. See F550: Based on observation, interview, and record review, the facility failed to utilize professional interpretive services for 1 of 1 resident (R66) reviewed for oral communication. The facility's QAPI minutes dated 3/20/25, 4/17/25, and 5/15/25 lacked ongoing data related to the above repeat citation related to dignity concerns. On 6/12/25 at 1:22 p.m., the administrator stated the QAPI committee meets monthly, and they use standard monarch documentation to trend and identify problematic areas for opportunities to improve. The current focus was pressure ulcers, and education with staff regarding abuse and vulnerable adult reporting expectations. The administrator stated they have a program that calculates percentages of change when looking at pressure ulcers and use the minimum data set to track information related to other identified issues. The QAPI program policy last reviewed 6/3/25, indicated the facility will gather and use QAPI data in and organized and meaningful way. Areas to evaluate and monitor include: a) Clinical outcomes: pressure ulcers, infections, medication use, pain, falls etc. b) Complaints from residents and families c) Rehospitalizations d) Staff turnover and assignments e) Staff satisfaction f) Care plans g) State surveys and deficiencies h) MDS assessment data.

Based on interview, and document review the facility failed to ensure 3 of 5 residents (R12, R61, and R65) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Adult Immunization Schedule by age topic, dated 11/21/2024, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was admitted on [DATE], was able to communicate clearly and understand others, was moderately cognitively impaired and had the following diagnoses: heart failure (HF) (heart pumps ineffectively), hypertension (HTN) (high blood pressure), renal failure, neurogenic bladder (inability to control ones' bladder), and Alzheimer's. R12's point click care (PCC) Immunizations form undated, indicated R12 had received the pneumococcal conjugate vaccine (PCV) 13 on 5/14/2015. In accordance with the CDC recommendations R12 was eligible for a dose any of the following pneumococcal conjugate vaccines: PCV15, PCV20, or PCV21. R12's resident vaccine administration consent form dated 2/11/25, indicated R12 had given consent to receive the pneumococcal vaccine. R12's medical record lacked evidence the vaccination was provided or administered. R61 quarterly MDS dated [DATE], indicated admitted on [DATE], was able to communicate clearly and understand others, was cognitively intact, and had the following diagnoses: hyperlipidemia (HLD) (high levels of fat in bloodstream), hip fracture, hemiplegia or hemiparesis (inability to move some of one's extremities) related to a stroke, anxiety, depression, and psychosis. R61's PCC immunizations form undated, indicated R61 had received PCV13 on 10/27/2017, and pneumococcal polysaccharide vaccine (PPSV23) on 10/26/2019. In accordance with the CDC recommendations R61 was eligible for a dose any of the following pneumococcal conjugate vaccines: PCV15, PCV20, or PCV21. R61's resident vaccine administration consent form dated 8/14/2025 and a second form dated 6/10/25 indicated R61 had given consent to receive the pneumococcal vaccine. R61's medical record lacked evidence the vaccination was provided or administered. R65's admission MDS dated [DATE], indicated R65 was admitted on [DATE], was able to communicate clearly and understand others, was cognitively intact, and had the following diagnoses: HTN, wound infection, diabetes, malnutrition, anxiety, depression, and asthma. R65's PCC immunizations form undated, indicated R65 had not received any pneumococcal vaccinations. In accordance with the CDC recommendations R65 was eligible for a dose any of the following pneumococcal conjugate vaccines: PCV15, PCV20, or PCV21. R65's resident vaccine administration consent form dated 5/9/2025, indicated R65 had given consent to receive the pneumococcal vaccine. R65's medical record lacked evidence the vaccination was provided or administered. On 6/12/25 at 10:10 a.m., the director of nursing (DON) who was also in the role of infection preventionist, stated they expected the health records department would pull the residents vaccination record upon admission. During the admission process the resident would be offered vaccinations they were eligible for and should be offered within 5 days of admission and administered within 30 days. The DON stated the vaccinations could be completed by the nurse managers, or the floor nurse on duty, just depended on who had time to complete them. Next, they will order it and schedule it on the electronic medical record, get from the pharmacy and then administer once it was received. The DON confirmed R12 and R65 had not received the vaccinations they had given consent for and stated the importance of providing vaccinations to lesson symptoms of diseases and lesson risk of hospitalization and preventable diseases. The facility Pneumococcal Policy last revised 6/3/25, indicated prior to admission to the facility (within 5 days) all residents will be assessed for current immunizations status and eligibility to receive the pneumococcal vaccine. Within 30 days, of admission, resident will be offered the vaccine, when indicated, and unless the resident has already been vaccinate or the vaccine is medially contraindicated

Based on observation and interview, the facility failed to ensure proper cleaning of wheelchairs for 2 of 2 residents (R14, R13) reviewed for dignity. Findings Include: R14's quarterly MDS dated [DATE], included R14 was cognitively intact. R14 utilized a wheelchair for mobility and required partial to moderate assistance for personal hygiene. R14 had diagnoses of arthritis, abnormalities of the gait or mobility, and essential tremor. On interview on 6/10/25 at 9:22 a.m., R14 commented on the condition of her wheelchair. R14 stated the wheels were worn out and had gouges and divots out of them which caused the wheelchair to be difficult to be maneuvered by transportation company. R14 also stated the arm rests were missing chucks of covering black covering. R14 stated it had been years since her wheelchair was cleaned and had dirt on it. R13's quarterly minimum data set (MDS) dated [DATE], included R13 was severely cognitively impaired, utilized a wheelchair for a mobility device, and required substantial assistance with personal grooming. R13 had diagnoses of dementia, depression, weakness. On 6/10/25 at 8:48 a.m., R13 was observed in the dining room at a table with other residents present. R13's wheelchair was noted to have light gray particles and small, sand size brown and tan pieces noted on the lower bars of the wheelchair. During interview on 6/10/25 at 3:38 p.m., nursing assistant (NA)-B stated the staff cleaned the wheelchairs as needed. NA-B stated staff used a disinfectant wipe to clean the wheelchair if it was noted to be dirty. During interview on 6/10/25 at 4:32 p.m., licensed practical nurse (LPN)-B stated wheelchairs were cleaned regularly by housekeeping, but he was unaware of the schedule. During interview on 6/10/25 at 4:38 p.m., director of housekeeping (DOH) stated housekeeping cleaned wheelchairs after resident's were discharged or if it was brought to them to be cleaned but did not routinely clean wheelchairs for residents. During interview on 6/10/25 at 4:47 p.m., nurse manager (NM)-D stated the director of nursing (DON) and DOH recently cleaned some wheelchairs and were working on a system to clean them all regularly because there was no one available to clean them overnight when residents tend to be out of their wheelchairs. NM-D confirmed R13's wheelchair had a spot that looked like spilled food on the curved bars of the wheelchair used for tilting the chair, along with other dirt and crumbs. NM-D confirmed R14's wheelchair had large gouges in the wheels and described them as dead. NM-D stated R14's wheelchair had disgusting, dried, I don't know what on it, along with dirt and dropped food and drink that had not been cleaned up. NM-D confirmed both wheelchairs have not been cleaned in an extended period of time. During interview on 6/10/25 at 5:15 p.m., DON stated he believed wheelchair cleaned was set up to be completed monthly by housekeeping when they complete a deep clean of the room. The DON stated the wheelchairs should be cleaned in between those deep cleans as needed. The DON confirmed both R13's and R14's wheelchairs had a build up of dirt and debris and had not been deep cleaned or spot cleaned recently. Facility policy for wheelchair cleaning requested and not provided.

Based on observation and interview, the facility failed to ensure dignity was maintained for 1 of 1 residents (R65) reviewed for dignity related to dressing. Findings Include: R65's admission minimum data set (MDS) dated [DATE], indicated R65 was admitted on [DATE], was able to communicate clearly and understand others, was cognitively intact, and had the following diagnoses: bilateral (both sides) below the knee amputation, HTN, wound infection, diabetes, malnutrition, anxiety, depression, and asthma. On 6/9/25 at 3:14 p.m , R65 was observed sitting in bed wearing only a black and tan sweater, tan grippy socks over R65's bilateral stumps, and a brief. R65 stated he should have been wearing pants, but staff didn't complete the task. F65 was upset and stated, how can you treat an elderly person this way?. R65 and R65's daughter (FM)-A stated R65 was a dignified person and was embarrassed to be left this way and would have never chosen to not wear pants. On 6/12/5 at 11:48 a.m., licensed practical nurse (LPN)-C stated when they were getting someone up in the morning and assisting them with activities of daily living (ADL), they would wear a full set of clothing which included a shirt, pants, etc. LPN-C stated R65 preferred to always wear pants, and R65 picked them out in advance and layed them out for staff to help with when getting dressed. On 6/12/25 at 12:45 p.m , the director of nursing (DON) stated their expectation was the staff washed and dressed the resident based on resident's preference. The DON stated the importance of respecting resident wishes related to dressing, to allow the resident to have control over their own image and feel good about how they looked. On 6/12/25 at 12:40 p.m., the administrator stated they expected staff to dress the residents in what they would prefer to wear whether it was a gown or shirt and pants. The administrator stated the importance of dressing the residents how they prefer because it was dignified and respectful of the resident and their wishes. The facility Abuse Prohibition/Vulnerable Adult policy last reviewed 4/2025, indicated the philosophy of Monarch healthcare management is to provide quality long-term care in a loving and caring atmosphere.

Based on observation, interview and document review the facility failed to ensure staff followed five rights of medication administration for 1 of 3 residents (R1) reviewed for significant medication errors. R1 received five times the prescribed dose of Methadone for three days (nine shifts) which impaired her speech, ability to verbalize needs and consume nutrition. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 4/26/25, when the facility staff administrating R1's medication failed to compare the written order on the Medication Administration Record (MAR) with the prescription label on the physical bottle of Methadone before administration which resulted in R1 receiving five times the prescribed dose of Methadone nine times over the course of three days. The IJ was identified on 5/7/25, and the administrator was notified of the IJ on 5/7/25 at 1:45 p.m. The immediate jeopardy was removed on 5/1/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated she received scheduled and as needed pain medication. The MDS indicated R1 had frequent pain that occasionally affected sleep and day to day activities and received opioid (a class of drugs that relieve pain, but can also cause side effects, dependence, and overdose) medications. Diagnosis included Multiple Sclerosis (MS), open wounds, paraplegia, and pain. R1's care plan dated 4/20/25, identified an alteration in comfort related to MS, polyneuropathy and wound cares. The care plan directed staff to assess for pain, document effectiveness of pain medication and administer pain medications as ordered by the physician. R1's prescription medication bottle dated 3/27/25, indicated Methadone SOL (solution) 10 milligrams (mg)/5 milliliters (ml) directed 10 ml (20 mg) by mouth three times daily. R1's Physician Order details dated 4/11/25, Methadone HCL (hydrochloride) oral solution 10 mg/5 ml. Give 30 mg by mouth three times daily for pain. Give 30 mg = 15 ml. R1's prescription medication bottle dated 4/25/25, indicated Methadone 10 mg/ml. Take three ml by mouth three times daily which equals, 30 mg. R1's MAR April 2025 indicated Methadone HCL oral solution 10 mg/5 ml. Give 30 mg. R1's narcotic record hand written by staff, indicated Methadone 10 mg/ml. Drug dosage indicated 15 mg. Directions: Take 15 ml's three times daily. The record indicated the transcribing staff member failed to identify the change of dosage on the prescription bottle. The record indicated staff gave the following amounts: 4/26/25 at 10:00 a.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/26/25 at 12:00 p.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/26/25 at (unable to read), 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/26/25 at 7:41 a.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/27/25 at 12:00 p.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/27/25 at 8:00 p.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/28/25 at (unable to read), 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/28/25 at 12:00 p.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). 4/28/25 at 8:00 p.m., 15 ml, equal to 150 mg. ( five times the prescribed dose). A Medication Error Reconciliation Form dated 4/30/25, indicated on 4/26/25 at 10:00 a.m. and 12:00 p.m., agency staff administered Methadone based on supply bottle from hospice which had a different concentration than previous bottle and administered wrong dose from old discontinued medication bottle. Nurse did not follow the five rights of medication administration (right drug, right patient, right dose, right route, right time.) Nurse educated on five rights of medication administration. A Medication Error Reconciliation Form dated 4/30/25, indicated on 4/26/25 at 8:41 p.m. and 4/29/25 at 8:00 a.m. and 12:00 p.m., registered nurse (RN)-A administered Methadone based on supply bottle from hospice which had a different concentration than previous bottle on hand administered wrong dose from old discontinued medication bottle. Nurse did not follow the five rights of medication administration. Nurse educated on five rights of medication administration. A Medication Error Reconciliation Form dated 4/30/25, indicated on 4/27/25 at 7:41 p.m., 12:00 p.m. and 8:00 p.m., licensed practical nurse (LPN)-A administered Methadone based on supply bottle from hospice which had a different concentration than previous bottle on hand administered wrong dose from old discontinued medication bottle. Nurse did not follow the five rights of medication administration. Nurse educated on five rights of medication administration. A Medication Error Reconciliation Form dated 4/30/25, indicated on 4/28/25 at 7:38 a.m., 12:00 p.m. and 8:00 p.m registered nurse (RN)-B administered Methadone based on supply bottle from hospice which had a different concentration than previous bottle on hand administered wrong dose from old discontinued medication bottle. Nurse did not follow the five rights of medication administration. Nurse educated on five rights of medication administration. R1's Progress Notes identified the following: 4/30/25, Nurse practitioner and hospice notified of medication concern. 4/30/25, Hospice nurse returned call regarding Methadone dosing, stated to continue to monitor for adverse reactions. R1 had been in active decline with changes in intakes, ability to tolerate meals or activity with therapeutic recreation. 4/30/25, R1 was weak, not much activity occurred. R1 did not eat, just took sips of water. 4/30/25, Hospice routine visit note indicated writer was alerted to change of condition by hospice aide. R1 displayed exertion to respond to yes or no questions. Hospice nurse and aide to start daily visits. 4/30/25, R1 was lethargic at beginning of shift. Awake at supper and requested food. R1 ate 15% of food and drank 40 cubic centimeters (cc) [a teaspoon is typically equal to about 5 cc of fluid] this shift. 5/1/25, R1 unable to take oral medications due to weakness and decline. 5/1/25, Hospice nurse visit: Upon arrival, R1 in bed sleeping, did not open eyes to verbal or physical stimuli. Respirations even with periods of apnea (the temporary cessation of breathing). All extremities cold to touch. Family member (FM) questioned if medication concern contributed to decline which writer was unable to provide an answer. 5/1/25, R1's verbal communication has declined. 5/2/25, Update to FM given. Notified R1 was unable to tolerate oral medications, not eating or able to tolerate oral intakes due to decline. During observation on 5/6/25 at 2:28 p.m., R1 was laying in bed with staff seated next to her bed. Upon introduction, R1 made a verbalization that sound like Ahhhh, but no words spoken. During interview on 5/6/25 at 3:45 p.m., R1's significant other (SO) stated the facility had told him the concentration of Methadone came in higher that it was supposed to be and no one had caught it. The SO said R1, went way down hill real fast and said prior to the medication error R1 was able to speak and now could not. The SO stated R1 had stopped eating and had trouble swallowing since the medication error occurred. The SO stated he was the person who visited R1 regularly as her family resided in another state. During interview on 5/7/25 at 8:28 a.m., LPN-A stated R1's Methadone order had increased from a previous order. LPN-A said they received a new bottle of Methadone which indicated 30 mg but said the concentration had changed and the staff had not noticed. LPN-A said staff followed the direction on the MAR but not the bottle. During interview on 5/7/25 at 8:41 a.m., the hospice RN stated they had received an e-mail from the facility about the error but it had gone to a different department than nursing. The hospice RN said she learned about the medication error via text from the hospice physician. The hospice RN stated the facility explained the staff had been giving the wrong dose of the Methadone due to not looking at the bottle. On 5/7/25 at 9:51 a.m., the director of nursing (DON) was interviewed along with the vice president of clinical operations (VPCO) for the Hospice agency. The DON stated the medication error was discovered during the afternoon medication count on 4/30/25. The DON said she was notified of the errors on 5/1/25 and completed the medication error forms along with LPN-A. The DON stated as soon as they learned about the error the nurses involved received immediate education. The DON stated the nurses had not followed the five rights of medication administration. The VPCO said R1 had been placed back on final moments which include daily nurse and aide visits, due to the medication error. The VPCO stated prior to the error it had been many months since R1 had received final moments care. The VPCO said R1 remained on final moments due to decreased appetitive, not eating/drinking as much and decline in verbalizations. During interview on 5/7/25 at 10:35 a.m., when asked about the significance of receiving five times the dose of methadone, the pharmacy consultant (PC) stated with any opioid medication there was a concern for respiratory depression, sedation, confusions or a potential overdose, which was a more life threatening situation. The CP said Methadone had a longer half life (indicates how long it takes for a drug to be removed from your body) which made it trickier to determine how long it would take for someone to return to their baseline following an over dose. The CP said typically it took from 24 - 36 ish hours but fluctuated with patients which was why changes were made slowly. The CP stated she considered the medication error to be significant. During interview on 5/7/25 at 11:33 a.m., nursing assistant (NA)-A and NA-B were interviewed. NA-A stated during the last two weeks, R1 had not been eating very much and would only drink fluids. NA-A said prior to a few weeks ago R1' appetite was normal. NA-B indicated when recently came into work R1's speech was unable to be understood which was a change from previously and said now R1 would not eat. NA-A said the speech had changed in the last week and said R1 was no longer speaking and would just look at him. During interview on 5/7/25 at 11:38 a.m., LPN-A said she had noticed R1 had been sleeping a lot more. LPN-A stated initially she had not realized it was related to the medication errors. LPN-A stated a couple weeks ago was R1's last good day. LPN-A said since the medication errors occurred R1 was eating less, drinking less and was more lethargic and said R1's speech used to be so clear but now required so much effort to get words out. An undated, untitled facility procedure directed staff to review the five rights, three times prior to medication administration. The past noncompliance immediate jeopardy began on 4/26/25. The immediate jeopardy was removed 5/1/25, and the deficient practice corrected after the facility implemented a systemic plan that included the following actions: - Immediate education was provided to the nurses involved in the medication errors to include: Medication administration and transcription, the five rights of medication administration and ensuring medication labels match physician orders along with contacting pharmacy or physician for clarification. - All nurses received education related to medication types, prevention of errors, high risk medications and compliance with national safety standards. - R1's Pain medication management was reviewed for accuracy along with ensuring the label on the bottle matched the physician ordered in the medical record. - All like residents have had their orders reviewed and liquid medication labels reviewed to ensure labels on bottles match the orders in the medical record. - Compliance audits were initiated.

Based on observation, interview and document review, the facility failed to notify resident representative timely following resident change of condition for 1 of 1 residents (R2) who had a weight loss of eight pounds in 27 days. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had cancer, diabetes mellitus, heart failure, seizure disorder and depression. The MDS indicated R2 was cognitively intact with no mood or behavior disorders, was independent with activities of daily living (ADL), including eating. R2's weight was 200 pounds (lbs) indicating, no weight loss with a therapeutic diet. R2's care plan (CP) dated 3/11/24, indicated nutritional problems or potential nutritional problems related to increased nutritional needs due to a diagnosis of malignant neoplasm (cancerous tumor) of left breast, increased protein needs, supplements discontinued by physician, weight stable for 180 days. The care plan directed staff to allow resident sufficient time to eat, evaluate weight changes, obtain and document weights per MD (Doctor of Medicine) orders and facility protocol, provide feeding dining assistance as needed, provide snacks as scheduled and as needed, provide and serve diet as ordered: controlled carbohydrate, regular texture, thin liquids. A faxed order dated 3/14/25, from R2's NP indicated diagnosis of anorexia, to check complete blood count, comprehensive metabolic panel (CMP) (check metabolic function and organs), comprehensive renal panel (CRP) (check kidneys), erythrocyte sedimentation rate (ESR) (test measures how quickly red blood cells settle at the bottom of a test tube, indicating inflammation in the body, with higher rates suggesting increased inflammation), and an abdominal x-ray. No new orders were noted from results. NP visit note dated 3/28/25, indicated R2 had loss of appetite with no recent complaints of nausea, but noted weight loss (although had previously weighed in the 180's); recent labs unrevealing. On 3/04/25, mirtazapine (antidepressant) was stopped and Aricept was started (January 2025). The note indicated on 3/14/25, per nursing, R2 did not have much of an appetite for two days and denied nausea, vomiting and complaints of abdominal pain with palpation to all quadrants no point specific area, overall not feeling well. Consider dose reduction versus stopping Aricept. The 3/28/25, note indicated discussion with family member (FM)-B. A faxed order dated 3/28/25, from R2's nurse practitioner (NP) indicated diagnosis loss of appetite and anorexia, decrease Aricept to 50 milligrams (mg) oral daily for seven days, then stop toprol XL (high blood pressure medication), start propranolol IR (beta blocker that lowers blood pressure) 40 mg twice daily for tremor and hypertension, and notify if weight is less than 175 lbs. During interview on 4/01/25 at 2:30 p.m., nurse aid NA-D stated R2 had been eating in her room for weeks, refused to go into the dining room and did not want help eating. NA-D stated R2 had been shaking more and believed the nurse practitioner (NP) had made medication changes to help with that. In addition, NA-D indicated R2 just didn't appear to want to eat lately. NA was not aware if anyone from the facility contacted the family. During observation and interview on 4/01/25, at 4:51 p.m. R2 was in her room sitting in her wheelchair when she stated she was having some diarrhea, but that had stopped. R2 stated she has lost some weight but does not know why, adding she was not crazy about the food at the facility. R2 stated she liked hamburgers, fries and soups. During interview on 4/01/25, at 7:38 p.m. R2's family (FM)-B stated the last two times she came to visit R2 past lunch time she had been in bed with the blinds closed in her room and staff told me she did not want to get up. FM-B stated she had noted more confusion and weight loss. FM-B stated she had just visited over the weekend and had to assist R2 with eating due to her shaking so bad, adding she was only notified of her weight loss by the NP on 3/28/25, and the facility had never notified her of R2's weight loss. In addition, FM-B indicated she was not notified of the NP notification for weight loss on 3/14/25, and that labs had been ordered along with an abdominal x-ray. FM-B stated had she been notified sooner of the weight loss she would have brought in supplements and snacks R2 liked and would liked to have talked with the NP sooner about the weight loss. Review of R2's medical record indicated from 3/06/25 to 4/02/25 R2 had a 8.9 lb weight loss. During observation 4/02/25 at 1:40 p.m., R2 was observed alone in her room with her lunch tray in front of her. R2's tray was observed to have a few bites taken from her 4 ounce (oz) garlic and herb baked chicken (approximately 25%), with her rotini pasta salad, lettuce salad with spinach dressing, and 8 oz juice all untouched. R2 stated she was just not hungry today and did not want to eat in the dinning room or have assistance with eating. R2 did not indicated if she was asked by staff if she wanted assistance, and no observation was made of this. During interview on 4/03/25 at 10:14 a.m., registered dietician (RD) stated she assessed R2's weight loss on 3/31/25, and noted a weight loss of 5% over 30 days, indicating she had been in the 180's, then gained towards 200 since November 2024 related to mirtazapine. RD added, mirtazapine was then discontinued on 3/4/25, along with a decreased intake of 50% leading to weight loss. RD stated she contacted the NP but did not contact R2's family about the weight loss, adding she would do that today (4/3/25). That now has been discontinued as of 3/04/25 and has decreased intakes of 50% and she left a message with R2's NP. RD stated she did not talk with R2's family about the weight loss but will call today. RD indicated she made not changes at that time, choosing to monitor and weight for NP to follow up as R2 had been at that weight previously with out concern. Review of R2's progress notes lacked evidence of communication with R2's family related to her weight loss. During interview on 4/03/25 at 10:59 a.m., licensed practical nurse (LPN)-A unit manager stated the NP saw R2 on 3/28/25, for weight loss and talked to R2's family. LPN-A further stated the NP is usually the one who notified the family of any changes. Notification Of Changes Policy dated 3/2024, indicated It is the policy of this facility that changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident.

Based on interview and document review the facility failed to comprehensively assess and implement appropriate pain monitoring to ensure comfort for 1 of 1 residents (R1) reviewed for pain management and whom was non-verbal and unable to communicate their needs. Findings include: R1's admission Minimum data Set (MDS) dated [DATE], had no MDS entries due to death on [DATE]. R1's care plan (CP) dated [DATE], indicated R1 received palliative care (focusing on improving quality of life for those with serious illnesses, during end-of-life care specifically focuses on the final months, weeks, or days of life), pneumonia, obesity due to excess calories, hypertension congestive heart failure, atrial fibrillation and long term use of insulin. In addition, R1's CP indicated he received hospice services as of [DATE], and comfort cares as desired with verbalized satisfaction with cares received. Additionally, R1's CP indicated he had alteration in cognition, mobility, mood and comfort, and directed staff to provide non-pharmacological treatments (address health concerns without relying on medications, encompassing physical therapies, behavioral strategies, and other modalities to improve well-being) for pain relief such as repositioning, rest, massage, as well as pain medication as ordered by physician. In addition, the staff were to encourage resident to verbalize discomfort and monitor for medication side effects. Review of R1's medication administration record (MAR) for [DATE], indicated the following: -HYDROmorphone HCl (also known as Dilaudid) (narcotic pain medication) 10 milligrams (mg)/milliliters (ml), give 0.4 ml by mouth every 4 hours for pain. The order indicated the order was started on [DATE], at 4:00 p.m. and first dose was given at 4:00 p.m. -HYDROmorphone HCl 0.4 mg by mouth every hour as needed for pain and shortness of breath, start date was [DATE] at 2:45 p.m., and first dose was given at 6:56 p.m. -HYDROmorphone HCl liquid give 0.4 mg one mg by mouth every one hour as needed for pain. Start date was [DATE] at 12:30 p.m. and discontinued at 2:11 p.m. on [DATE]. Last dose was given on [DATE], at 9:38 a.m. -HYDROmorphone HCl liquid give 2 mg/ml by mouth every one hour as needed for severe pain start date [DATE], at 12:30 p.m. and discontinued [DATE], at 2:11 p.m. last dose given on [DATE], at 12:17 p.m. R1 went almost four hours without pain medications from 12:17 p.m. to 4:00 p.m., due to medications orders being discontinued prior to the new medication orders transcribed into the computer system. Additional review of R1's [DATE] MAR pain scale from [DATE] and [DATE], nursing staff used a numerical pain scale (is a common tool used to assess pain intensity. It's a 11-point scale ranging from 0 (no pain) to 10 [worst pain imaginable], where patients verbally or in writing select a number that best represents their pain level) despite R1's inability to verbally communicate his pain. R1's MAR also failed to show evidence of an pain scale for R1 after [DATE] at 2:05 p.m. until his passing on [DATE] at 8:10 a.m. [DATE] at 4:33 p.m. Pain Rating of 4 using PAINAD scale (a tool used to assess pain in individuals with dementia or other cognitive impairments who cannot verbally report their pain.) [DATE] at 11:51 p.m. Pain Rating of 0 using PAINAD scale [DATE] at 4:32 a.m. Pain Rating of 5 using PAINAD scale [DATE] at 7:42 a.m. Pain Rating of 5 using PAINAD scale [DATE] at 9:25 a.m. Pain Rating of 2 using Numerical scale [DATE] at 11:37 a.m. Pain Rating of 4 using Numerical scale [DATE] 1:21 p.m. Pain Rating of 7 using Numerical scale [DATE] 1:27 p.m. Pain Rating of 6 using Numerical scale [DATE] 3:58 p.m. Pain Rating of 0 using Numerical scale R1's pain rating (using a numeric scale was documented as 0 for the following times on [DATE]: 4:04 p.m. 5:12 p.m. 6:32 p.m. 7:36 p.m. 8:29 p.m. 9:29 p.m. [DATE] at 1:40 a.m. Pain Rating of 3 using PAINAD scale [DATE] 03:07 a.m. Pain Rating of 1 using PAINAD scale [DATE] at 9:27 a.m. Pain Rating of 3 using Numerical scale [DATE] at 10:45 a.m. Pain Rating of 3 using Numerical scale [DATE] at 11:19 a.m. Pain Rating of 3 using Numerical scale [DATE] at 12:16 p.m. Pain Rating of 2 using Numerical scale [DATE] at 12:17 p.m. Pain Rating of 5 using Numerical scale [DATE] at 2:05 p.m. Pain Rating of 2 using Numerical scale R1's Hospice Visit Summary dated [DATE] at 9:15 a.m., indicated R1 was seen at the facility by registered nurse (RN)-J (hospice nurse) and indicated upon her visit at the facility she found R1, calling out in pain, wife in tears, with the wife (FM)-A reporting she, has had the call light on for over an hour wanting to request pain medications. The summary indicated RN-J went searching for a nurse to bring R1 some pain medications. A nurse brought R1 his scheduled buccal buprenorphine (long-acting opioid pain medicine, administered to R1 twice a day, a.m. and p.m.) and 2 mg dose of Dilaudid (HYDROmorphone)(narcotic used to treat severe pain) and, at that time, RN-J requested the RN come back again with lorazepam (anti-anxiety medication). R1 was also given Tylenol in yogurt, but he could not swallow it without a lot of effort. Swallow was impaired, with some coughing after medications. The Hospice Visit Summary went on to indicate R1 was very lethargic, had significant congestion and his pain was not controlled. RN-J documented they talked with wife about a scheduled pain medication plan and using medications which are proven to be highly effective for him and RN-J was provided education related to R1's presentation, showing RN-J that R1 was moving to an active dying process. The summary indicated FM-A was sad and cried but listened, she lived nearby but reported to RN-J that she felt she could not leave, otherwise R1 was not given his medications or attention by staff. We (RN-J and FM-A) discussed scheduling medications so staff are required to come in and provide pain medications on a regular basis (orders were as often as hourly if needed). RN-J indicated collaboration with nurse practitioner (NP) regarding medication changes and wrote out new orders. Summary then indicated RN-J reviewed new orders with nurse manager licensed practical nurse (LPN)- D and interim director of nursing (DON) who was going to enter the orders into the system. The medications were ordered by RN-J and facility staff were instructed as to when to expect the medications and to continue using current medication plan until concentrated Dilaudid (HYDROmorphone) arrived. Staff verbalized understanding. RN-J communicated to management the family's distressed related to R1's pain management and perceived lack of concern by nursing staff at facility. The note indicated the LPN-D (nurse manager) will encourage staff to be more attentive. During interview on [DATE] at 9:01 a.m., hospice nurse manager registered nurse (RN)-C stated he received a phone call from FM-A on [DATE], at 3:00 p.m. stating R1 was in pain and had not received any pain medication's for over two hours. RN-C indicated FM-A was upset during the phone call and he immediately attempted to call the (Nursing Home) unit on second floor where R1 was located but no one answered. RN-C then called the facility and finally reached RN-A from the first-floor transitional care unit (TCU) who went upstairs to check on R1. RN-C then stated RN-A informed him the new medication order from 10:00 a.m. had not been transcribed yet (now it was after 3:00 p.m.). Hospice RN-C stated from what he understood the nurse discontinued the previous orders and did not put in the new orders in the computer system, so there was no pain medications to give R1. During interview on [DATE] at 11:40 a.m., licensed practical nurse (LPN)-A nurse manager for second floor, stated R1 had always been in pain since admission, and he would just scream. RN-C hospice nurse provided new orders which had increased pain medications on [DATE], and the health unit coordinator (HUC) was off that day and LPN-A stated she gave the new orders to LPN- B to put the orders in the computer system. LPN-A stated the staff should still have provided the previous pain medication orders until the new medications arrived to the facility. LPN-A indicated the typical process would by to wait until the new medications arrived to discontinue the old order and input the new orders into the system. LPN-A stated she delegated the orders change to LPN-B that day and was never informed she did not have time to complete the task, adding she was made aware after the order confusion on [DATE] that LPN-B discontinued the order earlier in the day, before starting the new order around 4:00 p.m., leaving R1 with no pain options. LPN-A confirmed that was not the correct procedure and R1 should not have been left with out pain management for that amount of time. During interview on [DATE] at 1:53 p.m., nursing assistant (NA)-T stated she worked with R1 on [DATE], and his pain was severe. NA-T stated every time she would move him or touch him he would get agitated and would groan in pain. NA-T stated R1's wife would cry all day, indicating R1 was in too much pain. NA-T stated she worked 6 a.m. to 2:30 p.m. and informed the nurse of the wife's concerns and assumed the nurse provided pain medications. NA-T denied ever verbally confirming R1 received pain medication, adding R1 had been at the same level of pain since admission so it was hard to tell. During interview on [DATE] at 2:01 p.m., RN-A stated he received a phone call from hospice on [DATE], around 3:00 p.m. and was informed R1 was in pain and they were unable to reach his nurse. RN-A stated he went upstairs to confirm he received his medications. RN-A stated the family was in the room indicating R1 was in pain and wanted him to receive pain medication. RN-A indicated his observation of R1 was that he appeared to be lying comfortably with his legs twitching. RN-A stated he found out LPN-B had discontinued R1's previous orders and did not put in his new medication orders. RN-A stated he informed the pm shift nurse LPN-E to give R1 his pain medications at 3:30 p.m. and at that time his new medications had arrived. RN-A stated the nurses should have given his previous pain medication orders until the new medication arrived (had optional hourly pain medications); R1 should not have had to wait for pain medication. RN-A stated they have started re-educating all the nursing staff starting today on medication transcription and pain monitoring. During interview on [DATE] at 2:09 p.m., LPN-E stated she was the PM nurse for R1 on [DATE], and started at 2:30 p.m. LPN-E indicated upon arrival R1's family immediately asked for pain medication and when they looked at the medication administration record (MAR) there was no pain medication orders and they showed that to the family. LPN-E stated she informed the interim director of nursing, and was told to talk to the unit manager and she directed me to LPN-B who informed me she had discontinued the previous orders and was working on putting in the new orders. LPN-E stated finally around 3:30 p.m. the new medication came in and was able to provide it to R1. LPN-E confirmed she were not aware she could have given the previous medication orders until the new medication arrived since they were discontinued. During interview on [DATE] at 7:26 p.m., LPN-B stated she was provided the orders for R1 to transcribe from LPN-A nurse manager, and stated they were transcribed late due to having an entire unit of 27 residents herself to care for and did the best she could (not on R1's unit). LPN-B stated she discontinued the orders from [DATE] first around 1:00 p.m. and put in the new orders sometime before 3:00 p.m. before she left for the day. LPN-B stated the new orders were to start Robinul (reduce secretions) 1 milligram (mg) tablet, HYDROmorphone (narcotic to treat severe pain), 10 mg/1 ml, give 0.4 ml/ 4 mg by mouth every four hours for pain and every one hour as needed, Lorazepam (antianxiety) 1 mg by mouth four times a day for anxiety and muscle spasms, in addition 0.5 to 1 mg every four hours as needed for anxiety. During interview on [DATE] at 8:09 p.m., FM-A stated R1 was in a lot of pain while at the facility and had to ask for pain medication every hour due to his shaking and groaning, and on [DATE], at 3:00 p.m. she finally called hospice services since she knew the pain medications were changed at 10:00 a.m., and the facility had not implemented them yet at 3:00 p.m. including LPN-E telling her there was no orders to give pain medications at the start of her shift at 2:30 p.m. FM-A stated she spoke to hospice RN-C who then called the facility and finally things were worked out. FM-A stated R1 never should have gone through so much pain. During interview on [DATE] at 10:34 a.m., LPN- D stated RN-A informed her R1 looked like he was comfortable and was not moaning when he received the phone call from hospice RN-C. In addition, LPN-D stated the nurses were not completing the correct pain rating for R1 and they are in the process of re-educating the nurses for non-verbal residents who are not able to provide a numerical pain rating. In addition, LPN-D verified after the hospice nurse made the medication changes on [DATE], and LPN-B discontinued the previous pain medication orders, the staff no longer rated R1's pain, which was incorrect. LPN-D stated when the LPN-B inputted the new pain medication orders she did not put in to rate the pain, so R1's pain was never rated after [DATE], at 2:05 p.m. which was last rated on a numerical scale with a value of a two. LPN-D stated, because R1 was non-verbal, you can not use a numerical pain rating scale, a non-verbal pain rating scale should have been completed. Additionally, LPN-D indicated she did not even understand how LPN-B or any nurse could have come up with a numerical pain rating for R1. LPN-D added, the nurse working the day shift on [DATE] licensed vocational nurse (LVN)-A, used the numerical scale all shift. During interview on [DATE] at 8:00 a.m., LVN-A stated she worked with R1 on [DATE] and during that day shift R1's FM-A was constantly asking for pain medication all through that shift. LVN-A stated she provided pain medication and anti-anxiety medication approximately three times during her shift. LVN-A did state at the end of her shift a nursing assistant did come up to her requesting pain medication, and she was already busy getting another resident's weight and so had to tell the aide to ask the evening nurse to give the medications. Review of R1's [DATE] MAR revealed on [DATE] LVN-A administered R1's scheduled pain medication Acetaminophen (Acetaminophen Capsule 500 MG, Give 2 capsule by mouth three times a day for pain), at 12:00 p.m. No other pain relieving medication was administered to R1 until LVN-A administered his new order of HYDROmorphone 10 mg/ml Give 0.4 ml by mouth every 4 hours for pain. LVN-A additionally failed to monitor R1's pain, having only documented in his pain scale last at 12:17 p.m. recording a 5 and 2:05 p.m recording a 2 using the incorrect Numeric pain scale. Medication and Transcription Error's policy revised ,d+[DATE], indicated orders for medications and treatments will be transcribed accurately in a timely fashion. In addition the facilities Pain Management Protocol updated [DATE], indicated the purpose is to ensure that residents pain or at risk for pain, have an effective pain management plan in place with individualized interventions that are consistent with the resident goals for comfort.

Based on observation, interview and document review, the facility failed to protect one of one residents (R4) from abuse and neglect when R4 was deprived of her care planned bed mobility and transfer needs, while she voiced pain and signs of distress, visibly struggled with these movement activities, and was placed in apparent unsafe laying and seated positions. These actions resulted in a fall for R4 where she sustained a distal femur fracture that required hospitalization and surgical intervention. The facility implemented corrective action based on their investigation and so the deficient practice was issued at an immediate jeopardy (IJ) past non-compliance. The IJ at F600 began on 1/17/25 (Friday), after R4 was deprived of care planned bed mobility and transfers, along with additional staff support, despite her voiced complaints of pain and signs of distress, visible struggles with these movement activities and placement in apparent unsafe laying and seated positions, and when transferred by staff in a non-care planned approach. This resulted in harm with required medical interventions. The administrator and the director of nursing (DON) were notified of the past non-compliance IJ on 1/24/25 at 4:00 p.m. Based on the facility's implemented corrective actions to prevent recurrence, prior to the abbreviated survey, this was issued at past non-compliance. Findings include: R4's quarterly and state optional Minimum Data Sets (MDS), both dated 12/18/24, identified R4 was free of communication impairments; however, was moderately cognitively impaired. R4 was provided extensive physical assist of two staff for bed mobility and transfers, and she was diagnosed with the following: cerebrovascular accident (stroke), right sided hemiplegia (total or nearly complete paralysis), anxiety, depression, severe morbid obesity, generalized muscle weakness, abnormality of gait and mobility, along with the need for assist with personal cares. R1's face sheet identified additional diagnoses of aphasia (language ability impairments due to brain damage) chronic pain syndrome with history of right femoral (upper end of thigh bone) head fracture and right lateral fibula (lower leg bone) malleolus (ankle bone) fracture. R4's comprehensive care plan, dated 2/27/24, and reflective of 1/17/25, identified an initiated potential for alteration in blood formation and coagulation Focus related to the use of anticoagulation (decreased clotting) medication. An intervention directed staff to encourage R4 to avoid bumping herself. R4's comprehensive care plan, dated 2/27/24, and reflective of 1/17/25, identified an alteration in mobility related to stoke and right-sided weakness Focus with a goal for her to move safely within her environment. The interventions directed staff to help with bed mobility to sit up, boost up, and to get feet in and out of bed, along with a standing lift with one staff per therapy for transfers. R4's comprehensive care plan, dated 4/29/24, and reflective of 1/17/25, identified an alteration in cognition Focus related to difficulty finding and/or expressing her words, impaired thought processes with diagnoses of stroke and aphasia. Interventions directed to allow R4 time to communicate her needs and wants and to provide her with cues, reorientation, and supervision as needed. R4's comprehensive care plan, dated 4/29/24, and reflective of 1/17/25, identified R4 was a vulnerable adult due to her decreased cognitive function, aphasia, chronic pain, and decreased physical abilities with a goal to remain free of abuse and/or neglect. Interventions directed staff to explain cares prior to providing, monitor for signs of emotional distress, and follow the facility's vulnerable adult policy. Additionally, an intervention directed staff were to be educated as needed to ensure cares were provided in a gentle, unrushed, and thorough manner. R4's comprehensive care plan, dated 5/14/24, and reflective of 1/17/25, identified an initiated fall risk Focus related to a stroke with right hemiparesis, diabetes, aphasia, morbid obesity, obsessive impulsive disorder, chronic pain syndrome, generalized anxiety disorder, neuropathy, the need for assistance with transfers, bed mobility, and toileting. R4's goal was to be safe and free from falls with directives to follow therapy instructions for mobility function and to follow R4's specific fall prevention plan. This intervention allowed for specifications; however, this intervention was not specified. A Therapy Communication Form, dated 7/11/24, directed R4's transfers out of bed required a mechanical standing lift. R4's Care Guide (nursing assistant care plan), identified R4 was a fall risk, required assist of one staff for repositioning and bed mobility, required assist of one for dressing with directives to GO SLOW, and required assist of one staff and a Standing Lift to get out of bed. R4's electronic medical record Task (staff documentation) section, identified a task for the nursing assistants to sign off each shift that indicated Transferring: Standing Lift A1 (assist of one). R4's nursing and provider progress notes from 1/15/25, identified R4 complained of lower right leg pain with her pointing from her hip down her leg. A pain that she was unable to describe, and which was unable to be reproduced by the provider. R4 requested several times to go to the hospital. With hospital transfer prep, R4's weight was identified to be 211.4 pounds. R4 returned that evening in which scans completed on R4's right leg were negative for abnormal findings. A nursing progress note, dated 1/17/25, identified a nursing assistant [NA-B], called the nurse to R4's room and stated R4 was lowered to the floor during a transfer. R4 stated she, 'fell ,' when the nurse asked her what happened. R4 stated, 'Yes,' when asked if she was okay. Range of motion was completed and R4 denied pain. R4 was transferred with a full body lift into her wheelchair and went out to smoke; however, when she came back inside, she requested pain medication due to right lower ankle pain. A facility provided interview with NA-B, dated 1/17/25, identified NA-B stated she tried to get R4 dressed while R4 was seated edge of bed. As she tried to get R4's pants on, she had to slowly lower R4 to the floor, due to R4's sliding off the bed. NA-B denied noting any injuries toward R4 or that R4's legs were bent back or trapped underneath her. NA-B stated she lowered R4 to the floor, placed a pillow under her head, and went for help. The DON educated NA-B that R4 was an assist of one with a mechanical stand lift for transfers which NA-B stated she was unaware of; however, she only dressed R4. NA-B showed the DON where the Care Guides were located, and she was knowledgeable about lifts. A nursing progress note, dated 1/21/25, identified that on 1/17/25 at 10:40 a.m., R4 was transferred to the emergency department for right leg pain after being lowered to the floor by staff. An Orthopedic Operative Note, dated 1/20/25, identified a diagnosis of Peri-implant right supracondylar distal femur fracture. R4 underwent an open reduction internal fixation of this fracture with plate and screw construct. An Incident Review and Analysis form, dated 1/21/25, identified R4's 1/17/25 fall which occurred at 9:38 a.m. The nature of the incident indicated the fall was from bed and that R4 was lowered to the floor. An Incident Analysis identified R4 was in bed prior to the incident and getting ready for the day with the assistance of a nursing assistant where the nursing assistant transferred R4 from the bed to her wheelchair (w/c). The IDT (interdisciplinary team) met and determined the root cause of the fall was the nursing assistant did not follow the plan of care for mechanical stand lift transfers. On 1/20/25, a facility reported incident (FRI) was reported to the state agency (SA). The report identified R4's husband talked with the DON and stated the nursing assistant was rough with [R4] prior to her fall and he had camera footage from the event. On 1/23/25 at 12:01 p.m., video footage was reviewed with the administrator and the DON. The video revealed the following: -The video started at 8:42:39 a.m., where R4 was on her back in bed. She laid flat, across the bed toward the bed's left edge. Her left buttock region was on the mattress edge and both legs hung over the edge where her feet, encased in shoes, appeared on or very close to the floor. Due to a pillow on the floor, her actual foot position against the floor was blocked from view. R4 held onto the left grab bar with her left hand and appeared to be trying to sit herself up. R4 wore shorts, which were not completely pulled up and exposed the right side of her upper hip incontinence product region, and a shirt that was hiked up under her breasts allowed her entire abdominal area to be exposed. NA-B stood on the left side of the bed, approximately a foot or so from R4, between R4 ' s legs and the grab bar. NA-B's left hand was on her left hip and her right arm location was blocked by her body as she was sideways to the camera. NA-B did not speak to R4 but looked her direction. There was no evidence a stand lift was in R4's room. -At 8:42:41 a.m., R4 made a grunting type of noise, and continued to attempt sitting up unassisted. During this action, R4 started to slide off the mattress edge. In response, NA-B quickly approached R4, blocked R4 ' s left leg with her leg with enough force that the mattress pushed a few inches toward the right side of the bed frame, pushed on the left side of R4's abdominal area, and stated quickly, Lie down, lie down, lie down, as she pointed to the head of the bed. Immediately after, she placed one of her palms under each of R4's back upper legs and swiftly picked up R4's legs and swung them to the center of the bed where she let go. Due to gravity, this caused R4's right lower leg (calf to ankle) to fall and flop onto the leg's right side, onto two pillows located at the end of the bed. The lower leg bounced up when it first connected with the top pillow. -At 8:42:57 a.m., immediately after R4's legs contacted the bed, NA-B placed her hands on R4's outer left knee region and outer abdominal side area and forcibly pushed R4 more onto her right side, toward the right side of the bed, close to the bed edge. R4 did not remain on her side, and she started to roll onto her back. In response, NA-B placed her left palm on R4's lower left hip region and her upper left area. As she started to forcibly push R4 again onto her right side, she adjusted her right palm to R4's lower left back region, stated, Lie down, and while she held her onto her right side, she aggressively started to pull up R4's shorts, and finished with the use of both her hands. At this time, NA-B looked toward the camera. Once R4's pants were adjusted in the back, NA-B placed her right palm on R4's left hip and pushed quickly on R4's hip, enough to cause R4 to slightly rock toward the right, and she left go. NA-B then stepped away from the bed. -At 8:43:05 a.m., R4 started to roll back onto her back and started to use her left hand to adjust the front of her shorts. NA-B stated to R4 with increased tone and attitude, You are not getting out, as she held her hand above R4's body and shook a hand with a pointed finger side to side. NA-B directed, Move up, move up. R4 again attempted to reposition herself in bed. -At 8:43:20 a.m., R4 pointed at NA-B with her left pointer finger and then pointed at the wall that housed the camera; however, was not heard to make any verbalizations. NA-B failed to respond to R4's gesture. She then again started to attempt self-positioning. Almost right away, NA-B demanded, Get into the bed, go to the side, as she pointed with her hand to the right side of the bed and then patted R4's right outer hip area three times. Again, pointed to the right side of the bed and vocalized, Go to the side. R4 attempted to use her left leg, which was flat against the left side bed frame, while NA-B again pointed to the right side and stated quickly, Again. As R4 made a type of grunting noise, NA-B looked over R4, toward R4's right side and reached for R4's right hand/arm which she quickly removed from under R4's side, as R4 made a grunting type of noise, swung it out to the edge of the mattress, and set it down. NA-B instructed, Go again, and again pointed toward the side of the bed. As R4 again made grunting noises, NA-B used her left palm to swat R4's left hip region twice, which was heard when contact was made, and again instructed, Go again, while she pointed. Next, she stated, Push, as she made pushing motions with both hands. As R4 attempted to reposition, NA-B again stated, Again, push .more. R4 again attempted and made grunting type noises. NA-B elevated her tone and more forcibly stated, More, More. NA-B looked toward the camera. -At 8:43:57 a.m., R4 stated words that could not be made out, but which ended with the word okay. NA-B responded, It is not okay, you will fall down. She then proceeded to state to R4, More, and gestured toward the right side of the bed. R4 readjusted her body slightly with her left leg and NA-B then instructed her to, Bring your legs down and she motioned with a sweeping arm toward her legs and then the floor. Next, NA-B picked up a pillow that was on the floor and flung it over the top of R4 toward a pile of additional pillows located on the other side of the bed, adjacent to the headboard. -At 8:44:15 a.m., without any communication towards R4, NA-B grabbed onto R4's left shin area and forced it off the bed. When she let go, after it landed on the bed frame, the foot slipped off. NA-B then grabbed R4's right lower shin region and forcibly pulled the leg toward the bed edge, where R4's right heel hit her left knee, and she dropped it over the edge. R4's outer right lower leg/ankle region hit on the bed frame. During these actions, R4 cried out, OW. NA-B remained quiet, without any communication toward R4. NA-B then grabbed onto each of R4's knees and attempted to readjust them so that R4's feet were closer to the floor; however, R4's w/c was in the way which required NA-B to let go of R4 and adjust its placement. -At 8:44:27 a.m., after NA-B adjusted the w/c, she grabbed onto R4's left upper thigh with both of her hands and wrenched R4's leg up and toward the grab bar as R4 continued to lay flat on the bed. R4 made a grunting noise. NA-B spoke to R4; however, this was not understood. NA-B kept her left upper leg up against R4's left upper leg and grabbed onto R4's right lower arm/wrist area with both her hands and started to pull R4 into a seated position. R4 held onto the grab bar with her left hand. As NA-B and R4 struggled to get R4 seated, NA-B placed her right arm around R4's upper shoulder area while still holding her right arm. R4 grunted as they continued to struggle with the action. During this process, the mattress continued to slide toward the right and once R4 was relatively seated, she overall sat on the bed frame. At the same time, her right lower leg started to tremor up and down five or so times. -At 8:44:46 a.m., once R4 was seated, NA-B let go of her and stepped back. R4 sat on the bed frame, right arm hung down to her side, her right foot off to the right side a few inches. R4 made a grunting noise. R4 pointed to her w/c with her left pointer finger. NA-B made quick elevated toned verbalizations and bilateral closed fisted circular hand motions in front of R4; however, they were not understood due to the quickness of the speech and motions. After verbalizing, R4 started to adjust her sleeveless shirt; however, NA-B swatted the side of R4's right abdominal area twice, which could be heard when contact made, swung her hands, palm up to about R4's face level, and stated, You can remove it, as she brought her hands to R4's shirt, grabbed the shirt by the bunched up bottom and tugged the shirt from under R4's bilateral breasts without further direction or allowing R4 to assist. R4 stated, Oh, and something else unrecognizable. Next, NA-B grabbed R4's right wrist area with her right hand and the shirt bottom with her left and yanked R4's arm out of the arm hole, up over R4's head, and pulled it off R4's left arm without holding onto the arm or without communication to R4. -At 8:45:10 a.m., R4 started to position herself, as if she was going to stand, after she slightly adjusted her left foot so that it was more in front of her and stated, Ow. Her left hand was on the mattress and her right foot was about a foot or so from her left foot off to the side. NA-B stepped closer to R4, grabbed a hold of her right forearm area. R4 then sat back more onto the bed frame and grabbed onto the grab bar. NA-B brought R4's right foot forward and to the side so that it was more in line with R4's body without any forewarning or instructions. R4 stated, I can't. NA-B swung her hands out to the sides and stated with frustration, Than what should I do .I can't let you sit. -At 8:45:32 a.m., as R4 again appeared to position herself as if she was going to try standing, NA-B stood directly in front of R4, grabbed the w/c and positioned it on the right side of R4, bumping the w/c into R4's left leg, did not engage the right w/c break, and demanded, Stand up. We will get in your chair, as NA-B pointed toward the w/c. -At 8:45:41 a.m., NA-B grabbed R4 by the back of the shorts, and without providing R4 with any additional directions or communication, or application of a transfer belt, started to force R4 toward the w/c with a pivoting type of motion. Due to the angle, NA-B's right-hand placement could not be observed. R4 hung onto the grab bar. When NA-B moved R4 enough so that R4's buttocks were moved off the bed frame, R4's shorts significantly stretched out from NA-B's grip, R4's right leg could be seen bending under her weight, and R4 instantly started to fall to the floor. During this fall, R4 banged her left side on the bed frame and R4 started to make crying sounds of distress. R4's hand could be seen not holding onto R4. R4's left leg view was blocked by the w/c; however, R4's right leg could be seen underneath her, bent at the knee and the top of her shoe flush with the floor. R4 continued to cry out in distress. NA-B made no verbalizations towards R4. -At 8:45:47 a.m., NA-B pushed the w/c away from them, and positioned herself behind R4. From this angle, R4's left shoe could be seen as if it was directly under R4's buttocks and her right leg shin area was flush against the floor. NA-B instructed R4 to sit, provided R4 with no further directions, grabbed R4 by the shoulders, and applied force to pull her back towards her so that R4's basically sat on her calves. R4 continued to cry out in distress. -At 8:45:54 a.m. NA-B, without speaking to R4, grabbed R4's right leg by the calf region with both hands and pulled the leg from underneath her. R4 cried out, OW. Next, again without providing R4 with directions, grabbed R4 again by the shoulders and forced her back farther so that she was seated more on her buttocks versus her legs. R4 continued to cry out. NA-B reached over R4, as R4 leaned back, and extended R4's right leg further away from her body. NA-B guided R4 into more of a laying position and told her, It's alright. Lie down. When R4 stood up and moved, R4's right leg was bent at the knee about 90 degrees from her body with the right inner ankle flush with the floor. Next, NA-B reached over R4, grabbed her right calf with her right hand and brought R4's leg closer to her left leg. NA-B and R4 remained quiet; however, R4 could be heard breathing heavy. NA-B placed a pillow under R4's head and stated something unintelligible. -At 8:46:32 a.m., NA-B moved and R4's bilateral legs were both visualized. R4's left leg was bent at the knee with her shoe bottom flat on the floor; however, her right upper back leg was flush with the floor, her lower leg was bent at the knee with the back of the knee and the entire bottom portion of her leg flush to the floor, which included the inner ankle. As NA-B moved the w/c away from R4, the w/c hit R4 which elicited a distressed sound from R4. NA-B did not acknowledge the action or R4's distressed vocalization. As NA-B walked toward the door, R4 made a distressed sound. NA-B turned around and stated what sounded like, I am coming, walked toward the door, opened it, and called out to someone at 8:46:47. R4 again started to cry out in distress as the video ended. The total video recording was four minutes and 14 seconds. -During the video, from 8:42 a.m. to 8:46:47 a.m., for a total of four minutes and 14 seconds, NA-B was in R4's room attempting to get R4 up for the morning and transferred to her w/c. During this time, NA-B moved R4 with unnecessary roughness, did not alter her approach despite R4's complaints of pain, especially when pain was caused by NA-B's actions, repeatedly instructed R4 to position in manners she was unable to, along with positioned R4 into unsafe positions while in bed and while seated edge of bed, used demeaning gestures, actions, and direction towards R4, all without requesting, or attempting to get, more assistance for an unsafe situation. Additionally, NA-B proceeded to attempt a non-care planned bed to w/c transfer for R4 without a transfer belt, despite R4's care plan indicating the need to use a mechanical standing lift, in which R4 fell to the ground. -Immediately after the video was observed, the DON stated he was taken back by the video when he first saw it, after the husband provided it to them. The administrator also stated she was definitely taken back. The administrator stated NA-B was rough with [R4 ' s] care and she was not providing services in a manner that met their standards and expectations. The DON confirmed and verbalized I do not think anyone's standards. The DON indicated after hearing the audio, You can clearly tell [R4] was in pain throughout that. Additionally, he identified NA-B's actions did not change during the encounter, even after R4 made verbalizations of distress. He expected NA-B would have stopped the cares, asked for assistance, and verified R4 's transfer assist needs as safety always was expected. Both expected staff followed the care plan, or the care guides, and staff were expected to carry them with them. An Ad Hoc QAPI & Internal 4 Point Plan of Correction, dated 1/21/25, identified a meeting was held with leadership. The Findings/Summary/Notes section indicated, As evidenced by video footage, [NA-B] willfully treated [R4] with disrespect and failed to deliver care and services that aligns with her responsibilities as a professional care giver, and in a manner that is expected without our organization. [NA-B] transferred [R4] with an A1 (assist of 1) without a gait belt, when [R4's] plan of care states she is to transfer with a mechanical stand. Due to this, [R4] was lowered to the floor, resulting in her legs being pinned beneath her. [R4] was sent to the hospital due to excessive pain, where an x-ray indicated she sustained a right distal femur fracture .[NA-B] remains suspended pending investigation. Facility investigation initiated. A follow-up facility provided interview with NA-B, dated 1/22/25, identified R4 wished to smoke and thus NA-B started to get her ready. She explained she moved R4's legs into position so R4 could sit edge of bed as R4 always pivots into her [w/c]. R4 was having difficulty so she placed R4's legs back onto the bed. She pulled R4 up with the other hand and had to try multiple times. NA-B had to supplement R4 with her own body. She pulled R4's pants up. R4 was not stable so she lowered R4 to the ground and called for help. NA-B identified she should have checked the care plan and did not know R4 required the use of a mechanical stand lift. After, NA-B was shown the video. When asked her thoughts, NA-B stated, 'the video is as it is.' NA-B denied she was rough with R4; however, stated, 'noticed my tone was off, I could have taken it easier with my tone of voice.' NA-B stated R4 was larger, and she had to use more of her own strength to move R4. She was ashamed she did not use the care plan as she should have known R4 was a standing lift for transfers but stated, 'Never occurred to me that she is [a mechanical stand lift], I should have looked.' As R4 remained at the hospital during the abbreviated survey, R4 was not interviewed. When interviewed on 1/23/25 at 1:10 p.m., NA-B identified abuse as a deliberate hurting of a resident, and neglect pertained to not taking care of a resident when they needed staff to. She was expected to treat residents with as much love as she could. NA-B stated she overall does not review the care guides, especially for R4, as she knows her so well. She only reviewed these when there was a new admission, or she worked on another unit and was unfamiliar with the resident. She denied that she carried these care guides with her when she worked; however, now knows this was expected to decrease risks such as what occurred with R4. NA-B identified she was not aware R4 required a lift to help her stand on 1/27/25 when she transferred her, especially in light that when she has had assistance from other staff, they also did not use the lift. NA-B explained her reasoning for how she managed R4 's legs was due to her attempts to decrease pain for R4 associated with the leg movements as this often-caused R4 discomfort. Additionally, she explained R4 was very heavy, and she had to position herself to use her strength. Even when moving R4's legs, she had to apply force or they will not move. Furthermore, she explained she did not use a transfer belt when she transferred R4 as she did not want the transfer belt to injure R4's skin as R4 preferred to take off her top while seated edge of bed, assist her into her w/c after R4 stood up, (by grabbing the back of her shorts and helping her into the w/c as she held onto the grab bar), be brought to the closet, and then once she picked out her top for the day, the top would be applied. NA-B stated if at any time there were concerns with safety during cares, she was expected to get assistance; however, when she worked with R4 that day, her co-worker was busy answering lights. NA-B explained, what was witnessed related to the movement of R4 's legs, and her verbalizations and hand actions towards R4 was done for R4 's safety and for R4 to understand her. She denied abusing or neglecting R4 and stated, I would never hurt her. I would never do anything with the camera there. NA-B stated she worked the remainder of the day on 1/17/25, 1/18/25, 1/19/25, and 1/20/25 until she was sent home that day. During an interview on 1/23/25 at 2:42 p.m., R4's family member (FM)-A, identified himself as R4's husband. Initially, FM-A stated, It irked me very bad when I first saw [the video], and he was disappointed in the care R4 received. He explained he felt NA-B's actions seemed lackadaisical, lacked compassion, and she did not use proper transfer techniques. FM-A explained NA-B should have prepared herself better to improve the transfer's success and a transfer belt should have been used. He stated the aide tried to transfer R4, but R4 slipped off the bed, R4 appeared to turn her ankle which took away support, she fell and broke her femur right above the knee. FM-A stated it could have been much worse. FM-A was unsure of R4's care planned transfer intervention(s); however, he did not think she was care planned for a lift as when he visited with R4, approximately two times a week, and staff transferred her, they transferred her like the gal did on the video. He denied recent observations of staff using the lift. Despite FM-A's lack of R4's care planned interventions; he expected staff to follow intervention directives to help prevent R4 from getting hurt. When interviewed on 1/24/25 at 2:10 p.m., the medical director (MD) stated abuse was anything that did not respect the autonomy of the resident and neglect centered around not paying attention to the resident's needs or providing those needs. He was aware of R4's incident and the facility's follow-up which substantiated the abuse occurred; however, he had yet to personally review the video footage. MD explained this was a horrible situation and there was no tolerance for such situations. He expected staff to follow the plan of care to decrease the risk of resident harm. The IJ began on 1/17/25, and was corrected on 1/20/25, and issued at past non-compliance, after the facility implemented a plan that included the following actions: -An internal investigation was initiated. -An Ad Hoc QAPI meeting was held. -NA-B was placed on suspension. -An OHFC report was filed, along with a police report. -Staff education with associated quiz was initiated regarding Abuse, Safe Patient Handling, Resident Rights, and Care Planning. -Observation transfer and resident treatment audits were initiated. -Like resident care plans and care guides were reviewed to ensure current reflection of transfer needs. A Safe Resident Handling Program policy, dated 3/2020, directed the policy was to be followed whenever a resident required assistance in moving. When residents received assisted care, the assistance was to be provided in a manner that was safe to both the resident and the employee, and which was in accordance with that resident's care plan. The policy directed when mechanical lifting equipment was determined to be necessary for lifting/moving a resident, the lift was to be used in all circumstances unless absolutely necessary i.e. emergency situations. In addition, the policy directed gait (transfer) belts were to be used during stand pivot transfers. A Fall Prevention and Management policy, dated 2/2024, identified one of its purposes directed to implement fall prevention interventions to attempt to prevent resident falls or to attempt to minimize fall complications. An Abuse Prohibition/Vulnerable Adult Policy, dated 3/2024, identified the facility's philosophy was to provide quality long-term care in a loving and caring atmosphere. Its purpose was to protect residents against abuse by anyone. The policy described mistreatment as inappropriate treatment of a resident; neglect as a failure to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress; abuse as a willful infliction of injury, pain, or mental anguish and included deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful meant the staff acted deliberately, not that the staff must have intended to inflict injury or harm. A Care Planning policy, dated 11/2024, identified the care plan was developed for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan was to be utilized by staff for the purposes of providing care or services to the resident.

Based on observation, interview and document review, the facility failed to ensure adequate supervision to prevent an elopement (leaves premises or a safe area without authorization or necessary supervision) were provided to 1 of 3 residents (R1), who was at risk for elopement, utilized a wanderguard (elopement signaling device), and who had history of independent wanderguard removal. This resulted in immediate jeopardy (IJ) for R1 when she left the facility without staff knowledge and was outside for approximately 30 minutes exposed to lower temperature weather and unsafe conditions. The facility implemented corrective action based on their investigation and so the deficient practice was issued at IJ, past non-compliance. The IJ began on 1/11/25 (Saturday), after R1 removed her wanderguard, exited the facility's front door, was outside for approximately 30 minutes in 17-degree weather, was not immediately assessed upon reentry to the facility, the provider, family, and managerial staff were not alerted to the elopement for an investigation to occur in a timely manner, and another wanderguard was not immediately applied to R1 to decrease any increased risk(s) for additional elopement(s). The administrator, director of nursing (DON), and the regional nurse consultant were notified of the IJ on 1/23/25 at 4:29 p.m. The IJ was removed on 1/11/25, prior to the start of the survey, when the facility implemented corrective action, and was therefore issued at past noncompliance. Findings include: R1's quarterly Minimum Data Set, dated dated [DATE], identified R1 was moderately cognitively impaired with diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, diabetes, arthritis, history of transient cerebral ischemic attack (TIA), anxiety, depression, post traumatic distress disorder (PTSD), schizophrenia, unsteadiness on feet, muscle weakness, and abnormality of gait and mobility. R1 required oxygen, was enrolled in hospice services, and was identified to have range of motion limitations to bother her upper extremities. An MDS Alarm section lacked evidence R1 utilized a Wander/elopement alarm to monitor her movements and/or to alert staff when movement was detected. R1 was able to propel her w/c independently while in the facility. Provider and nursing progress notes, all dated 11/4/24, identified the provider was updated R1 went out the front door that morning due to attempts to find the smoking patio and as a result the provider identified R1 was at risk for elopement. Nursing indicated R1 was found outside in the front of the building, smoking in the inner doorways, and thus an elopement risk. Due to this, a wanderguard was placed on R1's right wrist to alert staff of her attempts to go outside unassisted and to help ensure safety of not getting lost and eloping. R1's comprehensive care plan identified that on 11/4/24 a Risk for Elopement care plan was initiated. Interventions included: right wrist wanderguard which was to be monitored for proper functioning, door alarms will be answered promptly, family will be kept informed, and R1 would be invited to activities of her choosing. R1's November 2024 TAR, identified the wanderguard monitoring directed orders were discontinued on 11/22/24. R1's comprehensive care plan for elopement risk remained unchanged despite this discontinuation. A nursing progress note dated 12/23/24 at 2:03 p.m., identified R1 wandered into other 's rooms and attempted to get her coat on to go outside after she took cigarettes from another resident. Due to her pacing and wandering in the w/c, a wanderguard was placed on her left ankle for safety. R1's 12/23/24 Elopement Risk Evaluation identified a score of 7 (potential for elopement). R1's Order Summary Report identified an order was initiated on 12/23/24 to monitor the left ankle wanderguard placement every shift. A nursing progress note dated 12/27/24, identified R1's wanderguard was moved to her right wrist due to lower extremity edema. R1's Order Summary Report identified an order was initiated on 12/27/24 to monitor the right wrist wanderguard placement every shift and the every shift left ankle wanderguard monitoring was discontinued. R1's January 2025 TAR identified the following: -From 1/1/25, through 1/10/25, an order, initiated 12/23/24, which directed staff to check a left ankle wanderguard functioning and expiration date every evening shift was signed off by seven different nurses despite documentation this was removed on 12/27/24, and applied to her right wrist. -From day shift on 1/1/25, through the night shift on 1/10/25, the 12/27/24 initiated order to monitor the right wrist wanderguard identified documented nurses' initials without any Chart Codes/Follow Up Codes that identified concerns with the monitoring. A Medication Admin Audit Report identified LPN-A signed the TAR on 1/10/25 at 11:50 p.m., that R1's right wrist wanderguard placement directive was completed. A nursing progress note dated 1/11/25 at 6:47 a.m., identified R1 was found outside at 5:30 a.m., down the street about a block away. R1 was crying and stated, oh I don't know what I am doing help me I'm lost. No wanderguard was found on R1. The nurse kept R1's coat. No additional information was documented related to post-elopement processes/actions. A nursing progress note dated 1/11/25 at 1:17 p.m., identified a wanderguard was on R1's right wrist. An email dated 1/13/25, from the administrator to another company employee, identified LPN-A's statement during the investigation. LPN-A stated, the wanderguard had been off for several days to my knowledge. I told [nurse manager] about it a week and a half ago. LPN-A explained R1 was found yelling out, was brought back into the facility, did not have oxygen on her w/c, and R1 was only outside for about five minutes. The statement did not include any information related to actions LPN-A took to decrease R1's attempt at continued elopements. A provider progress note dated 1/13/25, identified R1 exited from the front of the facility over the weekend when she attempted to go to the back patio to smoke and did not realize she was not in the right place. R1 previously had a wanderguard on but at some point, was able to get it removed unbeknownst to staff. A new wanderguard was placed that day on R1's wheelchair. A nursing progress note dated 1/13/25 at 3:40 p.m., identified staff found R1 without a wanderguard on her wrist that afternoon. Staff were unable to locate the wrist wanderguard but the wanderguard to her w/c continued. Once approached on the missing wanderguard, R1 pulled the wanderguard, which had an intact strap, from an unidentified location. R1 stated she slipped it off and hid it because she did not like it. A new wanderguard was placed to her right wrist. R1's medical record lacked evidence, until 1/13/25, that a wanderguard was identified on R1's w/c, or that the w/c wanderguard was monitored; however, an email dated 1/11/25, from the DON to administration, identified he placed a wanderguard on R1's w/c the day of the elopement. An Osseo Weather History report, provided by the facility, dated 1/11/25, identified at 5:53 a.m. the temperature was 17 degrees Fahrenheit. On 1/22/25, video footage was reviewed with the DON. The video started on 1/11/25 at 4:13 a.m. and identified R1 was in a wheelchair (w/c) outside of her room which was located two rooms down from the nurse's station and main lobby area. Between 4:13 a.m. and 5:36 a.m., R1 propelled her w/c to and from another resident's room twice, to and from her room a couple times, to and from the hallway that led to the smoking area exit doorway and interacted with the staff at the nurse's station. At 5:36 a.m., R1 propelled herself to the front door, engaged the handicapped door button, propelled herself into the front entryway vestibule, and then exited the front door once that door opened. R1 wore pants, shoes, and a coat. No staff were observed by the nurse's station. At 5:55 a.m., another resident, whom R1 had earlier visited with, exited the front doors and returned shortly after. At 6:01 a.m., licensed practical nurse (LPN)-A exited the front doors and returned at 6:02 a.m. At 6:03 a.m., LPN-A and another staff exited the front doors and returned with R1 at 6:05 a.m. Per observation on 1/22/25, the sidewalk distance to where R1 was approximately found (toward the end of the facility), was approximately 72 feet, which ended by a sidewalk egress ramp to the road. When interviewed on 1/22/25 at 10:11 a.m., R1 was overall oriented and remembered the surveyor from a previous interaction. A wanderguard was secured properly on her right wrist and there was another on the bottom of her w/c. R1 identified she was an outdoor person and initially denied going outside unsupervised; however, when her elopement was brought up, she acknowledged the incident and explained she was trying to go outside for some fresh air and to smoke; however, once outside she became lost, could not turn the w/c around, and was having the hardest time getting to where I was going. R1 was unable to remember where she was found after she went outside. R1 identified she had removed the wanderguard at times so she could go smoke. Prior to the elopement, she thought maybe she had removed them twice before and placed them in one of her drawers. She denied recent attempts to go outside unescorted as the alarms go off whether or not you take them off or not, so why take it off. During an interview on 1/22/25 at 1:53 p.m., the DON stated he expected the wanderguards were physically visualized for placement and functionality every shift based on the TAR order directives. The nurses' digital signature on the TAR was an indication the task was completed and he expected this to be truthful. If a wanderguard was not found, he expected staff to replace the wanderguard and to notify him and the administrator to ensure an investigation was started to determine cause and follow-up intervention(s). Post-elopement, he expected the resident's safety to be ensured, an assessment completed to determine any injury concerns, and appropriate notifications completed, such as to the provider and himself. The DON explained, on 1/11/25, he received a text message from the nurse manager after she came upon R1's elopement progress note. This was the first time he had ever been updated on any of R1 elopements and/or a missing wanderguard. He came into work that morning, ensured R1's safety and that she was free of injury, placed a wanderguard on R1 and another on her w/c, and started the investigation. The DON explained R1's memory waxes and wanes and her confusion fluctuated. The time frame of the incident occurred during her normal smoking time. During the investigation, it was assumed R1 removed her wanderguard sometime between the evening shift on 1/10/25 (Friday), as another nurse reported she responded to R1 that evening when she responded to the smoking patio door alarm and found R1 by the door, to the time she eloped; however, when he interviewed LPN-A after the elopement, LPN-A stated R1 had not had the wanderguard on for several days. Staff attempted to find the missing wanderguard but were unsuccessful. When interviewed on 1/22/25 at 3:08 p.m., the administrator stated during her interview with LPN-A, LPN-A thought R1's wanderguard was off after R1's elopement and identified she had not been physically checking the wanderguard. The administrator identified she did not follow up with additional questions to LPN-A as to her reason(s) for not checking the wanderguard but documenting that she had. The administrator expected the wanderguards to be checked every shift as directed. If a wanderguard was found missing, she expected the wanderguard to be replaced immediately and for her and the DON to be updated so they could initiate an investigation. The administrator identified she was aware R1 had historically removed her wanderguard as the nurse manager reported this during a past clinical meeting and informed them, she had replaced it. She was unable to remember exactly when this meeting occurred but thought maybe a week or two prior to R1's elopement. She was unable to identify steps taken at that time to investigate the missing wanderguard and/or any additional interventions initiated to decrease the risk of R1 again removing it. She stated there really were no continued concerns as staff documented it was on and visually checked. During an interview on 1/22/25 at 3:28 p.m., LPN-A stated she was expected to monitor wanderguards every shift to ensure placement and functionality. Functionality was tested using a specific wand type device. If the device was not found, or not functioning, she was expected to replace it or report it to the nurse manager; however, LPN-A identified she was initially never showed where to find the extra wanderguards and she reported these were locked up without the ability for her to access them. Since R1's incident, she now knows where to locate them, and she has access. When an elopement occurred, which she explained was when someone was lost for a period or just left with attempts to run away, she was expected to report it right away. LPN-A explained she did not look at R1's exit from the facility as an elopement as she thought R1 just tried to follow a friend out to smoke and got turned around. LPN-A identified she located R1 at the end of the building - not passed it but very close, and it appeared R1 could not get back in. When found, R1 was a little upset, and asked for help as she got confused. LPN-A stated R1 knew how to remove the wanderguard as, per reports, staff had to put it on her many times. That night, post-elopement, she realized R1's wanderguard was not on. She denied that she placed another due to the belief she did not have access to them, and she did not update management as she did not initially feel this was an elopement event. LPN-A identified she was unsure if she checked that night for placement and functioning, despite her initials on the TAR. Additionally, she identified with the two previous wanderguard checks on 1/8/25 and 1/9/25, maybe one of the nights the wanderguard was there but she could not say for sure that both nights it was. LPN-A stated she had found R1's wanderguard off at least twice prior to this incident. LPN-A explained at one point she found the wanderguard on R1's dresser, and with the other missing wanderguard observation she was unable to find the wanderguard. When found on the dresser, she updated the nurse manager. With the other, she was unsure if she updated anyone. LPN-A stated, when she updated the nurse manager, she was informed R1 kept removing them and this was not something new. When interviewed on 1/23/25 at 2:20 p.m., registered nurse (RN)-A stated R1 was a very high risk for elopements due to her recent elopement, attempted episodes of going outside to smoke unescorted, and her history of being found without the wanderguard on, typically when it was applied to her wrist. She acknowledged she had found R1's wanderguard missing during checks and had to replace it, at other times she was aware, based on other staff statements, they replaced it as they also had found it missing. She explained one of these episodes the nurse manager replaced it. During the past non-compliance IJ issuance on 1/23/25 at 4:29 p.m., the administrator stated the w/c wanderguard was placed on 1/11/25; however, after they talked with corporate, the monitoring for this was not put into place as they were concerned this monitoring would alert R1 there was a wanderguard on her w/c and they did not want her attempting to remove it. When interviewed on 1/24/25 at 2:10 p.m., the medical director (MD) stated, if a resident were to remove their wanderguard, he expected at a minimum, increased monitoring would be initiated, and staff would be alerted to be on the lookout for this continued action. MD was aware of R1's elopement as administration updated him and a QAPI (quality assurance performance improvement) meeting was held. An interview was attempted with the nurse manager; however, was unsuccessful due to her being out of the county at the time of the abbreviated survey. The IJ began on 1/11/25, and was corrected on 1/11/25 and issued at past non-compliance, after the facility implemented a plan that included the following actions: -An internal investigation was initiated. -LPN-A was placed on suspension. -An OHFC report was filed, and a Risk Management and Incident review and analysis was initiated. -R1's skin was assessed (no injuries observed), an elopement risk evaluation was completed (a score of 7), behavioral monitoring for emotional distress and exit seeking behavior was initiated, her care plan was reviewed and updated, provider and family notification were completed, she was placed on 15-minute checks, and a wanderguard was placed on her right wrist and w/c. -All wanderguards were tested for functionality. -Staff education with associated quiz was initiated regarding elopement policy and procedure, including interventions, response, and reporting. -Wanderguard placement audits were conducted on the 3 residents identified for wanderguard use. -All resident Elopement Evals were reviewed to ensure up to date. -An Ad Hoc QAPI meeting was held. The facility was free of additional elopements and the corrective actions were verified through documentation review and staff interviews. An Elopement Policy, dated 6/2023, identified the facility was committed to providing a safe environment for all resident and to ensure each resident had appropriate safety precautions in place. To prevent elopements, staff were directed to observe each shift that each resident's bracelet alarm/device (wanderguard) was in place and that the device batteries were checked according to manufacturer's direction. The policy also directed, for those residents at risk for elopement, documentation was to include all attempts to elope, full observation/visualization after an elopement for any injuries or new symptoms or conditions which may have developed, all actions taken to find the resident, that all parties were notified, and that the wanderguard was in place and functioning when applicable. If a resident was not located on their assigned unit, the charge nurse was to notify the administrator or nursing supervisor. Additionally, the post-elopement assessment was to be completed after the resident was located and returned to the unit and included observed behavior or resident statements, objective data, underlying illnesses or diagnosis, physical appearance, and general appearance. Furthermore, the family and the physician were to be updated.

Based on interview and record review the facility failed to comprehensively assess an open area for 1 of 1 residents (R1) reviewed for skin. The deficient practice resulted in harm when R1 was evaluated in the emergency department and received intravenous antibiotics for a skin bacterial infection. Findings include: R1's face sheet, printed 11/29/22, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was able to communicate her needs and had no cognitive impairment. No current skin concerns were identified. R1's progress notes were reviewed 11/11/22 thru 11/18/22. Progress notes identified an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked evidence R1 had a rash or other skin concern. R1's medical record lacked a skin assessment 11/1/22-11/28/22. Provider note dated 11/11/22, indicated provider was updated, patient has been scratching the back of her right arm. It is sore and raw. States she [updating nurse] just needed to let the doctor know that. They have not put anything on it at this point and the nurse manager will be calling to better explain what is going on. Hospital discharge summary signed 11/23/22, noted, skin and soft tissue infection, suspect [CONDITION(S)]. [MEDICATION(S)] (antibiotic used to treat bacterial infections) was administered in the emergency department. On 11/28/22, at 3:05 p.m. unit manager (UM)-A stated she observed an area that looked like scratch marks under R1's right arm on 11/18/22. UM-A confirmed the area had dried blood on it, but was not actively bleeding. UM-A updated the director of nursing (DON), instructed the floor nurse to clean up the area and watch it. UM-A stated she did not update R1's doctor and was not aware if another nurse did. UM-A indicated she expected floor staff to watch and document the area of concern. UM-A confirmed there was no documentation 11/18/22-11/20/22 regarding R1's skin. On 11/28/22, at 3:38 p.m. registered nurse (RN)-A confirmed she worked with R1 11/18/22-11/21/22. RN-A stated she was not aware of a skin concern under R1's right arm until 11/21/22 when she noted blood on R1's bedding. RN-A looked at the underside of R1's right arm and noticed a large reddened area with dried blood. On 11/29/22, at 8:27 a.m. licensed practical nurse (LPN)-A confirmed she worked with R1 on 11/18/22. LPN-A stated she was not told about any skin concerns with R1 and was not told to watch or document concerns regarding R1. On 11/29/22, at 9:58 a.m. RN-B confirmed she worked with R1 on 11/19/22. RN-B stated she was not aware of any skin concerns with R1 and was not told to watch or document concerns related to R1. On 11/29/22, at 10:13 a.m. LPN-B confirmed she worked with R1 on 11/19/22. LPN-B indicated she was not told about skin concerns with R1 and was not told watch or document concerns related to R1. On 11/29/22, at 10:21 a.m. DON confirmed UM-A made her aware of the skin concern on 11/18/22. R1 refused to allow DON to assess the area under her right arm so DON instructed UM-A to update R1's provider. DON stated UM-A told her the area was not open, but did not mentioned the dried blood on R1's skin either. DON stated she expected new or worsening skin concerns were assessed when they were noticed and were monitored each shift. DON expected documentation in R1's progress notes and to have the provider updated with any changes. DON confirmed there were no progress notes regarding R1's skin, until she was sent to the emergency room for eval on 11/21/22. DON confirmed there were no progress notes to indicate the provider was updated between 11/18/22-11/20/22. Policies for change in condition and skin observation were requested but not received.

Based on interview and document review, the facility failed to ensure a system for reconciliation of controlled substances, and transcription of medication for 1 of 1 resident (R1) reviewed for medication administration. R1's narcotic records were not reflective of R1's medication administration record. R1's [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were mis-administered by multiple staff. R1's [MEDICATION(S)] was administered over the prescribed dose or not administered, R1's [MEDICATION(S)] was transcribed to the medication administration record twice and was administered over the prescribed dose, and R1's [MEDICATION(S)] was administered under the prescribed dose. R1 was harmed when she was distraught over the lack of pain control and felt some withdrawal symptoms. Findings include: R1's Face Sheet printed 1/27/22, indicated diagnoses of fracture of shaft of right tibia, fracture of shaft of right fibula, psychoactive substance dependence, chronic pain syndrome, [CONDITION(S)], anxiety, depression, [CONDITION(S)], muscle weakness. R1 admitted on [DATE]. R1's physician order dated 12/21/21, indicated [MEDICATION(S)] ([MEDICATION(S)]) 1 film buccally every 12 hours. R1 was to receive [MEDICATION(S)] 2 times a day. [MEDICATION(S)] HCL tablet 5 milligram (mg) tablet by mouth as needed for pain once daily. R1's Medical Doctor (MD) Progress Note (PN) dated 12/22/21, indicated on 12/14/21, R1 presented to the emergency room (ER) with a fall. R1 had severe right hip, leg, and ankle pain. R1 was found to have a right ankle fracture which was splinted and was non weight bearing. R1 had 8/10 pain in her ankle. R1 was on chronic pain medications which made it hard to treat her pain. R1's Minimum Data Set (MDS) dated [DATE], indicated intact cognition. R1 required extensive assist with bed mobility, dressing, personal hygiene, total dependent of staff for toilet use. R1 had impairment on both sides of her upper extremities and an impairment on one side of lower extremity. R1 was on scheduled pain medication regimen. R1 had frequent pain on a numeric rate scale of 7 out of 10. R1's MD PN dated 12/29/21, indicated R1 continued to have ankle pain. R1 had chronic T9 compression fracture/back pain. R1's Narcotic Record (NR) dated 12/31/21, indicated one tablet of [MEDICATION(S)] HCL 5 mg signed out for administration at 1:26 a.m. and 5:30 a.m. R1's Medication Administration Record (MAR) dated 12/31/21, indicated R1 was not administered [MEDICATION(S)] HCL 5 mg. R1's NR dated 1/2/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was signed out for administration to R1 at 4:43 a.m. R1's January MAR dated 1/2/22, indicated R1 was not administered [MEDICATION(S)] HCL 5 mg. R1's MD PN dated 1/3/22, indicated R1 needed surgery as her ankle was not healing. R1's PN dated 1/7/22, indicated R1 was in the hospital for surgery. R1's Physician Order dated 1/7/22, indicated an order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg, provide two tablets by mouth every four hours as needed for pain rated 6-10; give one tablet for pain rated 1-5. R1's NR dated 1/8/22 indicated one tablet of [MEDICATION(S)] HCL 5 mg signed out for administration at 4:07 a.m. and 9:17 p.m. R1's January MAR dated 1/8/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was administered to R1 at 9:25 p.m. R1's NR dated 1/11/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was signed out for administration at 10:30 a.m. and 6:05 p.m. R1's January MAR dated 1/11/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was administered to R1 at 6:06 p.m. R1's NR dated 1/11/22, indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg signed out for administration at 12:50 a.m. R1's January MAR indicated on 1/11/22 indicated one tablet [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg was administered to R1 at 12:32 p.m. and two tablets at 1:52 a.m. (three total tablets). R1's care plan dated 1/12/22, indicated R1 had actual pain related to tibia fracture after a fall. Staff were to anticipate R1's need for pain relief and respond immediately to any complaint of pain. R1's NR dated 1/12/22 time indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg signed out for administration at 12:30 a.m. and an undocumented time. R1's MAR dated 1/12/22, indicated one tablet of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg administered at 2:21 p.m. and two tablets administrated at 12:28 a.m. R1's NR dated 1/12/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was signed out for administration to R1 at 4:00 a.m. and 9:00 a.m. R1's January MAR indicated on 1/12/22, one tablet of [MEDICATION(S)] HCL 5 mg was administered to R1 at 9:27 a.m. R1's NR dated 1/13/22, indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg were signed out for administration at 5:30 a.m., 9:17 a.m., and 2:06 p.m. R1's January MAR indicated on 1/13/22, one tablet of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg was administered at 8:04 p.m. and two tablets at 5:23 a.m. and 12:15 p.m. R1's NR dated 1/13/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was signed out for administration to R1 at an unidentifiable time and 2:17 p.m. R1's January MAR dated 1/13/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was administered to R1 at 2:44 a.m. and 2:16 p.m. R1's Pharmacy Consult dated 1/13/22, indicated R1 had two orders for as needed opioid medications: [MEDICATION(S)] HCL 5 mg once daily as needed and [MEDICATION(S)] 5-325 mg 1-2 tablet every 4 hours as needed. Request to please discontinue one of the orders to avoid having two as needed opioid medication orders. R1's Physician Order dated 1/14/22, indicated to discontinue an order [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg, provide two tablets by mouth every four hours as needed for pain rated 6-10; give one tablet for pain rated 1-5. R1's NR dated 1/15/22, indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg signed out for administration at an unidentifiable time, and an undocumented time. R1 January MAR indicated on 1/15/22, R1 was not administered [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg. R1's NR unidentifiable date and time, indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg were signed out for administration to R1. R1's MAR had no indication to reflect this. R1's NR dated 1/16/22, indicated one tablet of [MEDICATION(S)] HCL 5 mg was signed out for administration to R1 at 11:00 a.m., and two undocumented times. R1's January MAR dated 1/16/22, indicated R1 was administered one tablet of [MEDICATION(S)] HCL 5 mg at 2:25 a.m. and 2:23 p.m. R1's NR record indicated R1 ran out of [MEDICATION(S)] HCL 5 mg on 1/16/22. R1's January MAR indicated on 1/17/22, R1 had a pain level of 8. A handwritten note dated 1/18/22, indicated R1 complained of pain and of her pain medication. Nurse practitioner (NP)-B was contacted whom gave an order for R1's pain medication. R1's PN dated 1/18/22, at 3:07 p.m. indicated new order to use [MEDICATION(S)] in stock up to three times today until new [MEDICATION(S)] medication was received by pharmacy. R1's Provider PN dated 1/18/22, indicated R1 had a lot of pain. R1's medications had been hard to get straight. R1 did have [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) and [MEDICATION(S)] as needed but the [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) was recently stopped. R1 reported she has not had any pain medications over the weekend because she was told she was out. Registered nurse (RN)-A ordered [MEDICATION(S)] today. R1 reported she did not have her [MEDICATION(S)] ([MEDICATION(S)] Film 450 mcg) for several days and felt some withdrawal symptoms. R1 appeared to have been sweating often. R1 was distraught about her pain. R1 had good judgement, active, alert, and anxious. R1's pain was controlled with [MEDICATION(S)], Tylenol and [MEDICATION(S)]. RN-A and NP-B sorted out R1's medication. R1 was to increase her [MEDICATION(S)] to 5-10 mg every four hours as needed. [MEDICATION(S)] 4 mg 2 tables three times a day. R1 had a high risk for drug seeking but also with chronic opioids she is also a high risk for withdrawal which will exacerbate any sort of agitation. Plan to continue with [MEDICATION(S)] ([MEDICATION(S)]) 450 mg twice daily, [MEDICATION(S)] 5-10 mg every 4 hours as needed and [MEDICATION(S)] 8 mg TID. R1's Physician Order dated 1/18/22, indicated an order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg, provide two tablets by mouth every four hours as needed for pain rated 6-10 until 1/19/22, at 11:59 p.m. up to three tablets.; give one tablet for pain rated 1-5 every 4 hours for pain until 1/18/22, at 11:59 p.m. up to three tablets. R1's Physician Order dated 1/18/22, indicated to discontinue [MEDICATION(S)] HCL tablet 5 mg by mouth as needed for pain once daily. An order started [MEDICATION(S)] HCL tablet 5 mg: to give 1 tablet by mouth every four hours as need for pain rated 1-5 and an order to give 2 tables every four-hours as needed for pain rated 6-10. R1's NR dated 1/18/22, indicated two tablets of [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg signed out for administration at 1:00 p.m. and 6:00 p.m. R1's January MAR dated 1/18/22, indicated R1 administered was not administered [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) Tablet 5-325 mg. R1's Psychology Visit dated 1/18/22, indicated R1's primary focus was on pain and dissatisfaction with pain management. R1 had a history with chemical dependency treatment for opioids twice and was on a pain medication agreement. R1 reported inadequate relief of her pain associated with her surgery. R1's NR dated 1/19/22, indicated an [MEDICATION(S)] HCL Tablet 5 mg record was started. R1's January MAR dated 1/19/22 to 1/24/22, indicated R1 had two orders for [MEDICATION(S)] ([MEDICATION(S)]). An order indicated [MEDICATION(S)] 1 film buccally every 12 hours at 6:00 a.m. and 6:00 p.m. Another order indicated [MEDICATION(S)] ([MEDICATION(S)]) 1 film buccally every 12 hours at 8:00 a.m. and 8:00 p.m. R1's NR dated 1/20/22, indicated two tablets of [MEDICATION(S)] HCL 5 mg were signed out for administration to R1 at 8:41 a.m. and 1:43 p.m. R1's January MAR dated 1/20/22, indicated one tablet [MEDICATION(S)] HCL 5 mg was administered to R1 at 8:40 a.m. and two tablets at 1:43 p.m. R1 NR dated 1/20/22, indicated one film of [MEDICATION(S)] 1 film were signed out for administration at 6:00 a.m. 8:00 a.m. 6:00 p.m. and 8:00 p.m. R1's January MAR indicated on 1/20/22, R1 was administered one film of [MEDICATION(S)] at 6:00 a.m., 8:00 a.m , 6:00 p.m , and 8:00 p.m. R1's physician prescribed one film two times a day. R1's NR dated 1/21/22, indicated two tablets of [MEDICATION(S)] HCL 5 mg were signed out for administration at 12:36 a.m. 12:32 p.m. and 5:27 p.m. R1's January MAR indicated on 1/21/22, R1 was administered one tablet of [MEDICATION(S)] HCL 5 mg at 12:32 p.m. and two tablets at 12:36 a.m. and 5:26 p.m. R1's NR dated 1/21/22, indicated one film of [MEDICATION(S)] film were signed out for administration at 6:00 a.m. 8:00 a.m. 6:00 p.m. and 8:00 p.m. R1's January MAR indicated on 1/21/22, R1 was administered 1 film of [MEDICATION(S)] one film at 6:00 a.m., 8:00 a.m., 6:00 p.m. and 8:00 p.m. R1 NR dated 1/22/22, indicated one film of [MEDICATION(S)] film were signed out for administration at 5:40 a.m. 9:47 a.m. and 6:25 p.m. R1's January MAR indicated on 1/22/22, R1 was administered [MEDICATION(S)] one film of [MEDICATION(S)] at 6:00 a.m. 8:00 a.m. 6:00 p.m. R1's NR dated 1/22/22, indicated two tablets (four total) of [MEDICATION(S)] HCL 5 mg signed out for administration at 4:30 a.m. and 12:54 p.m. R1's January MAR indicated on 1/22/22, one tablets of [MEDICATION(S)] HCL 5 mg provided administered at 4:29 a.m. and 12:52 p.m. (two total). R1's NR dated 1/23/22, indicated two tablets of [MEDICATION(S)] HCL 5 mg were signed out for administration at 1:08 a.m. and 1:32 p.m. R1's January MAR indicated on 1/23/22, R1 was administered one tablet of [MEDICATION(S)] HCL 5 mg at 1:10 a.m. and 1:00 p.m. R1 NR dated 1/23/22, indicated one film of [MEDICATION(S)] was signed out for administration at 5:36 a.m., 8:00 a.m., and 6:00 p.m. R1's January MAR indicated on 1/23/22, R1 was administered [MEDICATION(S)] one film at 6:00 a.m. 8:00 a.m. 6:00 p.m. R1's NR dated 1/24/22, two tablets of [MEDICATION(S)] HCL 5 mg were signed out for administration to R1 at 3:26 a.m. 12:45 p.m. and 4:55 p.m. R1's January MAR indicated on 1/24/22, R1 was administered one tablet of [MEDICATION(S)] HCL 5 mg at 4:56 p.m. and two tablets at 3:26 a.m. and 12:45 p.m. R1's NR dated 2/1/22, indicated one tablet of [MEDICATION(S)] 5 mg was signed out for administration to R1. This date was inaccurate as it was dated in the future. During an interview on 1/24/22, at 11:27 a.m. R1 stated the facility ran out of medication. R1 further stated she had terrible pain when the facility ran out of her [MEDICATION(S)] and [MEDICATION(S)] last week. R1 stated she had to go two days without her medication. R1 stated she was in agony and suffering. R1 stated she needed the pain medications due to her surgery which caused her to hurt. R1 further stated she told staff she was in pain, but no one did anything until 1/18/22. R1 stated she had muscle spasm from sciatic nerve all the down and up her leg. R1 stated when she ran out of her pain medication it was like plunging one into withdrawal. During an interview on 1/25/22, at 9:49 a.m. RN-A stated on 1/18/22, R1 told her in the morning that she had been in pain. RN-A stated she became aware R1 was out of her pain mediation and informed R1. RN-A stated she had informed NP-B that R1 had run out of her [MEDICATION(S)] on 1/16/22. RN-A further stated NP-B saw her that day and ordered R1 to use [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) up to three times since it was on hand as needed until her [MEDICATION(S)] arrived from the pharmacy. RN-A further stated once the [MEDICATION(S)] arrived the [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) orders were to be discontinued. During an interview on 1/25/22, at 11:01 a.m. pharmacy technician (PT)-C stated an order for R1 was filled on 12/27/21, for a 29-day supply of as needed [MEDICATION(S)]. PT-C stated R1's order on 12/27/21, should not have been out on 1/16/22, as R1 was to only get the medication once a day. PT-C further stated the order should have lasted until 1/24/22, unless there was a new order made. PT-C stated on 1/18/22, there was an order made for a 5-day supply of [MEDICATION(S)] 5 mg, 1-2 tablets every 4 hours as needed. During an interview on 1/25/22, at 12:28 p.m. NP-B stated on 1/18/22, RN-A informed her that R1 ran out of [MEDICATION(S)] on 1/16/22, and verified R1 ran out earlier than she should have. NP-B further stated since R1 had some [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) in the cart she made an order to provide as needed until R1's [MEDICATION(S)] arrived from the pharmacy. NP-B also stated she became aware that the facility was doubling R1's [MEDICATION(S)] earlier that day on 1/25/22. NP-B stated R1 should have gotten 450 mg of [MEDICATION(S)] 2 times a day but instead the facility had given 450 mg of [MEDICATION(S)] four times a day. NP-B stated R1 did not appear have doubled dosed when she saw her around 12:10 p.m. on 1/25/22. NP-B stated she called licensed practical nurse (LPN)-A who worked the night prior for details, but LPN-A could not remember anything. During an interview on 1/25/22, at 1:22 p.m. the director of nursing (DON) stated when controlled substance came from the pharmacy it was the nurse's responsibility to put the quantity in the narcotics record book. DON further stated when a nurse gave a medication, they were to subtract the amount given from the quantity given in the narcotics book. DON stated at the end of a shift nurses were to count the number of medications left. DON stated on 12/21/21, R1 had an order for [MEDICATION(S)] 5 mg as needed once daily and on 12/27/21, the pharmacy delivered 29 tablets of [MEDICATION(S)]. DON verified R1 should not have run out of her [MEDICATION(S)] on 1/16/22. DON also verified R1 went 2 days without her [MEDICATION(S)] from 1/16/22, until 1/18/22. DON also verified that the MAR and NR did not match. During an interview on 1/25/22, at 2:04 p.m. the DON stated R1 accidentally got double the amount of [MEDICATION(S)]. DON further stated R1 was to have only two [MEDICATION(S)] films a day but instead received four for four days. DON stated the issue was the order was put into the MAR twice. DON further stated R1 had no side effects of being overdosed. During an interview on 1/26/22, at 10:44 a.m. LPN-D stated the reason he did not mark in the MAR after R1 received her medications could have been an issue with the facility's internet. LPN-D further stated he could not recall if the internet went out that day. During an interview on 1/26/22, at 11:12 a.m. R1 stated when she ran out of her pain medications, she felt horrible, was in pain, with anxiety and nausea. R1 stated she felt she was withdrawal. During an interview on 1/26/22, at 12:53 a.m. LPN-B stated when he worked, he likely messed up documenting in the MAR and narcotic record book as he was over tired and fatigue. LPN-B stated he should have given what the order indicated and documented currently in the MAR and narcotic record book. During an interview on 1/26/22, at 1:22 p.m. RN-C stated she was so sorry if she did not document accurately in the MAR. RN-C stated if she was to give R1 two versus one tablet under the wrong order she should have made a progress note in R1's medical record. During an interview on 1/26/22, at 1:45 p.m. LPN-A stated If there was an order for [MEDICATION(S)] 5 mg as needed once a day then a resident should only get 1 pill in 24 hours. LPN-A verified she should have not given R1 two pills in one day of [MEDICATION(S)] prior to her new order on 1/18/22. During an interview on 1/26/22, at 2:00 p.m. DON stated R1 had an order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) on 1/7/22, until 1/14/22. DON further stated on 1/18/22, NP-B gave a verbal one-day order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]). DON verified the narcotic book indicated pills were given between 1/14/22, and 1/18/22, when R1 did not have an order for [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]). DON also verified the MAR had no indication that [MEDICATION(S)]-Acetaminophen ([MEDICATION(S)]) was given to R1 from 1/15/22 until 1/18/22, when 10 tablets were subtracted from the narcotic book. The DON further stated her expectation would be for an order to be given per the physician order. DON stated her expectation was for the medication that was given should match medical record and the narcotic book. The facility Preparation and General Guidelines for Controlled Substance Policy dated 8/2019, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility. Accurate accountability of the inventory of all controlled drugs was maintained at all times. When a controlled substance was administered, the licensed nurse administering the mediation immediately enters the following information on the accountability record and the medication administration record (MAR): date and time of administration (MAR, Accountability Record), Amount administered (Accountability Record), Remaining quantity (Accountability Record), Initial of the nurse administrating the tablet after the medication was administered (MAR, Accountability Record). All controlled medications are reordered when a minimum supply remains to allow time for acquisition and transmittal of the required original written prescription to the provider pharmacy, if necessary.

Based on interview and document review, the facility failed to ensure documentation of a residents code status of do not resuscitate (DNR), do not intubate (DNI) (a tube inserted into an airway to maintain an airway and supplement a resident with oxygen) was documented in the electronic medical record (EMR) when 1 of 1 residents (R1) became unresponsive. This resulted in an immediate jeopardy (IJ) finding for R1 when the resident had a change in condition, stopped breathing and had no pulse, the order for DNR/DNI could not be located and emergency medical services (EMS) initiated cardiopulmonary resuscitation (CPR), including intubation of resident. The immediate jeopardy began on [DATE], after R1's resuscitation preference had changed from DNR-ok with short term intubation, to DNR/DNI. The change was not entered into R1's EMR. When R1 became unresponsive, without a pulse or breathing, the nurse could not locate R1's code status order in the EMR nor could the nurse locate R1's paper chart. As a result, EMS performed CPR for the resident who desired DNR/DNI. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 5:31 p.m. The immediate jeopardy was removed on [DATE], at 3:26 p.m. but remained at a lower scope and severity level of G, actual harm that is not immediate jeopardy. Finding include: R1's 5 day Minimum Data Set (MDS) dated [DATE], indicated R1 was rarely understood with unclear speech, did not have any behaviors or rejection of care. R1 used a wheelchair (wc) and received physical therapy, occupational therapy and speech therapy. R1's admitted from an acute care facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge paperwork dated [DATE], indicated partial code, no chest compressions, no defibrillation or cardioversion, but okay with short term intubation. R1's electronic admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Code Status Election Form was requested from the administrator for R1's admitted [DATE], and not provided. An admission progress note by licensed practical nurse (LPN)-A dated [DATE], at 4:11 p.m. indicated R1's code status was DNR with short term intubation. On [DATE], R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], by nurse practitioner (NP)-D indicated R1's code status was DNR with selective treatment, use medical treatment, antibiotics, IV fluids and cardiac monitor as indicated. No intubation, advanced airway interventions, or mechanical ventilation. May consider less invasive airway support such as continuous positive airway pressure (CPAP), a device to help you breathe. Transfer to hospital if indicated. Generally avoid the intensive care unit. All patients will receive comfort focused treatments. R1's care plan lacked documentation on R1's code status. A written verbal order [DATE], on R1's paper orders indicated R1's code status orders changed to DNR/DNI. A progress note dated [DATE], at 1:10 p.m. by LPN-B indicated the on-call physician was contacted and gave LPN-B the order to go to the emergency room at 11:46 a.m. based on R1's status. Immediately, LPN-B called 911. R1 expired at 12:30 p.m. before paramedics left the facility. On call physician, family and the management notified. A progress noted initiated by LPN-B dated [DATE], at 3:41 p.m. indicated the event that related to 911 call in the morning. LPN-B was in R1's room to check and administer medication and found R1's condition changed. Vitals: blood pressure ,d+[DATE], temperature 96.7, oxygen saturation 95% on room air, pulse 65, respiratory rate 20 per minute. During an interview on [DATE], at 9:30 a.m. NP-D stated during a visit on [DATE], R1 had an altered level of consciousness and was less responsive. NP-D attempted to call R1's family members (F)-E and (F)-F on [DATE]. NP-D stated she did get in touch with F-E and F-F on [DATE], at 5:00 p.m. updating them on R1's status. F-E and F-F agreed that R1 should be a DNR/DNI code status. NP-D wanted to fax the updated code status orders to the facility. NP-D stated she attempted to call the facility and no one answered the phone. Further, NP-D stated she received an e-mail from LPN-A and replied back with a scanned copy of the change in code status to DNR/DNI and LPN-A would be entering the order in the electronic medical record (EMR). Additionally, NP-D stated LPN-A planned on writing the orders on a paper order sheet as a telephone order with read back. Further, NP-D stated she heard they tried to resuscitate [R1], and it broke [NP-D's] heart. During an interview on [DATE], at 10:05 a.m. weekend manager (WM)-C stated she was notified that 911 had been called and WM-C waited for EMS to arrive to escort them to the second floor. Further, WM-C stated it was a chaotic day and the paramedics were frustrated that the facility did not know what R1's code status was. Additionally, WM-C stated R1's paper chart could not be located during an initial search on R1's unit. Further, WM-C stated she had mistakenly accessed another resident's record on the EMR, who was a full code when searching for R1's code status in the electronic medical records. And the reason for the over-site was both R1 and the second resident, had the same initials. During an interview on [DATE], at 10:55 a.m. LPN-B stated she called 911 because LPN-B had spoken to the on-call physician and was told to call 911. LPN-B stated no one could find R1's paper chart. LPN-B stated that R1's code status should be in the EMR, however it was not able to be located and would be in R1's paper chart and the paper chart should be located on the unit's chart rack. Further, LPN-B stated WM-C, who was assisting, stated she found R1's full code on a hospital discharge medical record and it indicated R1 was a full code, (however, as WM-C interview above indicated, WM-C was looking in the wrong chart). As a result, EMS initiated CPR and R1 was intubated. Additionally, LPN-B stated R1's paper chart was found approximately 20 minutes later and it was realized that R1's code status was DNR/DNI. LPN-B then contacted R1's on call physician who stated if R1 was a DNR/DNI they should stop working on R1. Paramedics stopped resuscitative efforts and R1 was pronounced dead on [DATE], at 12:30 p.m. Additionally, LPN-B stated the paper chart is where she would look if there were questions on R1's code status. During interview on [DATE], at 11:15 a.m. LPN-A stated R1's initial admission code status was DNR- short term intubation only. Further, LPN-A stated on [DATE], R1's code status had been changed to DNR/DNI in the EMR and LPN-A discontinued R1's order for DNR- short term intubation in the EMR and then LPN-A was pulled away and did not enter the new DNR/DNI into the EMR. LPN-A stated a POLST had been completed by NP-D on [DATE], and was attached to an e-mail sent to LPN-A. Additionally, LPN-A stated the paper chart is the source of truth on a resident's code status. During an interview on [DATE], at 12:40 p.m. F-E stated she and F-F had decided R1's code status should be DNR/DNI when they spoke with NP-D on [DATE]. During an interview on [DATE], at 1:10 p.m. the administrator and DON stated they completed a GAP analysis- (which involves the comparison of actual performance with potential or desired performance) after CPR was performed on R1. The administrator and DON stated they had audited the remaining residents' code status for accuracy, interviewed WM-C, LPN-A and LPN-B and provided performance feedback to WM-C and LPN-A. However, no other staff had yet been educated on the process on when a code status changes, where paper charts should be kept or completion of orders in the EMR or the process of proper identification of a resident. The administrator and DON stated the root cause of R1 being resuscitated against R1's wishes was due to a transcription error by LPN-A. Additionally, the administrator stated R1's advance directives should have been scanned into the EMR and had not. The immediate jeopardy that began on [DATE], was removed on [DATE] at 3:26 p.m., when it was verified that the facility had provided training to nurses and scheduled mandatory education sessions prior to staff working their next scheduled shift. The facility created a new process to identify where paper charts should be located and what staff are expected to do if they removed the paper chart from the chart rack including to use red laminated cards if the chart is removed from the chart rack. The red laminated cards indicate where the paper chart can be located in case of an emergency. The training also included education on processing orders, proper identification of a resident and the process for family notification. Further, the facility educated on when facility management should be notified of any event that requires law enforcement be notified. A facility policy titled, Advance Directives and Care Planning Guidelines dated [DATE], with no revision date. Objectives for this requirement is to establish a facility practice to educate and inform the resident of their rights, promoting the resident their right to accept or refuse medical or surgical treatment, refuse to participate in experimental research, and to formulate an advance directive in assisting the resident to exercise his/her rights. Resident choices will be incorporated into treatment, care and services. Upon admission, identify if the resident has an advanced directive and if not, determine if the resident wishes to formulate an advance directive. A resident has the option to execute advance directives but will not be required to do so. The facility will not discriminate against a resident based on whether he or she has executed an advance directive. All advance directives document copies will be obtained and located within the medical record The advance directives are present within the medical record for the facility staff and physicians The resident will be evaluated periodically for decision making ability capacity and for changes in resident preferences and choices In order for a resident to exercise his or her rights to make informed choices about care and treatment in preparation for a time when the resident may not be able to make decisions, designated personnel and/or physician will assist with defining and clarifying medical issues and presenting the information regarding relevant health care issues to the resident of his/her legal representative, in a language that the resident can understand, as appropriate