Every finding on record at The Villas at Robbinsdale

Based on observation, interview and document review the facility failed to ensure they had an accurate accounting of controlled substances in 2 of 2 medication carts reviewed for medication storage.Findings include:During an observation on 7/16/26 at 11:57 a.m., of the fourth-floor south medication cart with registered nurse (RN)-A a comparison of the narcotic control book and the narcotic cards was made. Page 81 carisoprodol (a prescription skeletal muscle relaxant used for the short-term relief of acute, painful muscle spasms and injuries) 250 milligrams (mg) showed there should have been one pill left in the card. RN-A was not able to find a matching card with the medication in the locked medication drawer. The last time the medication was dispensed was on 6/1/26.During an interview on 7/16/26 at 12:17 p.m., RN-A verified the count had been incorrect since 6/1/26.During an interview on 7/16/26 at 12:27 p.m., RN-D stated they control the count from the narcotic drawer by calling out the card and page number, then said it would be better to count from the book. RN-D checked the drawer and was not able to find the card to match page 81.During an observation on 7/16/26 at 12:31 p.m., the DON and RN-D performed a narcotic count using the index page to control the count. There were no corresponding cards to match the following pages:114 Hydromorphone 2 mg (a powerful prescription opioid medication used to treat moderate to severe pain)115 buprenorphine 2 mg (a partial opioid agonist prescribed to treat opioid disorder and to manage severe chronic or acute pain)118 alprazolam 1 mg (benzodiazepine used to treat anxiety, panic, and anxiety caused by depression)120 tramadol 25 mg (opioid pain medicine used to treat moderate to moderately severe pain)129 tramadol 50 mg130 buprenorphine 2 mg131 oxycodone 5 mg (strong opioid pain medicine)132 oxycodone 5 mg133 tramadol 50 mg134 alprazolam 1 mg139 oxycodone 5 mg141 butal/APAP 50-30 (prescription medicine used to treat tension headaches)142 oxycodone/APAP 10-325 mg143 oxycodone 10 mg144 carisoprodol 250 mg146 alprazolam 0.5 mg152 oxycodone 5 mg154 oxycodone 5 mg155 oxycodone 5 mg156 alprazolam157 butal/APAP 50-325 mg159 buprenorphine 2 mg161 oxycodone162 alprazolam 0.5 mg163 buprenorphine 2 mg165 oxycodone 10 mg166 alprazolam 1 mg167 alprazolam 0.5 mgDuring an interview on 7/16/26 at 12:41 p.m., the DON stated the facility was not following the process for narcotic counts and did not have control of their narcotics.During an observation on 7/16/26 at 12:42 p.m., the DON and licensed practical nurse (LPN)-C completed a narcotic count using the index page and found the same concern, medications listed as still current in the index page but no card to match. The [NAME] stated the narcotics had not been crossed out when they were used or destroyed. During an interview on 7/16/26 at 12:49 p.m., the DON stated narcotics should be signed into the index page and crossed out on the index page when the medication was completed or when the medication was destroyed.During an interview on 7/17/26 at 10:37 a.m., the consultant pharmacist (CP) stated she would expect staff to sign narcotics into the book using the index page. CP also stated she would expect the staff to perform a narcotic count at each shift change using the index page of the narcotic book and if there were any discrepancies she would expect them to look into the concern immediately and resolve and or report the concern. She stated the purpose of the shift count was to ensure they maintained an accurate accounting of the controlled substances. CP stated staff should log the narcotic into the book, sign the narcotic out of the book when it was dispensed or when the narcotic was destroyed. The policy Medication Storage in the facility - controlled substance storage dated 1/2026, identified at each shift change or when keys were transferred a physical inventory of all controlled substances, including refrigerated items would be conducted by two licensed nurses and would be documented. Any discrepancies would be reported to the DON or designee immediately and every reasonable effort would be made to reconcile the discrepancy.

Based on observation, interview, and document review, the facility failed to ensure the correct physician provider orders for life-sustaining treatment (POLST) were in the correct chart for 1 of 1 resident (R46) reviewed for resuscitation orders.Findings include:R46's Diagnosis Report dated [DATE], identified R46 had diagnoses which included hypo-osmolality and hyponatremia (this state causes water to shift into cells, leading to potentially dangerous cellular swelling, particularly in the brain), cellulitis of left lower limb, anxiety disorder, depressive disorder, and neoplasm of unspecified behavior of endocrine glands and other parts of nervous system.R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 was cognitively intact.R46's Order Summary Report identified R46 had an order dated [DATE], for do not resuscitate (DNR).R46's care plan dated [DATE], identified R46 had code status identified as a problem, interventions included to arrange a medical doctor consultation as necessary, review the resident's advance directive as needed per the resident's and/or family's request, and staff were directed to follow the POLST guidelines.R46's POLST dated [DATE], identified she had checked DNR and had signed the documentation of discussion.During a record review on [DATE] at 9:32 a.m., R46's electronic medical record (EMR) banner identified R46 showed DNR.During a record review on [DATE] at 9:33 a.m., R46's EMR record showed R48's POLST had been scanned into R46's record. R48's POLST identified she wished to have cardiopulmonary resuscitation (CPR), and the documentation of discussion was dated [DATE].During an interview on [DATE] at 9:43 a.m., R46 stated her wishes were to not have CPR .During an interview on [DATE] at 12:23 p.m., licensed practical nurse (LPN)-A reviewed R46's EMR and verified the EMR banner identified R46's was listed as DNR. LPN-A then reviewed the POLST in R46's EMR, she verified R48's POLST was in R46's EMR. LPN-A verified the wrong POLST was in R46's EMR.During an interview on [DATE] at 12:42 p.m., the director of nursing (DON) stated she had heard the wrong POLST was in R46's EMR. The DON stated having the wrong POLST in an EMR could lead to someone receiving CPR who didn't want it and the opposite someone who wanted CPR might not receive it. During an interview on [DATE] at 12:56 p.m., the DON stated the process for the POLST was to go over the resident's wishes upon admission with them, then the POLST would be completed and scanned into the EMR. The DON stated admissions or medical records would scan the document into the medical records.The POLST Documentation Procedure dated 4/2025, identified the wishes of the resident or the resident representative would be discussed and verified, an order would be obtained if needed, the order would be placed in the EMR, and the POLST document would be uploaded into the miscellaneous section of the EMR. The procedure identified a routine audit of the POLST documentation should be completed to ensure consistent and accurate documentation of the POLST form, physician orders, the care plan and entry in PCC (point click care).

Based on interview and document review, the facility failed to ensure physician-ordered monitoring for potential adverse effects related to antipsychotic medication use was completed when orthostatic blood pressures (BP) were not obtained as ordered for 1 of 5 residents (R6) reviewed for unnecessary medication use.Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and required assistance with activities of daily living (ADLs). Diagnoses included dementia, bipolar, sleep apnea, hyperlipidemia, and insomnia. R6's physician orders printed 7/17/26, identified an order for risperidone Oral Tablet 0.5 milligrams (mg) by mouth at bedtime for bipolar disorder. R6's physician orders further identified an order to obtain monthly orthostatic blood pressures (lying, sitting, standing blood pressures) due to antipsychotic medication use, initiated 2/1/26. R6's electronic medical record (EMR) was reviewed from March 2026 through July 2026. May 2026 R6's lying, sitting, and standing blood pressure were all recorded as 116/68, June 2026 R6's lying, sitting, and standing blood pressure were all recorded as 111/68, and July 2026 R6's lying, sitting and standing blood pressure were all recorded as 121/68. When interviewed on 7/16/26 at 10:25 a.m. licensed practical nurse (LPN)-B stated orthostatic blood pressures were done by doing a blood pressure while the resident was lying down, leave the blood pressure cuff on. The resident should be assisted to sit on the edge of the bed with another blood pressure completed while they were sitting. Then have the resident stand up if they were able to and do a third blood pressure. When interviewed on 7/16/26 at 11:09 a.m. registered nurse (RN)-B stated orthostatic blood pressures were expected to be done monthly, RN-B reviewed R6's orthostatic blood pressures and stated there was only one blood pressure that was done and that one reading was recorded for each of the three blood pressures rather than three different readings being done in succession. When interviewed on 7/16/26 at 11:35 a.m. director of nursing (DON) stated the expectation was for the nurses to do orthostatic blood pressures once monthly with lying, sitting, and standing blood pressures being done one after the other as residents receiving antipsychotic medications have a tendency for their blood pressures to drop when they changed positions. DON stated they were not aware that the nurses were not doing the orthostatic blood pressures correctly. Facility policy regarding monitoring orthostatic blood pressures was requested, however, none was provided.

Based on observation, interview and document review, the facility failed to ensure oxygen orders were followed as written for 1 of 1 resident (R48) reviewed for oxygen therapy.Findings include:R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 had diagnoses which included chronic obstructive pulmonary disease (COPD [a long-term lung condition that blocks airflow and makes it hard to breathe]), chronic pain, hypertension, and rheumatoid arthritis (a long-term autoimmune disease where the immune system attacks the lining of joints).R48's Order Summary Report identified R48 had an order for two liters of oxygen per nasal cannula continuously due to COPD related to hypoxia dated 6/16/26.R48's care plan, reviewed on 7/14/26, identified R48 had an alteration in oxygen/gas exchange, respiratory status related to chronic respiratory failure, and asthma. Interventions included the following: raise the head of the bed for comfort, monitor oxygen levels saturations as ordered and as needed, administer oxygen as ordered, monitor for cyanosis, accessory muscle use, shortness of breath, increased respirations, and difficulty coughing up sputum, and to keep the medical doctor informed of changes.During an observation on 7/13/26 at 2:36 p.m., R48's oxygen was noted to be at three liters per nasal cannula.On 7/16/26 at 8:51 a.m., R48's oxygen was observed at three liters per nasal cannula. Registered nurse (RN)-A verified the oxygen was at three liters and not at two liters as ordered. RN-A stated staff needed to follow the orders to prevent hypercapnia (a medical condition where a person would have too much carbon dioxide in their blood). RN-A stated staff should follow the orders as written and stated the day nurse said they often had to turn the oxygen down from the night shift.During an interview on 7/16/26 at 12:56 p.m., the director of nursing (DON) stated staff were expected to follow the oxygen orders as written and stated it could actually hurt a resident with COPD by giving them too much oxygen. The DON stated staff were expected to call the provider if they thought a resident needed more oxygen.The facility's Medication and Treatment Orders policy, dated 2/2024, identified medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state.

Based on observation, interview and document review, the facility failed to ensure tobacco products were maintained in a secured, locked container when not in use for 1 of 1 residents (R53) reviewed for smoking safety.Findings include:R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 refused to answer brief interview for mental status (BIMS) questions and was independent with activities of daily living. A previous BIMS assessment completed on 6/15/26 indicated R53 had severe cognitive impairment. R53's smoking evaluation dated 3/29/26, identified R53 as a smoker and was educated on safety and storage. The resident handled the cigarettes and lighter independently and stored them in a drawer. R53's care plan dated 4/12/26, indicated R53 currently smoked at the facility and was given a metal box for the smoking materials. The goal was R53 would follow the facility smoking policy with an intervention of risk and benefit of smoking violations, smoking assessment as needed for example if there was a change in resident's condition. The care plan also identified R53 used smokeless tobacco. R53 rolled own cigarettes and kept them in a lock box in the room. R53 was given the risks and consequences of inappropriate smoking or storage in the lock box. On 07/13/26 at 2:33 p.m., an open lock box containing loose tobacco was observed sitting on a small table next to the resident's bed. Loose tobacco was also observed on the tabletop. The lock box was wide open. At 2:36 p.m., R53 independently left the nursing unit to smoke. The opened lock box containing tobacco remained on the table next to the resident's bed. At 3:47 p.m. R53 again left the unit to smoke. The lock box remained open with tobacco accessible on the table next to the bed. On 07/14/2026 at 2:54 p.m. R53 independently left the unit, the lock box remained open on the small table with loose tobacco inside. On 07/15/2026 at 7:55 a.m., R53 was out of the room, the lock box was open on the small table next to the bed with loose tobacco inside the box and scattered across the tabletop. At 8:08 a.m. R53 was in the dining room, the lock box remained open with tobacco inside the box and scattered across the tabletop. At 2:41 p.m. R53 left the unit, the lock box remained open on the table with tobacco inside and scattered across the tabletop. On 07/16/2026 at 8:17 a.m., R53's lock box remained open on the small table with tobacco inside and a small amount of tobacco on the tabletop. During an interview on 7/16/26 at 11:00 a.m., registered nurse (RN)-C stated that residents who independently smoked were provided a lock box to store tobacco products. RN-C stated It was up to resident to lock it. RN-C further stated R53 would not allow the staff to lock the box. During an interview on 7/16/26 at 11:35 a.m., director of nursing (DON) stated smoking materials were expected to be stored in a locked drawer or a locked box when it was not in use. DON acknowledged R53 was not safely storing tobacco products and identified the potential risk of other residents accessing the tobacco products if left unsecured. The facility's Resident Smoking policy dated 11/2025, indicated if a resident identified as a current smoker the storage of supplies was determined by the facility based on the resident's smoking assessment.

Based on observation, interview and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 7.41% with 2 errors out of 27 opportunities for error involving 1 of 4 residents (R19) who were observed during the medication passes.Findings include:R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had diagnoses which included coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, and multiple sclerosis.R19's Order Summary Report dated 7/16/26, identified R19 had the following orders:insulin aspart (a fast-acting, man-made insulin) per sliding scale 150-199 = 8 units subcutaneously (sq)200-249 =10 units250-299 = 12 units300-349 = 14 units350-399 = 16 units400-999 = 18 units call provider if over 400 and administer 18 units dated 6/5/26insulin glargine (a long-acting man-made insulin) 12 units sq two times per day dated 6/5/26Januvia (an oral agent taken once daily to manage blood sugars) 50 milligrams (mg) by mouth one time a day dated 7/9/26During an observation on 7/15/26 at 7:49 a.m., licensed practical nurse (LPN)-C scrubbed the hub of the insulin pen, attached an insulin needle and drew up 12 units of insulin aspart. LPN-C did not waste two units of insulin prior to drawing up the 12 units of insulin. Next LPN-C scrubbed the hub of insulin glargine, attached an insulin needle and drew up 12 units of insulin. Again LPN-C failed to waste two units of insulin prior to drawing up the insulin.During an interview on 7/15/26 at 8:06 a.m., LPN-C verified she did not prime the insulin needles prior to drawing up the insulins, stating a prior nurse manager had told her it was not necessary.During an interview on 7/15/26 at 8:38 a.m., the director of nursing (DON) stated she expected nurses to prime the insulin needles with two units of insulin prior to drawing up the insulin dose to ensure the resident received the full dose as ordered.During an interview on 7/15/26 at 9:05 a.m., the consultant pharmacist (CP) stated in general the insulin needle should be primed with two units of insulin to push air out of the needle to ensure the resident received the ordered dose of insulin. The Medication and Treatment Orders policy dated 2/2024, did not address priming insulin needles.

Based on observation, interview and document review, the facility failed to ensure the medication refrigerators in 2 of 2 medication rooms were at the proper temperature for medication storage.Findings include:During an observation on 7/16/26 at 10:58 a.m., with the director of nursing (DON), the refrigerator in the second-floor medication room had a temperature reading of 30 degrees Fahrenheit (F). A review of the July temperature log identified eight of the recorded temperatures were below 36 degrees F. A copy of the July temperatures was requested but not provided.The refrigerator contained the following:Lantus insulin (a long-acting basal insulin to treat type 1 and type 2 diabetes)Novolog insulin (a rapid-acting insulin used to control high blood sugars)Latanoprost eye drops (used to treat high pressure inside the eye)Timolol eye drops (used to treat high pressure inside the eye)Formoterol (bronchodilator used to treat chronic obstructive pulmonary disease and asthma)Methylprednisolone (corticosteroid used to suppress the immune system and reduce severe inflammation in conditions like arthritis, asthma, severe allergies, and flare-ups of multiple sclerosis)Bisacodyl suppositories (a fast-acting, rectal stimulant laxative to treat occasional constipation)During an observation and interview on 7/16/26 at 11:16 a.m., with the DON of the fourth-floor medication room, the medication temperature reading was 39 degrees F. There were no temperatures recorded for July. A request for the past three months of temperatures was requested but not provided. The refrigerator had insulins, emergency kits and inhalers. A copy of the contents was requested but not provided. The DON stated staff were expected to record the medication refrigerators daily and to report any concerns if the temperature was out of the safe range.During an interview on 7/16/26 at 11:27 a.m., the consultant pharmacist (CP) said the facility needed to check the manufacturer's directions for each medication to determine if it was still viable and would consider the last recorded temperature out of range to be when the medication was no longer considered to be refrigerated. The CP stated they would expect the facility to take corrective action when the temperature was out of the safe temperature range.The facility's Medication Storage policy, dated 1/2026, identified the refrigerator temperature should be maintained between 36 degrees to 46 degrees F.

Based on observation, interview and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) prior to entering 1 of 1 resident's (R48) room who was in contact precautions.Findings include:R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 had diagnoses which included chronic obstructive pulmonary disease (COPD [a long-term lung condition that blocks airflow and makes it hard to breathe]), chronic pain, hypertension, and rheumatoid arthritis (a long-term autoimmune disease where the immune system attacks the lining of joints).R48's Order Summary Report identified R48 had an order for contact precautions dated 7/14/26.R48's care plan, reviewed on 7/14/26, identified R48 had isolation precautions related to left hand ring finger abscess initiated on 7/14/26. The goal was listed as All staff to follow isolation precautions. Interventions included to follow infection control precautions, and to place a sign on the resident's door.During an observation on 7/14/26 at 2:01 p.m., a staff was observed standing by R48's bed, staff were not wearing any personal protective equipment (PPE).During an observation on 7/15/26 at 12:39 p.m., nursing assistant (NA)-A was observed delivering a meal tray to R48, they were not wearing any PPE.During an interview on 7/15/26 at 12:43 p.m., NA-A stated when someone was in contact isolation staff should wear an isolation gown and gloves whenever they entered the room. NA-A verified they did not do this when they delivered the meal tray and situated R48 for lunch.During an interview on 7/16/26 at 9:41 a.m., the infection preventionist (IP) stated staff were trained on isolation precautions on hire, annually, and when there were changes. IP stated staff were expected to read the isolation sign posted on the door and to follow the directions on the sign.During an interview on 7/16/26 at 12:56 p.m., the director of nursing (DON) stated staff were expected to gown and glove every time they entered a resident's room if the resident was in contact isolation. The DON stated this was important to do to prevent the spread of infection.The sign Contact Precautions, undated, identified staff must put on gloves and gloves before entry into the room.The facility's Infection Prevention and Control - Contact Precautions policy, dated 7/31/23, identified healthcare personnel caring for residents in contact precautions should wear a gown and gloves for all interactions that may involve contact with the resident.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R6, R46) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).Findings included: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2025, 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 no prior pneumococcal vaccine should receive PCV20 or PCV21, those who 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. R6's face sheet dated 7/17/26, indicated R6 was [AGE] years old. The immunization report dated 7/17/26, indicated R6 received a PPSV23 on 8/1/07 followed by PCV13 on 10/17/14. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R6 was offered or received PCV20. R46's face sheet dated 7/17/26, indicated R46 was [AGE] years old. The immunization report dated 7/17/26, indicated R46 received a PPSV23 on 10/18/22. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R6 was offered or received PCV20. During interview on 7/15/26 at 8:28 a.m. registered nurse (RN)-B stated when a resident admitted they looked at immunizations the resident had already received. If the resident was eligible for a vaccine, the resident was talked to regarding which vaccinations were due and obtained consent or refusal. If consented, the vaccination was administered and documentation of receipt of the vaccination or refusal was indicated in the resident's medical record. RN-B stated annually when it was time for influenza vaccinations all residents were reviewed for other vaccinations, they may be due for and were again offered. When interviewed on 7/16/26 at 11:35 a.m. director of nursing (DON) reviewed R6 and R46 electronic medical records, stated both residents should have been offered the PCV20 and were not. The expectation was for pneumococcal to be offered and administered if they consented when admitted and then vaccinations were to be reviewed and offered if not up to date at least yearly when influenza vaccinations were done. Facility Pneumococcal policy dated 2/24 indicated all residents would be assessed for current immunization status and eligibility to receive the pneumococcal vaccine, within thirty days of admission the resident would be offered the vaccine. The policy further indicated the pneumococcal vaccination would be administered per physician order and CDC recommendations and would be documented in the residents' medical record, if the resident refused vaccination the date of refusal would be documented in the medical record.

Based on interview and document review, the facility failed to ensure the Ombudsman was notified of a facility transfer for 1 of 1 resident (R73). Findings include: R73's admission record dated 7/16/26, indicated diagnosis included acute cystitis (medical inflammation of the bladder, usually caused by a bacterial infection) without hematuria (red blood cells in the urine), adult failure to thrive, transient ischemic attack (TIA) and cerebral infarction without residual deficits, other symptoms and signs involving cognitive functions and awareness. R73's provider progress note dated 5/19/26, indicted R73 was being transferred to a memory care center. R73's discharge instructions and summary dated 5/19/26, indicated it was a facility-initiated discharge and must notify the Ombudsman. The facility's Monthly Notice to MN Office for Long-Term Care (LTC) of Emergency Acute Care Transfers and Discharges dated June 2026 lacked R73's name being faxed to the LTC Ombudsman. An interview on 7/14/26 at 2:16 p.m., social services designee (SSD) stated R73 had been transferred. SSD stated R73 was not on the list of transfers and discharges that were faxed to the LTC Ombudsman. SSD stated R73 should have been on the list. SSD stated R73 should have been put on the discharge log that was completed. At 3:27 p.m., SSD stated it was human error on my part. The facility policy Ombudsman Hospital Transfer Report dated 8/2025, indicated the report would be sent monthly, typically within the first 5 days of the month for the previous month. Run the report in PCC (Point Click Care), using the following instructions: go to Admin tab, reports, action summary, ensure your date range is correct, action code-clear it all and the scroll to the bottom and click Transfer out to hospital, discharge date , Discharge/Transfer New Facility. Ensure all payer types are selected, click show to/from description, run report. Then fax the report to the Ombudsman. Once faxed print a fax confirmation.

Based on interview and document review the facility failed to provide supervision and care planned individualized interventions resulting in the risk for serious harm, injury impairment or death for 1 of 5 residents (R1) who was an elopement risk, was actively attempting to leave the facility, and succeeded with eloping on 3/7/26. R1 was located one hour and 20 minutes later, by the police, about 5 blocks from the facility. In addition, to R1 in immediate jeopardy, the facility failed to develop supervision and care planned individualized interventions with the potential for harm that is not immediate jeopardy for 3 of 3, residents (R3, R4, R5) reviewed for elopement risks. The immediate jeopardy began on 3/7/26 when the facility failure to provide adequate supervision resulted in R1's elopement and was identified on 3/13/26. The administrator and director of nursing were notified of the immediate jeopardy at 12:05 p.m. on 3/13/26. The immediate jeopardy was removed on 3/17/26, but noncompliance remained at a lower scope and severity level 2, D isolated scope, and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include: R1's admission minimum data set (MDS), dated [DATE], indicated she had a diagnosis of malnutrition, severe cognitive impairment, did not exhibit wandering, and was completely dependent on staff for all personal care and mobility. R1's elopement assessment, dated 3/3/26, indicated R1 was an elopement risk, displayed agitation and wanted to go home. She had cognitive impairment, was able to self-propel her wheelchair, and was actively exit-seeking. R1's care plan, dated 3/3/26, indicated R1 was at risk for elopement. The care plan directed wander device in place, wander device will be monitored for proper functioning and door alarms would be answered promptly. The care plan lacked staff supervision and individualized interventions. A progress note dated 3/3/26 at 4:06 p.m., indicated R1 was exit-seeking, pushing on the exit door and was expressing she wanted to go home. R1 was going up and down the hallway in her wheelchair. She was cognitively impaired, and her elopement assessment indicated she was at risk for elopement. A wander device was placed on her right wrist. A progress note dated 3/3/26 at 5:56 p.m., indicated R1 was wandering around the unit all day long and had tried to leave. R1 was confused, disoriented, and walking around against nurse advice. She had tried to leave a few times. Continue to monitor for confusion and elopement. A progress note dated 3/6/26 at 1:07 p.m., indicated R1 was wandering up and down the hallway, was confused and disoriented. R1 was wandering against nurse advice and attempted to leave a few times. Continue to monitor for confusion and elopement. A progress note dated 3/7/26 at 11:15 a.m., indicated R1 was confused, disoriented, and very agitated. R1 was wandering into other residents' rooms and called the police. R1 stated staff were holding her hostage and attempted to leave the facility multiple times despite redirection. A progress note dated 3/8/26 at 3:12 a.m., indicated R1 wandered out of the facility through the fourth-floor door. R1 was found 5 blocks away, by the police. R1 was sent to the hospital for assessment and returned to the facility. Review of the facility's video surveillance of the fourth-floor door, on 3/7/26, showed the following activity by R1, without her walker:At 8:17 p.m., R1 attempted to open the stairwell door immediately to the right of the fourth-floor door. Nursing assistant (NA)-B was observed to redirect R1 and reset the alarm.At 8:20 p.m., R1 turned the doorknob for the stairwell door. NA-B redirected R1 from the door and reset the door code.At 9:06 p.m., R1 pushed on the fourth-floor door and was redirected from the door.At 9:19 p.m., R1 pushed on the fourth-floor door and was redirected by NA-B. NA-B reset the alarm.At 10:29 p.m., R1 pushed both exit doors. RN-B reset the alarm and staff redirected her.At 10:45 p.m., R1 walked out the fourth-floor door. No staff were present. A police report indicated the initial call to 911 was at 11:58 p.m., on 3/7/26. The report indicated R1 was not dressed for the weather and was wearing all black. The police report indicated another caller from a home approximately 5 blocks from the facility reported a person matching R1's description was knocking on the door, yelling please help, and attempting to pull on the door latch. The police located R1 at the residence at 12:06 a.m., on 3/8/26. R1 appeared confused and was sent to the hospital for evaluation. Hospital documentation from the emergency department, dated 3/8/26, indicated R1 was admitted to the emergency department at 12:51 a.m., and was discharged in stable condition at 6:05 a.m., without injuries or medical concerns. Weather report on 3/12/26 from wunderground.com indicated the temperature was 32 degrees Fahrenheit with eight mile per hour winds at 10:45 p.m. R3's elopement assessment, dated 2/10/26, indicated she was an elopement risk, was confused and asked to go home. R3's care plan, dated 2/10/26, indicated she was exit-seeking upon admission, and she was disoriented to time, place, and person. She had a wander device on her left wrist. The care plan lacked staff supervision and individualized interventions. The care plan directed staff to monitor and document for exit seeking behavior, wander device in place, door alarms answered promptly and invite resident to activities. The facility NA care sheet did not indicate R3 was an elopement risk and lacked interventions to prevent elopement. R4's quarterly MDS, dated [DATE], indicated he had a diagnosis of dementia and severe cognitive impairment. He required supervision to walk with his walker for ambulation. R4's elopement assessment, dated 1/26/25, indicated he was at risk for elopement. R4's care plan, dated 9/22/25 indicated he was an elopement risk and had a wander device on his right hand. The care plan lacked staff supervision and individualized interventions. The care plan directed staff to monitor and document for exit seeking behavior, wander device in place, door alarms answered promptly and invite resident to activities. The NA care sheet indicated R4 had a wander device but lacked interventions to prevent elopement. R5's quarterly MDS, dated [DATE], indicated she had diagnoses of breast cancer, dementia, and moderate cognitive impairment. She could ambulate with supervision. R5's elopement assessment, dated 1/26/26 indicate R5 was at risk for elopement. R5's care plan, dated 10/28/24 indicated she was at risk for elopement due to acute encephalopathy and confusion. She had a wander device in use. The care plan lacked staff supervision and individualized interventions. Staff were to monitor and document for exit seeking behavior, wander device in place, door alarms answered promptly and invite resident to activities. The facility NA care sheet did not indicate R5 was an elopement risk and lacked interventions to prevent elopement. During an interview on 3/12/26 at 11:46 a.m., nursing assistant (NA)-A, an agency NA, stated it was her first shift at the facility. She was not alerted to any residents who were at risk to wander or elope. NA-A stated she had a sheet to reference each residents' needs, but the sheet did not indicate elopement risks. During an interview on 3/12/26, at 12:00 p.m., NA-B, an agency NA, stated it was her first shift at the facility. She was not alerted to any residents who were at risk to wander or elope. NA-B stated her care sheet did not indicate any residents at risk for elopement. During an interview on 3/12/26, at 12:05 p.m., the social service designee (SSD) stated R1's physical condition improved quickly. The elopement assessment on 3/3/26 was conducted when R1 was observed halfway out the door, stating she wanted to go home, and the wander device was initiated at that time. SSD stated R1 also made attempts to leave via the elevator as well, stating she wanted to go home. During an interview on 3/12/26, at 12:25 p.m., licensed practical nurse (LPN)-A stated he was aware of the residents who were at risk for elopement. He was responsible to ensure the wander device was in place and check the expiration date every day but was not responsible for checking the functionality of the device. He stated the nurse managers (NM) were responsible for determining whether the device was working correctly. During an interview on 3/12/26, at 12:38 p.m., NM-A stated the nurses on the floor were responsible to test the wander device by bringing the test box to the resident every day on the day shift. She was responsible for replacing the device before the expiration date. NM-A stated the NA's received a care sheet at the start of their shift that indicated which residents were an elopement risk and how to care for them. During an interview on 3/12/26, at 1:05 p.m., NA-C, an agency NA stated it was her first shift at the facility. She received an orientation to the facility; it did not include which residents were at risk for elopement. She stated she received a care sheet indicating what each resident requires, but it did not include elopement risks. During an interview on 3/12/26, at 1:37 p.m., registered nurse (RN)-A stated she worked 3/7/26 in the evening before R1 eloped. RN-A stated the staff watched R1 closely and redirected her but did not implement any formal interventions, other than the wander device. During an interview on 3/12/26, at 2:31 p.m., RN-B stated she was working when R1 eloped and realized R1 was missing as she was giving report to the nurse for the night shift. R1 was wandering earlier in the evening and attempted to elope twice through the door and through the elevator during her shift. RN-B stated, it wasn't any problem, as R1 was able to be redirected. She did not implement additional interventions for R1 as she had a wander device in place and only the NM or director of nursing (DON) could make care plan changes. RN-B stated she was not advised that R1 had multiple attempts to leave the facility that evening. During an interview on 3/12/26, at 2:25 p.m., NM-B stated R1 had been escalating in the days prior to her elopement and was much more agitated and confused, setting off the wander alert system several times on 3/7/26 from approximately 10:00 a.m. to 2:00 p.m. NM-B stated additional supervision for residents should have been added to the care plan. She stated residents at risk for elopement should be noted on the care sheets provided to the NA's. NM-B stated R3's elopement risk was not indicated on the care sheet. NM-B also stated the nurses were expected to ensure placement of the wander device each shift and test the device on the day shift. During an interview on 3/12/26, at 3:10 p.m., the DON stated R1's physical condition progressed quickly, from being non-ambulatory to walking independently. R1 had not been exit-seeking prior to her elopement incident on 3/7/26. R1's wander device alerted when she walked too close to the sensors on the elevator as her friends left. The DON stated she expected the nurse would have called her that evening, when R1 made multiple attempts to exit the facility and interventions would have been established. There was a list of residents identified as elopement risks at each nursing station. The NA care sheets should have indicated which residents were at risk to elope. All nurses could make changes to the care plan. The wander device was expected to be checked for proper function daily. Immediately following the elopement incident, the code alert system and automatic locking doors were tested. The DON stated education related to the elopement policy and one-to-one resident supervision was reviewed with all staff. During an interview on 3/12/26, the administrator stated the code alert system and automatic locking doors were tested multiple times following R1's elopement incident and a technician came to the facility but was unable to determine why the system did not alert when R1 eloped. She stated she was unaware of R1's increased exit-seeking behaviors prior to her elopement. During an interview on 3/13/26, at 9:28 a.m., NA-D stated he was working directly with R1 on the evening of 3/7/26. R1 was acting differently on 3/7/26, as she wandered room to room, called the police, and was trying to get out. He stated he redirected her away from the doors multiple times and notified RN-B of this. The immediate jeopardy that began on 3/7/26 was removed on 3/17/26, when the facility audited the care plans of residents identified as elopement risks, provided education to staff regarding the elopement policy, elopement assessments, one-to-one supervision, every 15-minute safety checks, wander device management, development and implementation of individualized care plans with interventions including supervision for residents at risk for elopement but noncompliance remained at a lower scope and severity level 2, D isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy because removed the likelihood of serious harm, injury, impairment, or death. A facility document, Elopement Policy, dated 11/2025, directed staff to establish a process to check the bracelet alarm/device batteries according to the manufacturer's directions. The Code Alert Wander Management Transmitters User Guide directed transmitters must be tested at least weekly to verify proper operation.

Based on interview and document review the facility failed to ensure the facility assessment included the required components of a plan for recruitment and retention of staff. This had the opportunity to affect all 71 residents.Findings include: Review of the facility assessment, dated 12/17/25, failed to include a plan to maximize recruitment and retention of direct care staff. It also lacked a contingency plan for events that did not require activation of the facility's emergency plan, but had the potential to affect resident care, such as availability of direct care nurse staffing or other resources for resident care. On 3/13/26 at 3:32 p.m., the administrator stated they had a plan to recruit staff; however, it was not included in the facility assessment document. She stated the facility assessment did not include a plan for staff retention or a plan to address direct care staffing outside of the facility's emergency plan. A policy regarding the facility assessment was requested but not received.

Based on interview and document review the facility failed to ensure competency evaluation on the Minnesota Nursing Assistant Register for 1 of 1 nursing assistants (NA)-A) reviewed for registry verification. This had the potential to affect all 71 residents at the facility.Findings include: On 3/12/26 at 11:46 a.m., (nursing assistant) NA-A stated it was her first shift at the facility. The facility schedule, dated 3/12/26, indicated NA-A was assigned to work the day shift on the third floor, for 7.5 hours. The facility resident list indicated 26 residents were living on the third floor and a total of 71 residents in the facility, as of 3/12/26. The Minnesota Nurse Aide Registry Search, dated 3/13/26 at 11:45 a.m., provided by the facility, indicated NA-A was inactive since 12/7/24. On 3/12/26 at 3:30 p.m., the director of nursing (DON) stated she trusted the staffing agency sent them only staff on the registry. Further, she stated the facility did not verify an active status for agency staff. On 3/12/26 at 3:32 p.m., the administrator stated their process did not include verifying current certification of agency aide. She stated she expected only currently certified NA's would be sent. A facility policy was requested but not provided.

Based on interview and document review the facility failed to provide evidence of ongoing clinical assessments following a fall for 1 of 3 residents (R1) reviewed for falls. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with all activities of daily living and required supervision to walk 50 feet.R1's undated admission Record indicated R1 admitted to the facility on [DATE]. Diagnosis included fracture of vertebrae, diabetes, depression and hypertension.R1's care plan dated 11/14/25, identified a risk for falls and included the following interventions: use of a concave mattress, signs in room to remind R1 to call for assistance and use of a reacher. The care plan identified an alteration in mobility and staff to assist with transfers and bed mobility. R1's Progress Notes identified the following:11/11/25, Writer was conducting routine rounds and heard someone calling for help. When writer approached R1's room, she was found seated on the floor. Bruising was observed to right elbow and R1 was assisted back to bed.11/12/25, Writer went to room and found R1 on the floor with her head facing the window. When asked, R1 stated she wanted to get out of bed and go home. Assessment was completed, range of motion done to both upper and lower extremities. R1 denied pain or discomfort. No visible bruises or bleeding noted.11/14/25, Neurological flow sheet for fall follow-up, vital signs within normal range. No concerns noted at this time. Hourly checks performed.11/14/25, Social Worker (SW) was called to R1's room secondary to R1 not wanting to get dressed or changed. R1 was weepy and said her legs hurt and she did not want to get up. Family member (FM) was present and asked to have R1 sent to the emergency department for confusion and pain secondary to the two falls.11/14/25. R1 was transferred to the hospital due to weakness, confusion and lethargy. 11/16/25, R1 was discharge from the facility.R1's Associated Clinic of Psychology (ACP) visit note dated 11/13/25, indicated visit was requested due to increase in confusion and falls. R1 expressed concern for how a staff person had moved her around the previous day and spoke of people being in her bed with her. Staff was consulted after session to report psychotic symptoms and clients care concern. The visit note indicated R1's appearance was unkempt, lying in bed in a facility gown. Head was craned to the left and R1 lied still during the visit. R1 endorsed pain in the left leg that she said was new. The note indicated, Seems most likely that client is experiencing delirium - important to rule out underlying medical issue. R1's Physical Therapy Treatment Encounter Notes indicated the following:11/11/25, R1 was approached and not agreeable to therapy. Therapist attempted to discuss fall that occurred that morning. R1 stated, I don't know to all questions Increased time was spent locating registered nurse (RN), R1 was shaking, twitching and unable to lift head off the bed or keep her eyes open. Located RN who stated she thought R1 was just tired but agreed she did not look well. Response to session indicated; limited by fall, RN had no increased insight on incident, R1 had been found sitting on the floor in her room with no recollection of what had happened. R1 shaky and unable to stay alert through conversation.11/13/25. R1 was approached for therapy and not agreeable. Stated she had a fall the previous night reaching for something on the floor. Response to session indicated limited by not feeling well after fall, still looked unwell. R1's medical record lacked evidence the following was completed: neurological checks with vital signs as directed; assessment related to a change in condition.During interview on 11/20/25 at 8:48 a.m., FM-B said a few weeks prior, he received a call that R1 had an unwitnessed fall and there were no injuries. FM-B said the previous week he received another call to inform him R1 had a fall with no injuries. FM-B said he got another call later that R1 again had fallen 4-5 hours earlier. FM-B said FM-A went to the facility on [DATE], at about 8:20 a.m. and R1 was curled up on the bed in the fetal position, in dirty sheets and there was blood on the floor in the room. FM-A told FM-B R1 had not responded when she called to her from the door. When R1 got up she was in so much pain, FM-A had asked the SW to call an ambulance. FM-B said R1 had been and R1 was found to have bruising on one whole side of her body, a broken hip, fractured ribs and a urinary tract infection.FM-B said R1 had been at the facility for two days with a broken hip and was still in the hospital and had surgery to repair her hip. During interview on 11/20/25 at 12:04 p.m., nursing assistant (NA)-B stated she met R1 when she transitioned to the third floor. NA-B said R1 had been very independent and staff typically just checked on her. NA-B said before the two falls, R1 walked but afterward had been staying in her wheelchair.During interview on 11/20/25 at 12:09 p.m., NA-A stated on Friday morning (11/14/25), she asked R1 if she needed anything. NA-A said she attempted to change R1 due to incontinence and R1 did not want to put clothes on. NA-A said when she changed R1's incontinent brief she rolled a little to one side but could not roll onto the opposite side. NA-A said she did not recall if she saw any bruising.During interview on 11/20/25 at 12:47 p.m., the director of nursing (DON) stated R1 had a past medical history of falls and fractures and said any little thing would probably fracture her. The DON said after a fall, staff should perform and assessment, completed neurological checks for 72 hours and if an obvious injury was noted, send the resident to the hospital. The DON said he had been told a neurological flow sheet had been completed but he had not seen it and did not know where it was. The DON said he had been told after R1 went to the hospital she had a fracture.During interview on 11/20/25 at 1:53 p.m., the ACP-SW stated she had been onsite at the facility and was asked to see R1. The ACP-SW said R1 had presented as delusional. She said R1 was in bed during the visit and had been pretty still and reported pain in her leg which she had attributed to staff care. The ACP-SW said she reported the care concern and the report of pain to LSW-A.During interview on 11/13/25 at 2:01 p.m., the therapy director (TD) stated R1 had been doing better and was using a walker prior to her falls. The TD said after the falls R1 had not made much progress. The TD said she reviewed R1's therapy notes and she had not been wanting to walk. During interview on 11/20/25 at 2:40 p.m., LSW-A stated she had spoken to the ACP-SW after her session with R1. LSW-A said she did not report the concern about pain to anyone because the ACP-SW said she had talked to someone.During interview on 11/20/25 at 2:44 p.m., the DON stated he expected staff to perform ongoing monitoring of vital signs, any pain and/or injury. The DON stated if bruising was present staff were to put an order in the medication administration record to monitor. A policy related to ongoing assessment after a fall was requested but not received.

Based on interview and document review the facility failed to timely report an allegation of physical abuse to the state agency (SA) for 1 of 3 residents (R1) reviewed for abusefindings includeR1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with all activities of daily living. R1's undated admission Record identified R1 admitted to the facility on [DATE]. Diagnosis included fracture of vertebrae, diabetes, depression and hypertension.R1's care plan dated 11/14/25, identified an alteration in mobility and staff were to assist with transfers and bed mobility. R1's Associated Clinic of Psychology (ACP) visit note dated 11/13/25, indicated a visit was requested due to an increase in confusion and falls. R1 expressed concern for how a staff person moved her around the previous day and spoke of people being in her bed with her. Staff was consulted after session to report psychotic symptoms and clients care concern. The visit note indicated R1's appearance was unkempt, lying in bed in a facility gown. Head was craned to the left and R1 lied still during the visit. R1 endorsed pain in the left leg that she said was new. On 11/20/25 at 11:50 a.m., licensed social worker (SW)-A and the administrator were interviewed. SW-A stated R1 told her a staff member had picked her up and threw her on the floor, then picked her up and threw her back on the bed. SW-A stated R1 reported the allegation Friday morning on 11/14/25, when family member (FM)-A was present. SW-A said she reported the incident to the SA later that evening. SW-A said abuse allegations should have been reported to the SA within two hours but said R1's FM-A said R1 was confused. The administrator said she felt the problem was that FM-A was insistent R1 was confused but said abuse allegations should have been reported within two hours.During interview on 11/20/25 at 1:53 p.m., the ACP- social worker (SW) stated she had been onsite at the facility and was asked to see R1. The ACP-SW said R1 had presented as delusional. She said R1 was in bed during the visit and had been pretty still and reported pain in her leg which she had attributed to the way staff had moved her around the previous day. The ACP-SW said she reported the care concern and to LSW-A.During interview on 11/20/25 at 2:40 p.m., LSW-A stated she had spoken to the ACP-SW after her session with R1. LSW-A said she did not report the concern about pain to anyone because the ACP-SW said she had talked to someone.The facility Abuse Prohibition/Vulnerable Adult Policy dated 4/2025, indicated the policy was intended 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 and to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. Incidents to be reported included abuse and indicated suspected abuse shall be reported to the SA no later than two hours after forming the suspicion of abuse.

Based on observation, interview and document review, the facility failed to ensure soiled facility linens were handled in a manner that prevented potential contamination during the laundry process. This deficient practice had the potential to affect all 65 residents served by the facility laundry. Findings include During an observation and interview on 4/29/25 at 10:09 a.m., with laundry assistant (LA)-A, three towels and a shower curtain were observed not in a bag and laying in the bin located below the laundry chute. LA-A stated some laundry would come down the chute not bagged. During an interview on 4/29/25 at 10:15 a.m., environmental director (ED) confirmed the above findings and indicated soiled linens were to be placed into the bag before sending down the laundry chute. ED stated it could cause contamination and soil the laundry chute. During an interview on 4/29/25 at 4:15 p.m., infection preventionist (IP) stated all soiled linens should be bagged before going down the chute. LA-B further stated soiled linens could contaminate the chute and someone could be exposed to an infection. LA-B indicated she wanted staff to view infection control as a good way to prevent the spread of an infection. Requested facility policy for the laundry chute however, one was not provided.

Based on observation, interview and record review, the facility failed to ensure food items in community refrigerators were properly labeled and dated in 2 of 3 refrigerators where resident's personal food was stored. In addition, the facility failed to ensure food temperatures were maintained according to acceptable standards on 1 of 3 steam tables, and failed to maintain sanitary conditions during food prep. REFRIGERATORS During an observation on 4/28/25 at 12:52 p.m., the fourth floor refrigerator contained an undated and unlabeled plastic bag, 1/2 plastic pitcher with orange liquid, with no date, and a container of ice cream dated 3/4. The bag contained a Tupperware container. Dietary Manager (DM) verified the containers were for resident consumption and should have been dated. DM stated the juice should have been dated when it was placed in the refrigerator. During an observation on 4/28/25 at 12:54 p.m., the third floor dining room refrigerator contained an unlabeled, undated container of cooked pasta. The Dietary Manager verified the container was unlabeled and undated. HOLDING FOOD TEMPERATURES During an observation and interview on 4/28/25 at 5:56 p.m., dietary aide (DA)-A completed the temperatures of the food on the steam table on third floor. The chicken was 120 degree Fahrenheit (F). A recheck of the temperature was 120 degrees F. At 6:11 p.m., the dietary manager entered and asked if the temperatures were OK and DA-A answered yes. The surveyor asked the DM to look at the temperatures. The DM verified the chicken was 120 degrees F., and told DA-A that the chicken needed to be at 165 degrees F. The DM took the chicken and indicated he was going to heat it up in the kitchen, and verified that no residents had received any chicken. At 6:18 p.m., the DM returned and took the temperature of the chicken, and it was at 180 degrees F. DA-A proceeded to serve dinner. FOOD PREPARATION During an observation and interview on 4/29/25 at 10:20 a.m., DA-B was prepping fruit for lunch in the kitchen. DA-B picked up small plastic bowls for fruit and put the empty bowl on a tray. DA-B was not wearing gloves, and was observed touching the inside of every bowl with their thumb while setting on the tray. On 4/29/25 at 10:30 a.m., the DM indicated only the outside of the dish should be touched and touching the inside of the dish would contaminate it. Review of facility's Food Receiving and Storage policy revised 2017, indicated the following: 8. All food stored in the refrigerator or freezer would be covered, labeled and dated (use by date). 14. Food items and snacks kept on the nursing units must be maintained as indicated below: b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. Review of the facility's Food Preparation and Service policy dated 2019, indicated the following: Food Service/Distribution 1. Proper hot and cold temperature are maintained during food service. 2. The temperature of food held in steam tables are monitored throughout the meal by food and nutrition services staff. Review of the facility's Food Preparation and Service policy dated 2019, indicated the following: Food Preparation Area 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.

Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 2 residents (R 11, and R35) who resided on the second floor reviewed for food. This deficient practice had the potential to affect all 24 residents residing on this unit. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had intact cognition and was able to feed herself after staff set up her tray. R35's quarterly Minimum Data Set (MDS) dated [DATE], indicated R35 had moderate cognitive impairment and was able to feed herself after staff set up her tray. During an interview on 4/28/25 at 1:28 p.m., family member (FM)-A stated R35 usually ate her meals in her room and the food was usually cold by the time it was delivered. During an interview on 4/28/25 at 1:42 p.m., R11 stated she ate in her room and the hot food was not hot and the cold food was not cold by the time the tray was delivered. During an observation 4/28/25 at 6:08 p.m., food was being dished up onto plates and placed on a plate warmer from the steam table in the dining room. The plates were placed on trays and put on a cart. As the last plate was being placed onto the cart, a test tray was requested and placed onto the cart. The meal consisted of chicken, rice, mashed potatoes, and a glass of milk. -at 6:20 p.m., the cart was wheeled into the hallway on the second floor. at 6:30 p.m., as the last tray was being passed nursing assistant (NA)-A tested the food temperatures and the temps were as follows: -Chicken was 106 degrees Fahrenheit (F). -Rice was 119 degrees Fahrenheit (F). -Mashed potatoes were 127 degrees Fahrenheit (F). -Milk was 55 degrees Fahrenheit (F). After temping the meal, the surveyor tasted the food from the tray: the chicken and rice were cold, the mashed potatoes were luke warm and the milk was warm. During an interview on 4/28/25 at 6:27 p.m., NA-A stated she was unsure of what food temperatures food should be held at. During an interview on 4/28/25 at 6:30 p.m., R11 stated the chicken was cold and the milk was warm. During an interview on 4/28/25 at 6:39 p.m., dietary aide (DA)-C stated he was unsure of what the food temperatures should be held at but would find out. During an interview on 4/28/25 at 6:44 p.m., dietary manager (DM) stated his expectation was food holding temps for hot food would be at least 135 degrees Fahrenheit (F). DM further stated holding temperature for cold food should have been 41 degrees Fahrenheit (F). or lower. Review of a facility policy titled Food Preparation and Service dated revised 2019, identified the danger zone for food temperatures was between 41 and 135 degrees Fahrenheit (F). Identified the longer food remain in the danger zone the greater the risk for the growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit (F). or above 135 degrees Fahrenheit (F).

Based on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 3 (R41) residents identified at risk for falls. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 had moderate impaired cognition and had diagnoses which included diabetes mellitus and depression. Indicated R41 required extensive assistance from staff with toileting, transfers, and personal hygiene. R41's care area assessment (CAA) dated 1/14/25, triggered for a risk of falls due to balance problems, use of anti-depression medications and a history of falls. R41's care plan dated 2/17/25, identified R41 was at risk for falls and required assistance from staff with mobility and transfers. R41's care plan indicated the call light should have been within reach. The care plan identified R41 was to have bed in lowest position, mat on floor, door open when in room, call do not fall sign posted, staff were to check on R41 and offered the bathroom between 0200-0400. Review of R41's MHM incident and analysis reports from 11/18/24 to 4/13/25, revealed the following: - 11/18/24, R41 had a fall from R41's bed. Interventions included R41's bed to be in the lowest position and fall mat was to be next to the bed. - 12/4/24, R41 was found on the floor. Interventions included R41 was to have the door open at all times for staff to monitor R41 in R41's room. - 2/15/25, R41 was found on the floor. Interventions included to check on R41 during the hours of 2300 and 0500. - 4/13/25, R41 was found on the floor and had a fall from the toilet. Interventions included R41 was to wear gripper socks at night. Review of Nursing assistant (NA) worksheet undated, identified staff were to check on R41 when he was in his room. However, it lacked any additional fall interventions. During an observation on 4/30/25 at 10:43 a.m., R41 was laying in his is bed with the door closed. R41's eyes were closed and R41 was covered up with a blanket. During an observation on 4/30/25 at 10:56 a.m., R41 continued the same as above. During an observation/interview on 4/30/25 at 11:18 a.m., registered nurse (RN)-B confirmed the above findings and stated R41's door should have been open when R41 was in the room. RN-B opened R41's door. During an interview on 4/30/25 at 10:23 a.m., NA-C stated NA-C was unaware if R41 had any falls recently. NA-C indicated R41 was to have his bed in low position and his mat on the floor next to the bed. NA-C indicated NA-C was unaware of any other interventions for R41. During an interview on 4/30/25 at 10:32 a.m., RN-C identified R41 as a high fall risk and indicated RN-C was aware of R41's fall history. RN-C stated R41's door was to be open at all times when R41 was in the room. RN-C indicated R41 liked to be in his room throughout the day During an interview on 4/30/25 at 11:29 a.m., director of nursing (DON) confirmed the above findings and stated fall interventions were discussed after the fall during the interdisciplinary team meeting. DON further stated her expectations were staff were to be following the resident's care plans at all times. Facility fall policy requested, however one was not provided.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 3 residents (R26) observed for medication administration. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively impaired and had diagnoses which included dementia, anxiety and asthma. Identified R26 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. R26's care plan revised 12/11/23, identified R26 had an activity of daily living (ADL) self-care performance deficit related to weakness. R5's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Directed staff to administer medications as ordered. R26's Order Summary Report dated 3/13/25, directed staff to administer Budesonide inhalation suspension 0/5 MG/2 ML via nebulizer twice daily for asthma. During an observation on 4/28/25 at 5:10 p.m., registered nurse (RN)-A entered R26's room and placed the budesonide nebulizer solution in the nebulizer mask. RN-A placed the nebulizer mask on R26's face and informed R26 she would return in 10 minutes to remove the nebulizer mask. At 5:21 p.m., RN-A returned to R26's room, removed the nebulizer mask from R26's face and placed the nebulizer mask on the nebulizer. R26 was not observed to rinse her mouth out and RN-A had not instructed R26 to rinse mouth out after taking the Budenoside nebulizer. During an interview on 4/28/25 at 5:25 p.m., RN-A confirmed she had not instructed R26 to rinse her mouth after the Budesonide nebulizer. RN-A stated she should have instructed R26 to rinse her mouth however, was unsure if R26 was able to rinse and spit. RN-A stated it was important to rinse or swab the mouth after a steroid nebulizer was received to prevent any infections. During an observation of 4/29/25 at 4:06 p.m., nursing assistant (NA)-B placed a glass with water up to R26's mouth and instructed R26 to rinse and spit as NA-B held an empty glass up to R26's mouth. R26 took a drink of water, rinsed mouth and spit the water into the empty glass. During an interview on 4/29/25 at 4:11 p.m., licensed practical nurse (LPN)-A stated R26 had always been able to rinse and spit after receiving the Budesonide nebulizer. LPN-A stated it was important to rinse the mouth after a steroid nebulizer was received to prevent any infections. During an interview on 4/29/25 at 3:51 p.m., pharmacy consultant (PC)-A stated it was important to rinse the mouth after receiving Budesonide nebulizer because it was a steroid. PC-A indicated it could cause thrush, a fungal infection inside the mouth. PC-A stated it was her expectation nursing staff would instruct the resident to rinse their mouth after each use. During an interview on 4/29/25 at 3:51 p.m., director of nursing (DON) stated it was important for residents to rinse their mouth after use to prevent infections in the mouth. DON stated her expectation was nursing staff to instruct R26 to rinse mouth after receiving the Budesonide nebulizer. R26's Budesonide nebulizer box instructions indicated Budesonide was indicated for chronic respiratory conditions. Indicated Patients should rinse the mouth after inhalation of Budesonide inhalation suspension to prevent fungal infections. A facility policy titled Specific Medication Administration Procedures revised 2024, identified all medications would be administered in a safe and effective manner.

Based on observation, interview and document review, the facility failed to implement all suggested mitigation efforts based on Centers for Disease Control (CDC) and Minnesota Department of Health (MDH) recommended guidelines to ensure prevention, and minimize the transmission of Klebsiella pneumoniae carbapenemase (KPC) producing carbapenem-resistant Enterobacterales (CRE). KPC producing CRE is a type of bacteria that can cause serious infections that can be hard to treat; most often spread person-to-person in healthcare settings specifically through contact with the infected or colonized people through contact with wounds or stool. The facility had seven residents with active KPC-producing CRE. The facility transferred three residents (R1, R2, R3) to acute care hospitals without informing the acute care hospital of the outbreak status as directed by MDH. In addition, the facility failed to ensure infection control precautions were adhered to for 4 of 7 residents (R4, R6, R9, R11) observed to have breeches with infection control practices to prevent and minimize the spread of infections/disease. This had the potential to affect 68 residents currently residing at the facility. The facility's failures to implement all mitigation measures resulted in an Immediate Jeopardy (IJ). The IJ began on 7/23/23, when the facility failed to inform the acute care hospital about an ongoing outbreak status of KPC-CRE as directed by MDH when R1 was sent to the hospital. The administrator, the corporate nurse consultant, and the director of nursing (DON) were notified of the IJ on 8/24/23, at 7:03 p.m. The immediacy was removed on 8/25/23 at 4:00 p.m. after an acceptable removal plan was implemented, but noncompliance remained at the lower scope and severity of F, widespread, with no actual harm with the potential for more than minimal harm which is not immediate jeopardy. Findings include: R1's Admission Record dated 7/21/23, indicated R1's diagnoses included join replacement surgery aftercare, type 2 diabetes mellitus, and abnormalities of gait and mobility. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, required assistance of two staff for transfers, was non-ambulatory, and required limited assistance with activities of daily living (ADLs). R1's care plan dated 7/21/23, indicated R1 had right hip replacement. Staff intervention included to monitor and document on safety. The care plan further indicated R1 was non-ambulatory and required extensive assistance of two staff with transfers. On 7/21/23 at 11:01 p.m., a progress note indicated R1 was admitted to the facility from an acute care hospital (ACH) following right hip arthroplasty. On 7/23/23 at 5:16 p.m., a progress note indicated R1 was taken to a different ACH by paramedics after he called 911 without the facility knowledge. The progress note lacked information if the ACH was notified by the facility of the KPC-CRE outbreak status. On 8/24/23 at 2:31 p.m., license practical nurse (LPN)-A was interviewed and stated when the facility sends KPC-CRE positive resident to the hospital, a KPC-CRE outbreak status form should have been included with the discharge paperwork to be given the staff at the hospital. LPN-A stated he was the supervisor when R1 was sent to the hospital, and he confirmed he did not notify the hospital about the KPC-CRE outbreak status. On 8/24/23 at 4:31 p.m., R1 was interviewed and stated he was not aware of the KPC-CRE outbreak status in the facility. R1 stated he could not remember if any documents were sent with emergency medical services (EMS) about the KPC-CRE outbreak when he was taken to the hospital on 7/23/23 On 8/24/23 at 4:52 p.m., registered nurse (RN)-A (the infection preventionist from the ACH) stated R1's ACH medical record lacked notification by the facility of the KPC-CRE outbreak status. RN-A stated there was no notification in the EMS medical report. The EMS ambulance service report dated 7/23/23 at 2:18 p.m., lacked any notification by the facility of the KPC-CRE outbreak status in the facility. R2's Admission Record dated 8/9/23, indicated R2's diagnoses included nontraumatic subarachnoid hemorrhage, cerebrovascular disease, and mild to moderate dementia. R2's admission MDS dated [DATE], indicated R2 required assist of one for transfers, and required limited assistance with ADLs. R2's care plan dated 8/9/23, indicated R2 had moderate cognitive impairment. On 8/9/23 at 6:32 p.m. a progress note indicated R2 was admitted to the facility from an ACH after a fall with multiple visible bruises on her face. On 8/13/23 at 10:41 p.m., a progress note indicated R2 was sent to an ACH following a fall for further assessment. The note indicated EMS was updated about medication administered, but lacked information if the ACH was notified by the facility of the KPC-CRE outbreak status. On 8/14/23 at 6:03 a.m., a progress note indicated R2 was admitted to the hospital with left rib fractures. On 8/18/23 at 9:21 p.m., a progress note indicated R2 was readmitted to the facility from the ACH. On 8/24/23 RN-B (ACH nurse) stated she had not received any documents about a KPC-CRE outbreak status in the facility. RN-B stated it was the ACH infection preventionist (IP)-A at the ACH who had notified her about the KPC-CRE outbreak status at the facility. R3's Admission Record dated 8/1/23, indicated R3's diagnoses included bilateral primary osteoarthritis of hip, malignant neoplasm of bone, and type 2 diabetes mellitus. R3's admission MDS dated [DATE], indicated R3 was cognitively intact, required assist of two with transfers, and required assist of one with (ADLs). On 8/1/23 at 3:06 p.m., a progress note indicated R3 was admitted to the facility via EMS following recurrent falls at home. On 8/12/23 at 11:40 a.m., a progress note indicated R3 had refused CRE rectal swab testing. On 8/14/23 at 4:52 p.m., a progress note indicated R3 was sent to an ACH for further evaluation following signs of acute confusion. The progress note lacked information if the ACH was notified by the facility of the KPC-CRE outbreak status. On 8/14/23 at 8:49 p.m., a progress note indicated R3 was admitted to the hospital with altered mental status diagnosis. The progress note lacked information if the ACH was notified by the facility of the KPC-CRE outbreak status. On 8/24/23 at 11:45 a.m., the social worker designee (SW)-A stated she did not know if the KPC-CRE outbreak notification form was provided to EMS during transfers to the hospital. On 8/24/23 at 12:03 p.m., LPN-B (the clinical coordinator) stated the facility's discharge folder included information about the KPC-CRE outbreak. LPN-B stated if a resident had tested positive for KPC-CRE a verbal report was given to the hospital. LPN-B stated if a resident's KPC-CRE status was pending, there was no verbal report done, but the facility was supposed to send the information that was in the discharge folder. LPN-B stated if a resident called 911 and was picked up by EMS, they (EMS) will be notified about the KPC-CRE outbreak status in the facility. LPN-B stated she expected nurses to document in the resident's medical record when a verbal report was given to the hospital staff. On 8/24/23 at 5:15 p.m., the director of nursing (DON) stated every hospital that had received any of their residents had received the Important Infection Prevention Message from the Minnesota Department of Health when the resident was transferred to the hospital. The DON stated the nursing staff may or may not document what paperwork was sent to the acute care hospital. The DON verified R1, R2 and R3's medical records lacked documentation the ACHs were provided information on the KPC-CRE outbreak status in the facility, either verbally and/or in writing. On 8/24/23 at 5:30 p.m., IP-B (ACH infection preventionist) stated her ACH had not received either a notification letter or a phone call regarding the facility's KPC-CRE outbreak status. IP-B stated the ACH did not take any precautions regarding R3's admission to the ACH. The facility Infection Control policy revised 3/13/23, directed the facility to manage the outbreak by preventing the spread to other residents, reporting the information about the outbreak to appropriate public health authorities, and educate the staff, and the public. The Important Infection Prevention Message from Minnesota Department of Health undated, directed following: This patient resides in a long-term care facility that is experiencing transmission of Klebsiella pneumoniae carbapenemase (KPC) producing carbapenem-resistant Enterobacterales (KPC-producing CRE). KPC-producing CRE is an uncommon multidrug-resistant organism that can lead to difficult or impossible to treat infections. Healthcare facilities must use Contact Precautions when caring for patients with KPC-producing CRE to reduce the risk of transmission to other patients. Colonization testing is required to determine if this patient has KPC-producing CRE. Please take the following actions for your healthcare setting as soon as possible: EMS/Transport Services 1. Use Contact Precautions when transporting this patient. 2. Clean and disinfect all re-usable equipment thoroughly (e.g., blood pressure cuff, pulse oximetry, telemetry leads, etc.) 3. Share this letter with staff at the receiving facility. Acute Care Hospitals 1. Place the patient in Contact Precautions in a private room with a private bathroom, as able. 2. Share this message with your infection preventionist. 3. Ensure treating clinicians are aware of the possibility of infection with a carbapenem-resistant organism if empiric antibiotic therapy is required. 4. If patients are admitted to an inpatient unit, MDH recommends collecting a rectal swab to test for KPC colonization. Contact MDH at [PHONE NUMBER] to coordinate testing. a. MDH is available Monday-Friday from 8 am to 5 pm. b. Colonization testing is conducted free-of-charge in the MDH Public Health Laboratory, including supplies, instructions, specimen transport, and testing. c. Results are available in 1-2 business days after the rectal swab is collected. d. Patients should remain on Contact Precautions until testing can rule out colonization with KPC. BREECHES WITH INFECTION CONTROL On 8/23/23 at 1:34 p.m. RN-D stated she had not received any education about the facility's KPC-CRE outbreak status. RN-D stated she was not aware why some residents were on enhanced base precautions (EBP). RN-D stated she was caring for three residents on EBP, but was unable to identify why. On 8/23/23 at 2:40 p.m. housekeeper (HK)-A stated she had not cleaned the shower room since she started working the morning. HK-A stated she had not received any education about infection control or KPC-CRE outbreak precautions and how to clean the showers. On 8/23/23 at 3:05 p.m., nursing assistant (NA)-B was observed entering R4's room without any personal protective equipment (PPE) and without performing hand hygiene. R4 had tested positive for CRE, and EBP signage was on the outside of his door. NA-B placed a clean gown on R4 and brought her out of the room. NA-B did not perform hand hygiene upon exiting the room. NA-B stated she was told by the nurse manager to wear PPE only if she was going to do peri-care. NA-B was unable to provide any details about the facility's KPC-CRE outbreak status and why residents were on precautions. On 8/23/23 at 4:45 p.m. R6 was observed filling his pitcher with ice from the ice machine in the public dining room on the fourth floor. R6 was not wearing gloves. R6 had tested positive for CRE. On 8/23/23 at 5:10 p.m. R9's family member (FM)-A was observed feeding R9. FM-A was wearing a mask, but no other PPE. FM-A stated he did not know if he should be wearing PPE while feeding R9. R9 had tested positive for CRE, and EBP signage was on the outside of his door. On 8/24/23 at 8:30 a.m. dietary aide (DA)-A was observed in the dining room. DA-A served R11 his meal plate. DA-A took a container of milk, and filled R11's milk glass. R11 finished his milk, and DA-A refilled the milk glass, touching the glass that R11 had touched. DA-A then put the milk back in the ice bucket and continued to serve milk to other residents from the container of milk touching each of the other resident's drinking glasses. On 8/24/23 at 1:20 p.m. HK-B stated it was not housekeeping's responsibility for cleaning the shower rooms after use. HK-B stated nursing should be cleaning the shower rooms after they were used. HK-B stated there was not a policy for cleaning the shower rooms after use. On 8/24/23 at 2:15 p.m. NA-C stated it was housekeeping's responsibility to clean the shower rooms after residents used them. NA-C was unable to provided information on any specific product that would be used to clean the shower rooms. On 8/24/23 at 5:15 p.m., the DON stated she expected nursing staff to wear PPE and perform hand hygiene when they were in close contact with a CRE resident (positive or pending result). The facility's Infection Prevention and Control Program dated 3/13/23 directed the primary mission of the facility is to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. All personnel will be trained on infection control policies and procedures upon hire and periodically thereafter, including when and how to find pertinent procedures and equipment related to infection control. The content of the employee training is dependent on the degree of direct resident contact and job responsibilities. The IJ was removed on 8/25/23 at 4:00 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review: new processes were put in place to ensure The Important Infection Prevention Message from Minnesota Department of Health was provided to all receiving health care facilities, the facility was to ensure verbal notification regarding KPC-CRE was provided to receiving health care facilities, and ongoing reviews and audits of the transfer/discharge process was completed. All nurses, social service staff, and the admission coordinator were educated on the procedure for transfers and discharges to another health facility.

Based on interview and document review, the facility failed to provide follow-up appointments with a urologist for 1 of 3 residents (R1) reviewed for indwelling catheter use. This resulted in actual harm to R1 when he developed a urinary tract infection (UTI), became septic, and was hospitalized . Findings include: R1's Admission Record dated 11/14/22, indicated R1's diagnoses included neuromuscular dysfunction of bladder, and type 2 diabetes mellitus. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had neuromuscular dysfunction of bladder. The MDS also indicated R1 had an indwelling Foley catheter, required total assistance for transfers and toileting, and was cognitively intact. R1's care plan initiated 11/14/22, indicated R1 had neuromuscular dysfunction of bladder. Staff interventions included monitor/document for pain/discomfort due to catheter, monitor/record/report to MD for signs/symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills altered mental status, change in behavior, change in eating patterns. Change Foley catheter per policy. On 11/14/22, R1's hospital Discharge Summary note recommended R1 to follow up with urologist for indwelling catheter evaluation. R1's medical record lacked documentation of an appointment. On 2/24/23 during a medical visit with R1, the nurse practitioner (NP)-A ordered a follow-up with urology. R1's medical record lacked documentation of an appointment. On 4/11/23 during a medical visit with R1, the provider ordered to schedule a urology appointment for evaluation and treatment of his Foley catheter. R1's medical record lacked documentation of an appointment. On 4/28/23 at 4:20 p.m., a progress note indicated R1 was scheduled for a urology appointment on 5/17/23 at 2:30 p.m., for indwelling catheter evaluation and treatment. R1's medical record lacked indication if R1 went to this appointment. On 5/26/23, a provider note indicated assessed R1 who voiced concern about his health, and had stated his stomach was acting funny. NP-A instructed to send R1 to the hospital for further evaluation related to abdominal pain and weight loss. On 5/26/23 at 2:34 p.m., a progress note indicated NP-A assessed R1 and instructed to send R1 to the hospital for further evaluation related to abdominal pain and weight loss. On 5/26/23 at 3:46 p.m., a hospital admission note indicated R1's indwelling catheter had not been changed since his admission to the facility (11/22) and according to the staff at the facility, the Foley catheter had not been draining properly. The note further indicated R1's Foley catheter was covered with mucus and appeared black, the bulb was not working properly, and R1's urine sample was positive for bacteremia (a bacterial infection in the blood). On 5/31/23 at 11:33 a.m., a hospital progress note indicated R1's indwelling catheter was changed at the hospital and was draining clear yellow urine. The note further indicated R1 was on antibiotic for a urinary tract infection (UTI). On 6/1/23 at 2:20 p.m., a progress note indicated R1 returned from hospital with diagnoses of UTI and sepsis (sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body). On 6/1/23 at 10:30 a.m., R1 was interviewed. R1 stated he had been to the hospital recently, and was treated for UTI and sepsis. R1 stated his Foley catheter was changed at the hospital, and he started a new antibiotic for the UTI. On 6/1/23 at 10:37 a.m., license practical nurse (LPN)-A stated nurses were responsible for indwelling catheter care. LPN-A stated Foley catheter were changed monthly, but acknowledged she was not familiar with the facility Foley catheter policy. On 6/1/23 at 1:47 p.m., health unit coordinator (HUC)-B stated R1 was scheduled for urologist appointment on 5/17/23 at 2:30 p.m., but R1 refused to go due to transportation issue, and no other transportation alternative was provided that day. HUC-B stated she tried to reschedule R1 on 5/18/23, but was informed urology did not have an opening. HUC-B stated she notified registered nurse (RN)-A, who said she would investigate and get back to her. HUC-A stated she never heard back from RN-A. HUC-B further stated she was not aware of any urology appointment made for R1 prior to 5/17/23. On 6/1/23 at 4:10 p.m., RN-A stated R1 refused to go to the appointment. RN-A stated she did not know the reason for the appointment, she assumed it was for evaluation and to rule out infection. RN-A stated she did not document the refusal. On 6/2/23 at 11:24 a.m., the director of nursing (DON) stated she could not find any nursing note about R1's refusal or rescheduled for urology appointment around 5/17/23. The DON stated she just spoke with HUC-A, who said she had told RN-A of the refusal. The DON further stated she was not aware of any other urology appointment for R1. On 6/2/23 at 1:34 p.m., NP-A was interviewed. NP-A stated when residents have a Foley catheter, the standard of practice would be to get them to a comfortable situation and then discontinue the catheter or refer them to urology for evaluation and treatment. NP-A further stated the facility needed to come up with better procedures to assess and monitor catheter care. NP-A stated she was not notified about R1's refusal, or any issues with the urology appointment. NP-A stated, That's sepsis waiting to happen. The facility's Bladder Assessment Procedure revised 5/31/23, directed the facility to proceed to Foley catheter evaluation if the resident has an indwelling catheter. The facility policy Standing Orders revised 2023, directed nurses to change a Foley catheter as needed for leaking or decreased urinary output using a similar-sized catheter. The facility policy Notification Physician of Change in Resident Health Status revised 3/8/23, directed nurses to notify the resident's attending physician or physician on call when there has been a refusal of treatment.

Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) transmission based precautions guidelines were followed to prevent and minimize the transmission of carbapenem-resistant Enterobacterales (CRE-type of bacteria that can cause serious infections that can be hard to treat; most often spread person-to-person in healthcare settings specifically through contact with the infected or colonized people through contact with wounds or stool) for 3 of 3 residents (R1, R2, R3) who remained in the building and R5 and R6 who discharged from the facility that had confirmed or history of CRE results; failed to ensure proper hand hygiene and glove use to prevent the spread of CRE for 2 of 2 residents (R1, R2); failed to ensure education was provided to staff and residents about CRE and failed to ensure multi-use equipment was being disinfected in between residents as recommended by the manufacturer to prevent and minimize the spread of infections/disease. Further, the facility failed to conducting ongoing tracking and trending of infections included [MEDICAL RECORD OR PHYSICIAN ORDER] . The immediate jeopardy (IJ) began on 7/13/22, when the facility failed to appropriately implement enhanced precautions for two positive and one confirmed positive residents with CRE. On 7/13/22, at 4:29 p.m. the facility administrator, the corporate vice president of operations and two regional directors of clinical operations were notified of the IJ. The IJ was removed on 7/14/22, at 7:22 p.m. but remained at a lower scope and severity of F, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. Findings include: R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R1 required extensive physical assistance of one staff with activities of daily leaving (ADL's), was incontinent of both bowel and bladder and had severely impaired cognition. During review of R1's medical record, the following was revealed: -A laboratory result dated 3/29/22, indicated R1 had a confirmed positive result for CRE. -A progress note dated 4/2/22, 1:33 p.m. indicated Laboratory Data: [CONDITION(S)] pneumonia carbapenemase [KPC] polymerase chain reaction [PCR] Positive, Action: Faxed to MD; Response: None at this time. -Nurse Practitioner (NP) note dated 4/7/22, identified R1 had tested positive for CRE however indicated resident was asymptomatic therefore likely colonized and no precautions were required. R1's medical record lacked documentation when precautions were implemented and what further action was put into place since the facility staff was aware of the confirmed CRE test result. R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R1 required extensive to total dependence of one to two staff on all ADL's including toileting and wound care, had a indwelling catheter and [CONDITION(S)] and had moderately impaired cognition. During review of R2's medical record, it was revealed R2 had a confirmed positive laboratory result for CRE dated 3/23/20, however, medical record lacked documentation when and if precautions were implemented when R2 had been admitted to the facility on [DATE]. In addition, the medical record lacked documentation of what further action by the facility was put into place upon admission and on-going by the facility related to the confirmed CRE test result. R3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R3 required extensive to total dependence of one to two staff on all ADL's including toileting and wound care, had an indwelling catheter and [CONDITION(S)] and had moderately impaired cognition. During review of the medical record, it was revealed R3 had tested positive for CRE on 6/9/22, during a facility test prevalence study. The medical record lacked documentation from 6/9/22, to 6/14/22, on when precautions were implemented and what further action was put into place since the facility staff was aware of the confirmed CRE test result. R5 was admitted to the facility 2/1/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R5 required extensive physical assistance of two staff on all ADL's including toileting which R5 was incontinent of both bowel and bladder and was cognitively intact. During review of R5's medical record it was revealed: -A laboratory result dated 3/24/22, indicated R5 had a confirmed positive result for CRE and a note on the sheet indicated the result had been seen by the nurse practitioner and R5 was started on an antibiotic on 3/25/22. -A review of a progress note dated 5/5/22, indicated R5 was sent to the hospital for evaluation and was not returning to the facility. The medical record lacked documentation of if precautions were implemented and what further action was put into place since the facility staff was aware of the confirmed CRE test result. In addition, the medical record lacked documentation of the receiving facility/hospital being informed of R5 being positive for CRE. R6 was admitted to the facility 2/16/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R6 required extensive physical assistance of two staff on all ADL's including toileting and wound care, had a indwelling catheter, was incontinent of bowel and was cognitively intact. During review of R6's medical record it was revealed: -A laboratory result dated 4/7/22, indicated R7 had a confirmed positive result for CRE. -A review of a progress note dated 4/11/22, indicated R6 was discharged home, however, the medical record lacked documentation of if precautions were implemented prior to the discharge and what further actions were put in place including education provided to the family/representative about CRE management in the community. On 7/13/22, at 6:45 a.m. surveyors observed on the table next to the screening kiosk located at the front desk were several handouts titled Frequently Asked Questions about screening Tests for Antibiotic-Resistant Germs that colonize the Gut, such as Carbapenem-Resistant Enterobacterales (CRE). Also next to the handouts was a staff sign-in sheet which had five signatures of staff of which four signed it on 7/12/22 and one 7/13/22. On 7/13/22, at 7:33 a.m. registered nurse (RN)-B was observed to sanitize his hands before he prepared R4's medications. RN-B took the blood pressure cuff and went into the room R4's room to get R4's blood pressure.(applied cuff to upper arm and obtained a blood pressure reading. RN-B walked out of R4's room with blood pressure cuff, immediately placed it on top of the medication cart without disinfecting the cuff and did not sanitize or wash his hands.) -At 7:40 a.m. RN-B brought medications and blood glucose machine in a pink basin with supplies into R4's room, applied gloves and gave R4 her medications. RN-B then took the glucometer and placed it on the bedside table, proceeded to wipe R4's middle finger with a alcohol swab, stabbed it with a lancet. RN-B then placed a drop of blood on the glucometer strip to obtain a reading. After the reading was obtained, RN-B removed the dirty strip from the glucometer and returned to the pink basin with clean supplies. RN-B then removed his dirty gloves, threw them in the trash can and walked to the medication cart and sanitized his hands. RN-B then placed the pink basin with the clean with the dirty glucometer on the medication cart. RN-B did not disinfect the glucometer during the entire observation. On 7/13/22, at 7:35 a.m. nursing assistant (NA)-D walked out of R8's room with a vital sign machine and went directly into R9's room with the vital sign machine without cleaning the machine between the residents. NA-D then came out of R9's room and placed vital sign machine in hallway and walked away without cleaning it. On 7/13/22 7:39 a.m. NA-D then grabbed the vital machine without cleaning it and went into R10's room. During interview on 7/13/22, at 8:08 a.m. NA-D stated I was not trained to clean the vitals machine in between rooms. It makes sense to clean in between rooms to stop the infections. NA-D then verified she went into three rooms and did not clean the machine between the residents. On 7/13/22, at 7:39 a.m. NA-A was observed to enter R1's room wearing eye protection and mask only and did not have gloves or gown on. NA-A then approached R1 from the front and wrapped both arms around R1's torso and waist lifted R1 up and transferred R1 to the wheelchair. During the observation, NA-A's uniform brushed R1, R1's bedding and clothing during the transfer. NA-A immediately left the room without washing or sanitizing hands and brought R1 to a common area in the unit. NA-A immediately approached R7 in the common area and reached up to R7's face and and adjusted R7's nasal cannula in her nose. -At 7:43 a.m. NA-A stated she was supposed to wash her hands when entering and leaving resident rooms. -At 7:48 a.m. NA-A stated she knew R1 had a bacteria and stated she was supposed to use contact precautions while assisting R1, however, she thought since she had assisted R1 to get ready that morning and because she was not doing cares, she did not need to wear the PPE when assisting R1. NA-A stated she should have put on a gown when in R1's room as she had come in contact with R1's personal items including bedding. On 7/13/22, at 7:59 a.m. RN-B was observed to prepare R11's medications and took with him a cup of water and pink basin with the same glucometer that was used at 7:40 a.m. for R4 and was not cleaned after use and entered R11's room and approached the resident in bed. As RN-B was going to use the multiple resident use glucometer on R11, surveyor intervened. RN-B stated I should have cleaned the accucheck machine with the bleach wipes. RN-B then picked up the container and showed surveyor the container of wipes and then stated, I'm not familiar if the wipes have a dry time but they dry very fast. RN-B then confirmed the glucometer in the pink basin was a common use glucometer and without cleaning multiple resident use equipment he could spread infections. During observation on 7/13/22 8:25 a.m. outside of R1's room was a cart with personal protective equipment which included gowns and wipes for cleaning. On R1's door was a sign which indicated Contact precautions for special [MEDICATION(S)]. Must perform hand hygiene. Wear gloves. Wear gown when entering room and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces and use patient dedicated equipment. During observation on 7/13/22, at 8:36 a.m. housekeeping staff (HK)-A was observed apply gloves and then entered R12's room with a wet mop. HK-A was observed go into R12's bathroom and mopped the floor, then went to mop by R12's bed while resident was in the bed. During the observation a sign on door indicated Enhanced barrier precautions. Providers and staff must use gloves and gowns. Gowns only if they are doing cares to resident. As HK-A was coming out of the room surveyor asked why R12 was on precautions and HK-A stated, I don't know why he is on precautions. HK-A had come out of the room with both pairs of gloves on and started pushing his cart down the hallway and had grabbed the broom and was sweeping the hallway. HK-A, then still wearing the same gloves from R12's room, then opened R2's door. HK-A then went in with the same gloves on and was observed to gather trash in the room and came out of the room and disposed it in the cart. HK-A then picked up a cleaner and went into R2's bathroom and was observed clean R2's sink with the same gloves still on. HK-A then came out of the room and at this time surveyor intervened and HK-A stated I should have removed the gloves and washed my hands before doing anything else or going into another room. I could spread infection. On 7/13/22, at 8:48 a.m. NA-B was observed to push R1 in her wheelchair, using the handles on the chair near R1's body, down the hallway into the resident room. The Enhanced Barrier Precaution sign remained on the door. She stopped, briefly touched her shoulder and spoke to R1 and then immediately left the room without washing or sanitizing her hands despite sign on the door which directed staff to wash hands while leaving the room as this was a contact precaution room related to R1's confirmed CRE positive test. On 7/13/22, at 9:23 a.m. NA-B stated there were three residents in the facility who had an infection but did not know the name of it. NA-B stated the director of nursing (DON) had given the staff a paper which had information about the infection. NA-B then stated, I should always have a gown and gloves on and to take close precautions because you could get it from them even touching our clothing and we should always wash our hands and keep washing our hands. NA-B confirmed she had not washed her hands when she had brought R1 back to the room and after touching her shoulder and wheelchair because she was trying to do several different things. On 7/13/22, at 9:23 a.m. NA-C stated was a regular at the facility and worked all units. NA-C stated he did not know why R1, R2 and R3 were on precautions the nurse should know. NA-C then stated he was just following the signs on the door with personal protective equipment (PPE) into the resident rooms with the signs on and staff was supposed to wear the appropriate PPE while in the rooms. On 7/13/22, at 9:30 a.m. licensed practical nurse (LPN)-A stated there was three residents on the floor with confirmed CRE positive tests and for any contact and touching anything in the room they were supposed to wear all the PPE and the staff was supposed to sanitizer in and out of the room. -At 9:40 a.m. LPN-A stated she did not know why R12 was on enhanced precautions at the door. LPN-A stated she knew R12 had history of Clostridiodes difficile and was in and out of the hospital but was not still certain the reason for the precautions as nothing had been communicated to her or the other staff on the unit. During review of the facility Infection Control Logs for January 2022 through July 2022, it was revealed the facility did not conduct ongoing tracking and trending of the confirmed CRE cases at the facility. During a review of facility CRE testing worksheet revealed the facility had attempted to conduct facility wide testing on 7/10/22, 7/11/22 and 7/12/22, however on 7/13/22, at 1:49 p.m. the worksheet had a note that listed 14 residents had refused testing. Through observations on 7/13/22, on the nursing units these residents that refused testing did not have signs on their doors to indicate they were on any precautions. The DON and director of clinical operations (DCO) both stated they were following infection control assessment and response program (ICAR) recommendations and had not implemented precautions due to not having enough PPE carts available in the facility to hold supplies for staff to utilize. During an interview on 7/13/22, at 11:15 a.m. to 12:15 p.m. with the interim DON, DCO and RN-A infection control preventionist (IP), the DON stated one of the challenges the facility was experiencing was 45 to 50% of the staff who currently worked at the facility were agency staff which made it a hard to educate. The DON stated the facility leadership was fragmented as there had not been a full time DON and two nurse managers which created a challenge in some issues. The DON stated the facility had policies and procedures in place and the current staff available was doing the best that they could. The IP then stated although she had completed the training a couple months back, and had gone through training with the DCO, she was currently the nurse manager for two floors which created a challenge for her to fully resume responsibility for infection control at the facility. The DCO stated she had received a call from Infectious Disease Epidemiology, Prevention and Control (IDEPC) at the beginning of June but not a lot was communicated to her, and she was informed IDEPC wanted to conduct a point of prevalence testing at the facility. The DCO then stated she was out of the facility, however, a meeting had been scheduled for 6/14/22, with the facility IP and DON. The DON stated at the meeting on 6/14/22, she had asked IDEPC staff for more time to be able to get some education done and wanted to have a follow up meeting after 7/4/22, as she thought this would give her more time to do more testing on the residents. The DON, DCO and IP all confirmed following the meeting with ICAR the facility had at that time placed all three residents with confirmed positive CRE results on precautions. The DON stated there was another meeting which was scheduled for 7/14/22, which the facility staff was going to show IDEPC staff the facility action plan and on what the facility was following up on. The IP reviewed the infection control logs and the IP, DON and DCO confirmed the resident(s) who had past confirmed positive CRE results should have been on the infection control logs for the last 6 months reviewed. The DCO stated If they have an active infection they should go on the listing. The DCO stated she was not able to address what past staff managed the infection control logs did with tracking and stated this was something the facility staff was planning to address. The DCO stated the tracking of infections was something they had identified when IDEPC had called them at the beginning of June 2022, however, she confirmed the June and July infection logs were not fixed to address the issue. The DCO stated they were trying to get residents to be tested and figure out those who refused to be tested were going to be put on enhanced precautions. The DCO confirmed this had not been implemented despite knowing 14 residents had refused to be tested as of 7/13/22. The DON stated she had started to put signs on doors for resident who had refused as they were just finishing up the point prevalence testing. The DON stated the education that was being provided to staff was by the front door for anyone to take and sign off. The DON stated they had also put the sign-in sheet on the floors by kiosk as they thought staff would see it there. The DON also stated she and the IP were starting to do shift by shift basis education to ensure staff was educated, however, they were still in the process of putting the education together. The DON stated she felt staff did not need to know why the resident was on precautions due to the Health Insurance Portability and Accountability Act (HIPAA) and staff only needed to follow precautions as posted on the door. The DCO stated although they were working with ICAR, there was not clear instructions on what they should do when they first called her. She then stated The expectations have changed since 2016 so we were just trying to get on the same page from ICARs guidance. We were trying to get everyone on the same page, so everyone is safe. The DON then stated when they had a meeting with ICAR on 6/14/22, she thought ICAR was going to be our helper to help educate and help us be proactive and move forward with them. The DON then stated the delay in education was not done because she was new but because she was busy. The DON and DCO stated staff were supposed to wear gown, gloves, masks, and eye protection when assisting resident on enhanced precautions for CRE and resident shared equipment was all supposed be cleaned between residents and hand hygiene was supposed to be done when entering and leaving a room and per the facility policy. The facility Infection Prevention and Control Guideline revised 3/25/20, directed: The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. 1. Written standards, practices, and procedures for the Infection Prevention and Control program, include: a. Surveillance: A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. c. Standard and transmission-based precautions to be followed to prevent the spread of infections. a. Hand Hygiene to be followed by staff with direct care, handling resident care equipment and the environment b. Selection and Use of PPE . The facility Hand Hygiene Guideline policy revised 3/4/20, directed: Hand hygiene is one of the most effective ways to prevent the spread of microorganisms. Clean hands can stop germs from spreading from one person to another and throughout an entire facility or community. Multiple opportunities for hand hygiene may occur during a single care episode. The following are the clinical indications for hand hygiene: -Before and after care -When hands are visibly soiled -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices -After caring for a person with known or suspected infectious diseases -Before moving from work on a soiled body site to a clean body site on the same patient -After known or suspected exposure to spores (e.g. C difficile outbreaks- hand sanitizer cannot replace soap and water) -After touching a patient's immediate environment -After contact with blood, body fluids or contaminated surfaces -Immediately after glove removal . The facility Guideline for Standard and Transmission-based Precautions revised 11/9/20, directed: Standard and Transmission-based precautions represent the infection prevention measures that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is being delivered. These evidence-based practices are designed to protect healthcare staff and residents by preventing the spread of infections among residents and ensuring staff do not carry infectious pathogens on their hands or via equipment during resident care. As mentioned in the definitions section, standard precautions include hand hygiene, use of PPE (e.g., gloves, gowns, facemasks), respiratory hygiene and cough etiquette, safe injection practices, and safe handling of equipment or items that are likely contaminated with infectious body fluids, as well as cleaning and disinfecting or sterilizing of potentially contaminated equipment. In order to perform hand hygiene appropriately, soap, water, ABHR2, and a sink should be readily accessible in appropriate locations including but not limited to resident care areas, and food and medication preparation areas. Staff must perform hand hygiene (even if gloves are used): · Before and after contact with the resident; · Before performing an aseptic task; · After contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident ' s room; · After removing personal protective equipment (e.g., gloves, gown, facemask); · After using the restroom; and · Before meals . The IJ was removed on 7/14/22, at 7:22 p.m. when it could be verified by observation, interview, and record review that the facility took the following steps: -Identified residents Rl, R2, and R3 were placed on Enhanced Barrier Precautions to include correct signage outside their doors. -The facility implemented Enhanced Barrier Precautions with signage for 20 residents that are awaiting CRE lab results and for residents that had refused CRE testing. -The infection control line listing logs were updated and ongoing tracking and trending of infections in the facility was implemented by the infection preventionist. -Rl, R2, and R3 medical records were reviewed and updated to ensure appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility stocked adequate amounts of PPE supplies for staff. -All residents in the facility have been reviewed to ensure appropriate transmission-based precautions are in place in regards to CRE. -The facility reviewed policies and procedures and updated as appropriate. -Staff was educated on use of PPE for Transmission Based precautions and Enhanced Barrier Precautions, appropriate PPE usage, CRE, hand hygiene and disinfection of shared equipment between resident use. -Education for providers was implemented on CRE and Enhanced Barrier Precautions. -Residents and responsible parties were mailed or received education via handouts and face to face on CRE and enhanced precautions.

Based on observation, interview, and document review, the facility failed to implement interventions to prevent the worsening of open areas on the skin, as well as the development of new open areas for 1 of 3 residents (R1) reviewed for skin breakdown. This resulted in actual harm to R1 when he sustained moisture associated skin damage (MASD, damage to skin when it is in contact to moisture for too long) breakdown on his buttocks that worsened, and developed two new areas of MASD breakdown. Findings include: R1's Face Sheet printed on 12/30/21, indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden Scale (skin risk assessment) dated 12/1/21, indicated R1's was at low risk for skin breakdown. On 12/15/21, R1's Braden scale indicated he was at high risk for skin breakdown. R1's readmission Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact. The MDS indicated R1 required extensive assistance with two staff for bed mobility (including repositioning) and was totally dependent on two staff for transfers. The MDS also indicated R1 required extensive assistance with toileting and personal hygiene. The MDS further indicated R1 was frequently incontinent of bowels, and occasionally incontinent of bladder, and he was not on a urinary or bowel toileting program. The MDS indicated R1 was at risk for developing pressure ulcers. R1's care plan dated 10/30/21, indicated R1 was at risk for skin breakdown to his buttocks related to bowel incontinence. The plan was to provide peri cares (cleaning skin post incontinence episode). The care plan indicated R1 had limited physical mobility of his left lower leg requiring the use of a wheelchair (w/c). The care plan indicated R1 had altered musculoskeletal status due to left sided weakness, and the plan was to anticipate his needs and keeping his call light within reach. The care plan further indicated R1 had the potential for MASD to his buttocks related to bowel incontinence, the plan was to observe for signs and symptoms of skin breakdown and refer to alteration in bowel elimination care plan. No further interventions were in place. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, one tablet of Senna Plus ([MEDICATION(S)]) 8.5 milligrams(mg)/50 mg two times per day by mouth as needed for constipation. Apply Dermaceptin (skin protective cream) two times daily and as needed to wound on his buttocks. R1's Medical Administration Record (MAR) dated 12/1/21, through 12/30/21, indicated the orders to cleanse the open area on R1's left buttock with wound cleanser, pat dry, and apply Dermaceptin cream was completed two times per day as ordered. On 12/1/21, R1's Skin and Wound Evaluation on admission indicated R1's upper left buttock MASD open area measured 0.3 centimeters (cm) x 0.2 cm in size. The wound bed was pink or red with no evidence of infection or drainage. The surrounding tissue was macerated. The evaluation indicated a turning and repositioning program should be implemented, and apply barrier cream two times daily and as needed. Wound progress was not indicated. No new interventions were added. On 12/15/21, R1's Skin and Wound Evaluation lacked measurement of the open area on R1's upper left buttock. The evaluation indicated the wound bed was 100% epithelialized (intact skin closed over wound). Surrounding tissue was intact and blanchable. The wound was to continue to be monitored. No new interventions were added. On 12/24/21, R1's Skin and Wound Evaluation indicated the wound had reopened, and measured 0.9 cm x 0.8 cm in size. The wound bed was pink and red with no evidence of infection or drainage. The surrounding tissue was blanching, intact, with redness. The wound was documented as stable. No new interventions were added. On 12/30/21, at 1:40 p.m. R1's wound cares were observed with the director of nursing (DON) and registered nurse (RN)-B. Three open areas were observed on R1's bottom. The first wound was on the upper left buttock and measured approximately 1.5 cm x 1.0 cm. This was the primary wound, and was identified as MASD by the DON. The open area had a pink edge, white slough in the wound bed, and lacked signs or symptoms of infection. The surrounding tissue had minimal maceration (soggy tissue cause by prolonged exposure to moisture). A second open area which was previously unidentified, was identified on R1's med to upper right buttock. The open area resembled a skin tear and measured 2 cm x 1 cm. The open area had a red wound bed, and the surrounding tissue was not macerated. Both the DON and RN-B agreed it was a new wound they had never seen prior and identified it as a skin tear. A previously unidentified third open area on R1's coccyx was not acknowledged by the DON or RN-B, and measured approximately 0.25 cm x 0.25 cm. The wound bed was observed as pink and dry. On 12/30/21, R1's Skin and Wound Evaluation indicated the open area had increased in size to 1.3 cm x 1.1 cm, and lacked additional descriptions other than it was MASD. A new open area measuring approximately 1.5 cm x 0.7 cm was present on his mid-upper right buttock. Additionally, the third open area measured at approximately 0.25 cm x 0.25 cm on R1's coccyx was not documented. No new interventions were noted to be in place. On 12/30/21, at 10:29 a.m. occupational therapist (OT)-A was interviewed and stated R1 was often soiled with feces when he would arrive to perform therapy. OT-A stated R1 would tell him he had been waiting to be changed for a while, but no one was coming. OT-A stated there were multiple days he would push R1's call light to have R1 changed before therapy, but nobody would arrive to answer the call light. OT-A stated he would leave R1 and move to his next resident, and plan to return to R1 later. OT-A stated on 12/22/21, when he returned to R1's room after he had pushed the call light button, an aide came into his room, shut off the call light, and left without changing him. OT-A stated R1 was still soiled with feces. OT-A stated he ended up changing R1's incontinent brief as he could not find help. OT-A stated providing incontinent cares took time away from providing therapy to R1. OT-A stated he felt therapy gains were being compromised due to time being spent on personal cares. On 12/30/21, at 10:53 a.m. NA-B was interviewed. NA-B stated R1 had bowel movements (BMs) very frequently and required incontinent brief changes. NA-B stated R1 had been incontinent of BM three times so far that day. NA-B stated she did not notice any open areas on R1's bottom, and said she thought they were healed. On 12/30/21, at 11:00 a.m. R1 was interviewed. R1 stated he had been incontinent of stool and changed three times already that morning. R1 stated there were many times where staff had answered his call light, and would leave without changing his soiled incontinent brief. R1 stated staff get upset with him because he kept having as many incontinent stools as he did, which could be having as many as ten incontinent BMs a day. On 12/30/21, at 1:01 p.m. RN-B was interviewed. RN-B stated R1 was confused. RN-B stated R1's family had told him there were concerns with R1's call lights not being answered timely. RN-B stated he had not addressed these concerns as they were not formal grievances. RN-B stated R1 did have a lot of bowel movements, and he has had to help change R1 in the past. RN-B stated R1 did not currently have skin breakdown, and the wounds he was admitted with had healed. RN-B stated R1 was not on a toileting or repositioning plan, as he was able to reposition himself. On 12/30/21, at 1:22 p.m. the DON was interviewed. The DON stated R1 had not specifically voiced concerns of issues with call light response or with his incontinence. The DON stated when R1 admitted to the facility, he had a large sacral wound which also covered some of his buttocks. The DON stated R1's wounds were healed. The DON stated she had not noticed any new skin breakdown on R1's buttocks, and his skin has looked good. The DON stated she did provide wound cares to R1 on a regular basis. The DON stated there had not been a discussion about putting R1 on a toileting schedule or a repositioning schedule. On 12/30/21, at 2:52 p.m. following observation of the DON and RN-B providing wound cares, the DON was interviewed again. The DON stated R1 now had a second open area, stated it was a skin tear, but was not sure of when it occurred. The DON stated those were the only two open areas R1 had on his buttocks. When asked about the third open area, the DON stated R1 had 2 open areas. When shown a picture of R1's open areas that included the third open area, the DON stated she could not say what type it was, until she had a chance to assess it. The DON stated the first wound on R1's left upper buttocks wasn't healed. The DON stated skin assessments were done weekly and during wound cares, personal cares, and toileting. The DON stated anyone who sees new or worsening open areas should be reporting them. On 12/30/21, at 3:50 p.m. RN-A was interviewed. RN-A stated she was a certified wound care nurse, and went to multiple buildings within the organization to provide wound cares for residents. RN-A stated she attempted to see wound care residents weekly, however, she had not seen R1 in approximately 3 weeks. RN-A stated this was not uncommon if a resident's wounds were improving. RN-A stated she would review pictures of the wounds located in the resident's medical record remotely. RN-A acknowledged there was no documentation showing she reviewed R1's wounds remotely. RN-A agreed there had been a fair number of changes to R1's skin. RN-A stated the second open area on R1's upper right buttocks was new, and looked like a skin tear. RN-A stated she was unsure about the third open area, stating it could be a pressure ulcer, or it could be MASD, but she wanted to assess it herself. RN-A stated she had spoken to RN-B earlier today at 1:40 p.m. after he and the DON provided wound cares to R1, and RN-B had told her R1's wounds looked better today. RN-A acknowledged R1 had two new open areas, and stated she wanted to explore new options for treatment, as she was worried the open areas were due to bowel acidity. The facility Skin Protection Guideline policy dated 7/7/21, directed if a resident was admitted with impaired skin integrity the licensed nurse should implement monitoring and modifying interventions to stabilize, reduce, or remove underlying risk factors including: -Offloading devices -Incontinence management -Medication review -Positioning -Pressure, friction, shear reduction