Every finding on record at The Villas at St Louis Park

Based on interview and document review, the facility failed to ensure physician orders for blood pressure monitoring were accurately transcribed, implemented, and recorded in the record to provide continuity of care for 1 of 3 residents (R1) reviewed. R1 had physician orders placed on 6/24/26 to perform manual blood pressure checks (i.e., not using an electronic device) at alternating times which were not correctly placed in the record system and, as a result, not completed in accordance with the order.Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but had no delusional thinking or hallucinations. R1 had a history of cardiovascular conditions with debility, coronary artery disease, and heart failure. R1's care plan, last reviewed 5/1/26, identified R1 had an alteration in cardiovascular status and impaired circulation due to diabetes, cellulitis and high blood pressure. The plan listed a goal for R1 to be free of complications from cardiac problems along with four interventions to help R1 meet that goal including assessing fingers and toes for warmth/color, medications per order, monitor edema of legs, and monitor vital signs per house orders. R1's Follow-up Visit note, dated 6/24/26, identified R1 was evaluated by nurse practitioner (NP)-A at the care center. The staff voiced no concerns with R1, and the note identified multiple medical conditions for R1 were reviewed including, 8. Essential hypertension . More elevated blood pressures recently[,] question if some retention [urinary] that was not caught due to every 3 hour PVR [post-void residual]. The note listed a series of recently collected blood pressures which included: 6/11/26 - 162/68 mmHg 6/15/26 - 164/82 mmHg 6/17/26 - 167/54 mmHg 6/22/26 - 170/63 mmHg 6/23/26 - 170/70 mmHg The note continued and R1's medication regimen review included torsemide (a diuretic) and hydralazine (used to treat high blood pressure). NP-A listed four orders for the visit which included, 3 - all blood pressures manually done daily alternating times am [morning] and bedtime.R1's Blood Pressure Summary, printed 7/10/26, identified all R1's collected blood pressures in the medical record system. This identified several missing blood pressures to meet the written order from NP-A (dated 6/24/26) including: 6/25/26 - only a single blood pressure was recorded which was 148/70 mmHg. 6/26/26 - no blood pressures were recorded for the day. 6/27/26 - only a single blood pressure was recorded which was 147/73 mmHg. 6/28/26 and 6/29/26 - no blood pressures were recorded. 6/30/26 - only a single blood pressure was recorded which was 145/72 mmHg. 7/2/26 - no blood pressures were recorded. 7/4/26 - no blood pressures were recorded. 7/6/26 - only a single blood pressure was recorded which was 194/83 mmHg. 7/8/26 - no blood pressures were recorded. R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 7/2026, identified R1's medications and orders, including physician and nursing, along with spaces to record data and staff initials. This recorded two current orders about blood pressure collection which read: - Monitor Blood Pressure in the evening on odd days ., with start date 05/23/26. This recorded a blood pressure reading collected every other day (on 7/1, 7/3, 7/5, 7/7) in the evening with the results. The data written on the MAR was also copied to the Blood Pressure Summary. - B/P [blood pressure] every 48 hours, with a start date 05/22/26. This recorded a blood pressure reading collected every other day (on 7/1, 7/3, 7/5, 7/7) at different times with some in the morning and others in the evening hours. These results were also listed on the Blood Pressure Summary.R1's medical record was reviewed and lacked evidence NP-A's order for manual readings had been entered on the MAR/TAR, nor evidence the blood pressures were being collected daily at alternating times (i.e., morning and evenings) as NP-A directed. When interviewed on 7/10/26 at 9:38 a.m., R1 was asked about his blood pressure and stated he thought staff checked it often but was unsure exactly how often or what times of the day they did. R1 stated staff used a machine to check it and did not recall anyone doing it manually in the past few weeks. R1 stated he thought his blood pressure was stable but then added, I run high. R1 denied dizziness or headache when asked. When interviewed on 7/10/26 at 9:53 a.m., licensed practical nurse (LPN)-A stated they were assigned to R1 currently and had also worked with him a few times in the past weeks. LPN-A explained R1 had heart failure and was on a daily weight for that. The nurses would check his blood pressure when it comes up on the MAR/TAR to do so. LPN-A stated they thought it was ordered for every-other-day currently or something like that. LPN-A stated they used either the electronic wrist cuff or the standing Rosey [machine] to check R1's blood pressure. LPN-A reviewed R1's order (dated 6/24/26) and stated manual blood pressures would mean to use the old fashioned cuff and not the electronic machines. LPN-A stated they were unaware of the order until just then adding, I did not see that until you just showed me. LPN-A stated using an electronic device to capture R1's blood pressure readings would not be correct under that order guidance. Further, the order from NP-A should have been entered on the TAR like a normal order so the nurses were aware of it. When interviewed on 7/10/26 at 10:06 a.m., registered nurse unit manager (RN)-B reviewed R1's medical record and MAR/TAR. RN-B stated there were multiple orders in the TAR for R1's blood pressure collection including the order from 6/24/26, however, that order (from NP-A) had been placed as an other order and didn't have data collection points attached to it. The order currently would not be one which showed up on the MAR/TAR for the nurses to see or know and, as a result, RN-B stated it was likely that the blood pressures were not getting done correctly or entered for data collection. RN-B reviewed R1's Blood Pressure Summary and acknowledged several points of missing data to show the order was being acted on. RN-B verified the entered data from the MAR/TAR would also flow onto the Summary, and verified the center had a manual blood pressure cuff and could do those. RN-B stated the order should have been placed in the MAR/TAR with the setting to record blood pressure readings when it was signed off to ensure the data was captured. Further, RN-B stated they would fix the orders in the MAR/TAR, and that it was important to follow physician orders adding, We have to follow the order. On 7/10/26 at 10:25 a.m., NP-A was interviewed and verified the order written on 6/24/26 was still current adding, I have not changed it. NP-A stated R1 did not like the electronic machines used as it sometimes hurt him and he'd yell out which would then artificially raise the blood pressure reading. NP-A stated the order was written to ensure accurate, better data was being captured as R1 had issues with urinary retention and they were trying to determine if R1's high pressures were related to that or not. A facility policy on blood pressure monitoring and/or physician orders was requested; however, none was received.

Based on observation and interview the facility failed to ensure medications were properly labeled to prevent medication errors for 4 residents (R48, R56, R109, and R102) observed during review of medication carts. Additionally, the facility failed to permanently affix two lock boxes used for controlled medications in the medication room refrigerator reviewed for medication storage. Findings include: During observation and interview on 2/12/26 at 10:58 a.m., review of transitional care unit (TCU) medication cart was completed. R48 had two Lantus insulin pens which were not clearly marked with open date and expiration dates. Additionally, R56's bottle of prednisolone 1% solution (eye drop) had no open date or expiration date. Care Coordinator (CC) stated all injectable medications as well as eye drops, ear drops, nasal sprays and creams must be labeled with open and expiration dates otherwise staff would not know if the medication were safe to use. CC confirmed the items were not clearly labeled for use. During observation and interview on 2/12/26 at 11:23 a.m., review of long-term (LTC) medication cart station 3 was performed. A blue water cup contained the following: 2 Humalog, 2 Lantus, and 1 Victoza injectable pens; no pharmacy labels were affixed on the pens. Licensed practical nurse (LPN)-D stated she was unsure how to perform the 3 checks. LPN-D confirmed there was no pharmacy label located on the pens to indicate name/dose/route/time. During observation and interview on 2/12/26 at 12:33 p.m., two square locked metal boxes were noted inside the medication refrigerator in med room [ROOM NUMBER] on the first floor. Director of Nursing (DON) was unable to locate keys for the boxes and requested maintenance to pry open the locked boxes which revealed two bottles of liquid lorazepam intensol in one box and one bottle of liquid lorazepam intensol in the second lock box. During observation and interview on 2/12/26 at 12:43 p.m., review of LTC medication cart station 4 was completed. A Lantus insulin pen for R109 was found to have no pharmacy label. A Lantus insulin pen for R102 was found to have no pharmacy label. LPN-E confirmed there was no pharmacy label located on the pens to indicate dose/route/time. During interview 2/13/26 at 11:28 a.m., DON stated all medications were required to have a pharmacy label affixed with clear dosing instructions for every medication. She went on to say, all insulin pens, eye drops, nasal sprays and creams required an opened date and an expiration date attached to the container. DON stated it was her expectation staff ensured these items were present prior to administering any medications and expected all metal lock boxes use for controlled medication storage to be permanently affixed to a cabinet or refrigerator. DON stated these things were important to ensure residents were not receiving expired medications, to ensure residents were receiving the medications per physician orders, and to reduce the potential of drug diversion. Facility policy titled Medications Storage in the Facility dated May 2022 indicated the following: Certain medications or package types such as multiple dose injectables, and Ophthalmic, once opened require an expiration date shorter than the manufacturer 's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated; the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The nurse will check the expiration date of each medication before administering it. The policy lacked instructions specific to controlled medication storage.

Based on observation, interview and document review, the facility failed to ensure facial hair was trimmed for 1 of 1 residents (R84) reviewed for dignity.R84's quarterly Minimum Data Set (MDS) dated [DATE], included R84 was cognitively intact. R84's diagnoses included arthritis, stroke, and dementia. R84 had impairment to both upper extremities. R84 required substantial to maximum assistance with personal hygiene, which included shaving. During observation on 2/9/26 at 1:30 p.m., R84 was observed with 1/4 to 1/2 inch long white hairs on her chin. R84 had contractures on both of her hands and commented on how she was unable to open her hands because it was too painful. R84's electronic medical record included a note entered by social worker (SW)-A on 2/9/26 at 3:04 p.m., including SW-A offered to have her face shaved, which resident agreed too. During interview on 2/11/26 at 8:14 a.m., SW-A stated she does not do hands on care with residents. SW-A confirmed she noticed R84 had long chin hair and offered to find someone shave it for her. SW-A declined to estimate on the length of the chin hair prior to it being shaved. SW-A stated facial hair preference should have been included in a resident's care plan. During interview on 2/11/26 at 11:42 a.m., nursing assistant (NA)-A stated staff offeres to shave facial hair daily when they are assisting residents with morning grooming. NA-A stated she did not know any female residents who refused to have their face shaved when offered. During interview on 2/11/26 at 11:48 a.m., NA-B confirmed staff assisted with shaving facial hair. NA-B stated she was unaware of R84 refusing to have her facial hair shaved when offered. During interview on 2/11/26 at 12:32 p.m., family member (FM)-A stated R84 would have preferred to have her facial hair removed. During interview on 2/12/26 at 12:01 p.m., R84 confirmed she would have preferred her facial hair to be shaved. During interview on 2/11/26 at 1:03 p.m., director of nursing (DON) stated she expected staff to brush hair, teeth and other basic grooming daily. DON stated she expected nail care to be completed weekly and shaving to be offered weekly. DON expected staff to reapproach if the resident refused and to add a progress note if a resident continued to refuse. Facility policy for activities of daily living dated 3/31/23, included care and services would be person-centered and honor and support each resident's preferences.

Based on observation, interview and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 2 of 2 residents (R37, R75) observed with medications at bedside. Findings include:R37's admission record dated 12/4/25, indicated R37 admitted to the facility 12/4/25, and had the following diagnoses: heart failure, chronic kidney disease stage 4, anemia and hypertensive urgency. R37's order summary report dated 2/17/26, included orders for the following medications: Carvedilol 25mg, Ergocalciferol 1.25mg, Furosemide 20mg, Omeprazole 20mg, Sodium bicarbonate 650mg, Lyrica 25mg, Methocarbamol 500mg. The provider signed order summary report lacked an order for self-administration of medications or an order to leave dispensed medications at the bedside. R37's medical record lacked evidence of a self-administration of medication evaluation being completed. During initial resident screening/observation on 2/10/26 at 8:58 a.m., R37 was in room seated on bed with bedside table pushed next to bed. A tray of food was noted on bedside table. A medication cup with approximately 6 unidentified pills/capsules was noted on the food tray. Registered nurse (RN-E) entered room and asked R37 if she was done with her meds. R37 stated she was not but that she would take them. RN-E then picked up the medication cup of unidentified medications and left the room. R37 stated staff 'always leaves my meds here'. During interview on 2/13/26 at 11:28 a.m., Director of Nursing (DON) stated residents who wish to take medications independently needed to have a physician's order and must be assessed as being competent to safely self-administer medications. DON stated staff should never leave medications at the beside for a resident to self-administer without an order or a complete self-administer assessment. DON confirmed R37 did not have an order to self-administer medications and no self-administering assessment had been completed for R37. DON stated she expected staff to confirm a resident had a physician's order and self-administering assessment completed prior to allowing a resident to self-administer medications. DON stated this was important to ensure a resident was taking medications as prescribed and not missing doses or stockpiling medications. R75's quarterly Minimum Data Set (MDS) dated [DATE], included R75 was cognitively intact. R75's diagnoses included stroke and Barrett's esophagus with dysplasia (a condition where the lining of the esophagus changes). R75's order summary report dated 2/13/26, included an order for biotine lozenges per package directions per patient request. Order summary report failed to include an order for self-administration of medications. R75's self-administration of medication evaluation dated 11/5/25, included a summary that R75 lacked the capacity for self-administration of medications. During observation on 2/9/26 at 4:49 p.m., R75 had throat lozenges in her room on her bedside table. R75 stated her provider was aware she used them and recommended them for her dry mouth. She said her brother currently purchased them and brought them to her. During observation on 2/10/26 at 1:04 p.m., R75 had a biotine lozenge in a white cup on her tray table and two Halls cough drops. R75 stated she had more lozenges in a box in her room. During interview on 2/10/26 at 4:09 p.m., registered nurse (RN)-A confirmed R75 had biotine lozenges in her room and that she was able to take them independently. RN-A stated a resident would need an assessment completed by the nurse manager and an order from a provider prior to keeping medications in their room. During interview on 2/10/26 at 4:16 p.m., nurse manager (RN)-B stated an order was needed from a provider prior to self-administration of medication and a self-administration assessment completed to ensure the resident was safe to manage medications. RN-B confirmed R75 did not have a provider order for self-administration of medication or a current self-administration assessment that stated she was able to manage the medications. During interview on 2/11/26 at 1:20 p.m., director of nursing (DON) stated an assessment needed to be completed prior to a resident self-administering medication. The DON stated an order was also needed from a provider. The DON confirmed the facility was aware R75 was utilizing the biotin lozenges, but a self-administration assessment was not completed. Facility self-administration policy dated February 2024, included a resident who wished to self-administer medications would have a comprehensive assessment to evaluate the cognitive and physical abilities of the resident. The resident would need to be able to store the medication in a safe area that was not accessible to other residents.

Based on interview and document review, the facility failed to ensure a Notice of Medicare Non-Coverage (CMS-10123 - NOMNC) was provided at least two days before the end of a Medicare-covered Part A stay for for 1 of 3 residents (R23) whose Medicare covered Part A stay ended.Findings include: R27's Comprehensive Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. R27's Notice of Medicare Non-Coverage (NOMNC) indicated services would end on 1/30/26. However, R27 signed and dated the form on 1/29/26, which was less than two days before the end of Medicare-covered Part A services. R27's electronic health record (EHR) lacked evidence that a NOMNC had been provided to R27 at least two days before the end of the Medicare-covered Part A stay. On 2/12/26 at 11:34 a.m., the business office manager (BOM) verified R27's NOMNC indicated the last covered day was 1/30/26, and R27 signed the NOMNC on 1/29/26. BOM stated the NOMNC should have been provided to the resident three days before the last covered day. On 2/13/26 at 3:09 p.m., the associate administrator stated staff were expected to provide and explain the NOMNC at lease 48 hours before the end of a Medicare-covered Part A stay so residents had adequate time to make decisions regarding their care. The facility's ABN/NOMNC Policy and Procedure, effective 2/20/23, indicated the NOMNC was used for communicating appeal rights and appeal information, and would be completed within 48 hours of being notified of the last covered day for a Medicare/Manage Care primary resident.

Based on observation, record review, and interview, the facility failed to ensure resident rooms were kept in good working condition for 1 of 2 (R82) reviewed for environment.Findings include:R82's undated face sheet, indicated R82 was admitted on [DATE], and had the following diagnoses: borderline personality disorder, pain, anxiety, insomnia, neuropathy (nerve pain), and depression.Durning the screening process on 2/10/26 at approximately 9:20 a.m., R82 stated their drawers, and closet had been broken for a long time, and they had nowhere to keep their belongings. R82 stated they had reported their concern to the facility social worker, filed maintenance reports and they were still broken. R82 stated the maintenance department had come and tried to fix the issue but were not able to, and it needed to be replaced. Writer observed the drawers and closet in the room, the drawers lacked any pull tracks and when pulled would come out of the cabinet with very little effort, if they were not being held strongly, they would have fallen to the floor. All the drawers shared the same characteristics. Additionally, the closet doors did not close. R82 voiced their frustration of not being able to store anything other than very light weight items in the drawers and having no shelving in the closets to be able to store items, because of this they had to keep their belongings in bags and boxes throughout the room.The Facility work order #12986 dated 9/3/25, indicated maintenance had been requested for R82's room, which stated, the front of the drawers are coming off, and hooks for hanging. The order was marked as complete on 9/22/25.The facility work order #13074 dated 10/15/25, indicated a maintenance request for R82's room, which stated, Drawers and cabinets need to be addressed and resolved. The order was marked as complete on 10/17/25.The facility work order #13135 dated 11/19/2025, indicated a maintenance request for R82's room, which stated, Drawers are unusable-off the track and broken. The order was marked as complete on 11/26/25.On 12/16/2025 at 1:44 p.m., an email chain between the administrator and the director of plant operations of Monarch indicated they were aware of the need for room renovations.On 2/13/26 at 10:02 a.m., the maintenance director (MD) stated they had been aware of the maintenance concerns and request related to the R82's broken drawers and closet. MD confirmed they had attempted to fix the problem however the items were due to be replaced in a remodel of the building; however, they were unable to move forward with the upgrades until it had been approved by upper management. MD confirmed the broken drawers and closet were broken and needed to be replaced, and it was their expectation it would have already been completed.On 2/13/26 at 1:04 p.m., the administrator stated they were aware of the concerns related to the drawers and closet doors in R82's room. The administrator stated their expectation was if drawers or cabinets were broken, they should be addressed right away and was important to protect the safety of the resident. The administrator confirmed they were aware of the plan to update the long-term care unit, however, was unsure of the timeline of the project, and confirmed R82's cabinets should have been fixed as they had been aware of the concern since September of 2025.A facility maintenance policy was requested; however, none were provided.

Based on interview and document review, the facility failed to complete regular care conferences for 1 of 1 residents (R9) reviewed for care conferences.Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], included R9 was cognitively intact. R9's diagnoses included anxiety, depression, bipolar disorder, and schizophrenia. R9's last four care conferences listed in her electronic medical record (EMR) were dated 8/22/24, 2/5/25, 6/15/25 and 11/13/25. During interview on 2/9/26 at 4:58 p.m., R9 stated she does not get invited to quarterly care conferences. During interview on 2/11/26 at 8:14 a.m., social worker (SW)-A stated care conferences were completed quarterly. SW-A stated she contacted families to invite them to the care conference and informed the resident. SW-A stated the care conference would still be completed if the resident and family did not want to attend. SW-A stated all care conferences were documented on the care conference assessment form, and a progress note was added with any refusals from the resident and family. SW-A confirmed she was unable to locate any additional notes regarding care conferences for R9 in addition to the ones held 8/22/24, 2/5/25, 6/15/25 and 11/13/25. During interview on 2/11/26 at 1:03 p.m., director of nursing (DON) stated she did not typically attend care conferences. DON stated social work set them up and the nurse managers attended them to review the nursing aspect of care. The DON stated it was important to have these conferences to discuss the care and give the resident and family a regular update. No facility policy for care conferences provided.

Based on observation, interview and document review, the facility failed to maintain fingernails at a reasonable length for 1 of 4 residents (R84) reviewed for activities of daily living (ADLs).R84's quarterly Minimum Data Set (MDS) dated [DATE], included R84 was cognitively intact. R84's diagnoses included arthritis, stroke, and dementia. R84 had impairment to both upper extremities. R84 required substantial to maximum assistance with personal hygiene. During observation on 2/9/26 at 1:30 p.m., R84 was observed having contractures on both of her hands and commented on how she was unable to open her hands because it was too painful. R84's fingernails were long, had uneven, chipping red paint. During interview on 2/11/26 at 11:42 a.m., nursing assistant (NA)-A stated assistance with nail care happened on shower days. During interview on 2/11/26 at 11:44 a.m., registered nurse (RN)-C stated residents were offered nail care every shower day. The nurse manager was updated with continued refusals. During interview on 2/11/26 at 12:32 p.m., family member (FM)-A stated she brought up the length of R84's fingernails at the most recent care conference because she was concerned about the length with R84's contractures. R84's last care conference in electronic medical record was dated 1/23/26. During interview on 2/11/26 at 1:03 p.m., director of nursing (DON) stated she expected nail care to be completed weekly. DON expected staff to reapproach if the resident refused and to add a progress note if a resident continued to refuse. DON confirmed R84's nails tend to be long and she has contracted hands which she is unable to open. DON stated all concerns brought forward from a resident or family member should have been addressed in a timely manner. Facility policy for activities of daily living dated 3/31/23, included residents who were unable to carry out ADLs would received necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and document review, the facility failed to update the provider with insulin readings outside of parameters for 1 of 1 residents (R101) reviewed for physician parameters.Findings include:R101's quarterly Minimum Data Set (MDS) dated [DATE], included R101 was cognitively intact. R101 had diagnoses of heart failure, diabetes, and traumatic brain injury. R101 received insulin injections 7 out of 7 days. R101's order review report dated 2/11/26, included to check blood sugars three times a day and Lantus SoloStar 100 unit/ml (a long acting insulin used to control blood sugar levels) inject 10 units subcutaneously in the morning. R101's medication administration record (MAR) for 2/1/26 - 2/28/26 included blood sugar readings as follows:2/9/26 at 1100: 4692/9/26 at 1700: 4152/10/26 at 700: 5132/10/26 at 1100: 4662/10/26 at 1700: 5102/11/26 at 700: 5392/11/26 at 1100: 5422/11/26 at 1700: 481 R101's standing orders signed 1/8/26, include to notify the provider with two blood glucose readings less than 70 or greater than 400 in a 24 hour time frame and/or change in condition. R101's electronic medical record (EMR) included a progress note dated 2/10/26 at 4:37 p.m., which included the nurse practitioner was updated on the blood sugar reading of 510. No additional updates were noted in R101's EMR. During interview on 2/12/26 at 11:08 a.m., licensed practical nurse (LPN)-B stated blood sugar orders typically have parameters with the order that indicate when the provider should be updated. LPN-B confirmed R101's blood sugar reading orders did not include parameters on when to update the provider. LPN-B stated she would use her own judgement based on the resident when no parameters were provided. During interview on 2/12/26 at 11:13 a.m., registered nurse manager (RN)-B stated the nurse should follow the parameters included in the order for when to update the provider. The nurse should use the standing orders when no parameters were provided in the order to obtain a blood sugar. RN-B confirmed R101's order for blood sugars did not include parameters on when to update the provider. RN-B confirmed R101's blood sugar readings were elevated, and the provider should have been updated prior to the 2/10/26 update. During interview on 2/12/26 at 2:30 a.m., director of nursing (DON) stated orders should contain parameters on when to update the provider. DON stated it was important to update the provider when readings were outside of parameters so they could address concerns about high or low values. Facility policy for blood sugar parameters not provided.

Based on observation and interview the facility failed to ensure gastrostomy tube water flushes with medication administration were provided per physician orders for 1 of 1 residents (R48) reviewed for tube feedings. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE] indicated R48 was severely cognitively impaired, dependent on staff for nutrition/hydration needs, medication administration, oral and personal hygiene, and mobility. In addition, R48 had diagnoses of stroke (poor blood flow to a part of the brain causing cell death resulting in parts of the brain to not function properly), hypertension (high blood pressure), diabetes, and a gastrostomy (feeding tube inserted into the stomach). R48's signed order review history report with a provider reviewed date of 2/1/26, indicated an order for facility Standing Orders: May use facility standing orders as signed by provider. The orders also indicated the following medication orders to be administered via gastrostomy tube: Folic Acid 1mg one time a day, Aspirin 81mg one time a day, Metoprolol Tartrate 50mg one time a day, multivitamin 400mcg one time a day, Amlodipine 10mg one time a day, Acetaminophen 500mg three times per day, Miralax 17 grams one time a day. Facility standing orders indicated the following: If a patient has a feeding tube-Medication administration: flush tube with 30mL water before and after administering each medication. Flush with 50mL water after all medications have been administered and upon completion of enteral feeding. R48's care plan indicated a focus of the resident has actual alteration in nutrition and interventions listed as administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan focus/intervention was dated 1/20/26. The care plan lacked a specific focus related to medication administration. During observation and interview on 2/11/26 at 8:14 a.m., Registered Nurse (RN)-D entered R48's room to administer medication via gastrostomy tube (GT). R48 was lying in bed with the head of the bed elevated to 30 degrees. R48's GT was connected to her enteral feeding using a feeding pump. RN-D performed hand hygiene and donned personal protective equipment (PPE). RN-D set 8 medication cups containing crushed medications on a counter. RN-D mixed 20mL of water to each medication cup and stirred with spoon. RN-D paused and then disconnected R48's tube feeding from the pump and capped the tube. RN-D used a large piston syringe and drew the crushed medication/water solution from a cup, removed the GT cap and slowly pushed the solution into the GT. RN-D did not administer a 30mL water flush after administering the medication. RN-D then repeated this process until all 8 medications had been administered. RN-D did not administer a 50mL water flush after administering all medications. RN-D reattached R48's enteral feeding and restarted the pump. RN-D confirmed she had not performed a 30mL flush between medications, or a 50mL flush after administering all medications. During interview on 2/13/26 at 10:35 a.m., licensed practical nurse (LPN)-B stated when administering multiple medications via GT you need to flush between each medication and after you have completed all medications. LPN-B was unsure of the amount needed to flush between or after medications and stated a doctor would specify the amount in an order. LPN-B stated this was important to avoid potential interactions of medications or meds getting stuck in the tube. During interview on 2/13/26 at 10:44 a.m., RN-F stated to flush with 15-20mL of water between medications when administering multiple medications via GT. RN-F stated to use the same amount to flush the GT after completing all medications. RN-F stated this was important to avoid clogging the GT and ensure the resident received the medications and they were not sitting in the GT. During interview on 2/13/26 at 11:28 a.m., Director of Nursing (DON) stated a water flush of 15-20mL was required between medications for residents receiving medications via GT. DON stated a final flush was needed after all medication had been administered but she was unsure of the amount needed for the final flush. DON stated her expectation was staff would complete this step with all residents who received medications via GT. DON stated it was important to follow the correct steps of medication administration via GT to ensure the GT did not become clogged and the resident received all meds as prescribed by the provider. Facility policy titled Medication Administration - General Guidelines dated May 2022 lacked specific instructions related to flushes with medication administration via GT. A policy on medication administration via GT was requested but not provided.

Based on observation and interview, the facility failed to ensure oxygen was administered as ordered for 1 of 1 resident (R38) reviewed for oxygen therapy.R38's quarterly Minimum Data Set (MDS) dated [DATE], included R38 was cognitively intact, could understand others and could express ideals and wants. R38's diagnoses include heart failure, multiple sclerosis (a chronic condition that can lead to vision loss, numbness, fatigue and mobility issues), and respiratory failure. R38's summary report dated 2/13/26, included an order for oxygen at 2-3 liters per minute (LPM) via nasal cannula continuously to maintain oxygen saturation at 90% or above. During observation on 2/10/26 at 9:28 a.m., R38 was in her wheelchair at the side of her bed with her feet in footrests. R38's oxygen nasal cannula was hanging off of her right ear and not properly placed in her nostrils. R38 stated she just got back to her room but was unsure where she came from. R38 stated she was looking forward to laying down in bed because she was tired but was unable to reach her call light for assistance. On 2/10/26 at 9:35 a.m., business office manager (BOM) entered R38's room. BOM confirmed R38's oxygen nasal cannula was not properly placed in R38's nose and she was unable to reach her call light. BOM stated she would alert a nurse with any medial concerns when answering a call light. On 210/26 at 9:52 a.m., licensed practical nurse (LPN)-A entered R38's room and adjusted R38's nasal cannula to place it over both ears and fitted into her nostrils. LPN-A confirmed R38's oxygen was not properly on when she came into her room and LPN-A was unsure how long R38 was without her oxygen. LPN-A checked R38's oxygen saturation with a reading of 86%. LPN-A confirmed R38 was not showing signs of respiratory distress including gasping, shortness of breath, confusion or cyanosis (blue tint on her lips due to low oxygen).During interview on 2/11/26 at 1:15 p.m., director of nursing (DON) stated the nurse should ensure oxygen was placed correctly and then check oxygen saturations if a resident was found without their oxygen as ordered. The DON stated the nurse should encourage deep breathing and utilize an incentive spirometer if the oxygen was below the ordered level. The nurse should update the provider if the oxygen was unable to be maintained at the ordered level. No policy for call lights provided.

Based on observation, interview and document review, the facility failed to implement a system to monitor stored narcotics and complete controlled substance reconciliation for discontinued medications/discharged residents to prevent potential diversion. Additionally, the facility failed to complete medication reconciliation and medication destruction of non controlled medications that were stored in trash bags and boxes throughout the facility. Findings include:During observation and interview on 2/11/26 at 1:52 p.m., approximately 25 cards containing discontinued/expired medications were noted on a shelf in the Care Coordinators (CC) office located in the transitional care unit. CC stated the medication cards were from residents who had discharged or had their orders changed and the medications needed to be destroyed but she didn't have any time to destroy them. During medication storage observation and interview on 2/12/26 at 10:58 a.m., CC stated the facility had previously had two care coordinators who were responsible for medication destruction but that recently one had quit leaving all medication destruction to one staff. CC stated she was doing the work of two people and destroying medications just isn't a priority and she relied on the pharmacy staff to assist in auditing the medication rooms and carts. The following medications for discharged /deceased residents were observed on the transitional care unit (TCU) medication cart #1:104 capsules of Lyrica 50mg45 tablets of Oxycodone 5mg61 tablets of Oxycodone 2.5mg27 tablets of Percocet 10mg/325mg2 tablets of Norco 30mg/300mg8 tablets of Zolpidem 5mg11 tablets of Tramadol 50mg10 tabs of Fioricet 50mg/325mg/40mg During medication storage observation on 2/12/26 at 12:05 p.m., the following was observed in the TCU medication room [ROOM NUMBER]:1 30-gallon clear plastic bag full of non-controlled medication cards for discharge/deceased residents During medication storage observation on 2/12/26 at 12:07 p.m., the following medications for discharged /deceased residents were observed in the TCU medication cart #2:57 tablets of Oxycodone 5mg25 tablets of Oxycodone 10mg37 tablets of Lorazepam 0.5mg61 tablets of Hydromorphone 2mg6 tablets of Norco 7.5mg/325mg8 tablets of Norco 5mg/325mg11 tablets of Lyrica 100mg9 patches of Belcuca 900mcg15mL of Hydromorphone 10mcg/mL During medication storage observation on 2/12/26 at 12:17 p.m., the following was observed in the TCU medication room [ROOM NUMBER]:2 40-45-gallon clear plastic trash bags full of non-controlled medication cards for discharge/deceased residents2 boxes approximately 12-14 inches high by 20-24 inches long overflowing with non-controlled medication cards for discharge/deceased residents2 metal boxes approximately 6 inches by 6 inches; box 1 contained 2 bottles of liquid lorazepam, box 2 contained 1 bottle of liquid lorazepam. The metal boxes were inside the unlocked medication refrigeratorDocuments titled PolarisRX Medication Unit Review dated 9/11/25 indicated the following: Station 1(first floor)- Med room door was not locked, Cart was unlocked; Station 2- (Second floor) Medication room cabinets not secured, discontinued/expired med were not removed from the medication room. Did not indicate who reviewed findings.Documents titled PolarisRX Medication Unit Review dated 10/22/25 indicated the following: Station 1(first floor) - Door to medication room unlocked, lock box in fridge locked but not attached; Station 2 (Second floor)- Lock box in fridge locked but not attached. Did not indicate who reviewed findings.Documents titled PolarisRX Medication Unit Review dated 12/08/25 indicated the following: Station 1(first floor) - Reviewed expired medications with nurse on cart; Nurse informed to remove any discontinued or expired meds, refrigerator lock box locked but not secured. Indicated findings reviewed with AdministratorDocuments titled PolarisRX Medication Unit Review dated 1/06/26 indicated the following: Station 1(first floor)-medication room door unlocked and propped open, unauthorized drugs or supplies noted; Station 2 (First floor)- medication room unlocked; Station 4 (Second floor)-medication room unlocked; medication cart unlocked. Indicated findings reviewed with AdministratorDuring interview on 2/13/26 at 11:28 a.m., Director of Nursing stated the metal boxes located in the TCU medication room [ROOM NUMBER] refrigerator contained controlled medications that were required to be double locked and counted. DON stated she was unaware the medication boxes were in the refrigerator and could not locate any documentation indicating the medications had been counted in the required narcotic counts. DON stated the medication carts were routinely monitored by facility staff and audited monthly by a pharmacy consultant. DON stated the most recent pharmacy cart audit was in January 2026 and she had not seen a report for that visit. DON stated she was aware there were medications to be destroyed from discharged /deceased residents and that she had been trying to slowly complete the process since she was hired in the fall of 2025. DON stated she had previously gone through the bagged and boxed medications located in the TCU medication rooms to be sure there were no narcotics but didn't have time to destroy the medications. DON stated when a resident discharged or passed away, she expected staff to package all medications together and put in a locked medication room for destruction as soon as possible. DON stated the overnight nurses assisted with medication destruction, but narcotics were to be destroyed by the unit managers/care coordinators. DON stated this was important to avoid a resident gaining access to excess medications and to reduce the risk of drug diversion.During interview on 2/13/26 at 2:00 p.m., Polaris Pharmacy consultant (PC) stated she completed monthly audits of facility medication carts and medication rooms. PC stated she looked for expired/outdated medications, medication carts/rooms locked, opened date stickers and loose pills in carts. PC stated after each visit a copy of the audit report was reviewed with facility staff, preferably the DON or Administrator (Admin), but would review with floor staff if DON and Admin were unavailable. PC stated a copy of the audit would be electronically shared with the DON, the medical director, Admin, the pharmacy nurse consultant, consulting pharmacist and the director of the Monarch facilities. PC stated if she repeatedly identified a concern, it would be indicated on the audit report as well as addressed in an email to the facility leadership.Facility Policy titled Disposal of Medications and Medication-Related Supplies with a last review date of May 2022 lacked a specific timeline for destruction of discontinued/discharged resident medications.

Based on interview and document review, the facility failed follow up on pharmacist recommendations for 1 of 5 residents (R9) reviewed for monthly pharmacist reviews.Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], included R9 was cognitively intact. R9's diagnoses included anxiety, depression, bipolar disorder and schizophrenia. MDS included R9 was taking antipsychotic medication and antianxiety medication. Review of R9's electronic medical record (EMR) included progress notes from the consultant pharmacist indicating recommendations for the facility on 9/8/25, 10/13/25, 11/9/25, 12/7/25, 1/12/26, and 2/8/26. R9's pharmacy recommendation dated 1/12/26 included a recommendation to complete an AIMS assessment (a tool used to monitor and evaluate side effects of certain medications) with a notation that the recommendation was reissued from November 2025. R9's pharmacy recommendation dated 2/8/26, again included a recommendation to complete an AIMS assessment with a notation it was reissued from November 2025. R9's EMR included an AIMS assessment completed 2/10/26.-after start of survey? - yes During interview on 2/12/26 at 12:04 p.m., consultant pharmacist (CP) stated he reviews resident's monthly to ensure all necessary monitoring was in place, that there were no interactions with medications and that gradual dose reductions were completed. CP confirmed he had requested AIMS assessments be completed on residents and has had to reissue the request because they were not getting completed. During interview on 2/12/26 at 11:22 a.m., registered nurse manager (RN)-B stated she received pharmacist reviews monthly. RN-B confirmed she had received some requests to complete AIMS assessments and had not kept up with the requests. RN-B stated the facility did not have a process for completing the AIMS assessment and only completed the assessment when recommended by the CP. During interview on 2/11/26 at 9:15 a.m., director of nursing (DON) stated the monthly pharmacist review came to her and she passed them on to either the nurse managers or the provider for follow up. DON stated there had been a problem tracking the pharmacist reviews to ensure they were all addressed timely. Facility policy for psychotropic medication dated 5/2025, included an AIMS would be completed semi-annually.

Based on interview and document review the facility failed to provide physician ordered physical and occupational therapy (PT and OT) services in a timely manner for 1 of 1 residents (R95) reviewed for rehab services. Findings include: R95's admission minimum data set (MDS) dated [DATE], indicated R95 admitted to the facility on [DATE] and had the following diagnosis: hypertension (high blood pressure), hyperlipidemia (high levels of fat in blood) and displaced fracture of left tibial spine (broken ankle bones). The MDS also indicated R95 required substantial/maximal assistance with rolling in bed from side to side, sit to stand, chair/bed-to-chair transfers, toilet transfers, and mobility with wheelchair 50 ft. R95's hospital discharge paperwork dated 12/22/25, indicated an order for referral to physical and occupational therapy services. It further indicated R95 would likely need a Transitional Care Unit (TCU) stay, PT/OT post op. R95's historical care plan with a closed date of 2/3/26, indicated R95 had an alteration in mobility and listed interventions to include PT per medical doctor (MD) orders and follow PT instructions. The care plan also indicated R95 was a fall risk and listed interventions to follow PT and OT instructions for mobility function. The care plan indicated an initiated date of 12/29/25. During interview on 2/10/26 at 4:46 p.m., R95's family member (FM-B) stated R95 admitted on [DATE] but was not evaluated by PT/OT services until 12/29/25. FM-B stated they asked several staff when therapy would start but were not given a clear answer. FM-B stated on approximately 12/28/25, R95 and FM-B were reportedly advised by TCU care coordinator (CC) that the facility was switching therapy companies. FM-B went on to state later that same day a male who identified himself as therapy staff advised R95 that therapy staff was unaware R95 had been admitted on [DATE] and was waiting for therapy services. OT evaluation and plan of treatment note dated 12/29/25 indicated the following: patient presents with impairments in balance, mobility and strength resulting in limitations and/or participation restrictions in the areas of self-care, social life , mobility, general tasks and demands, and domestic life which requires skilled OT services to provision modalities and strengthening, increase safety awareness, increase independence with activities of daily living (ADL's), increase functional activity tolerance and facilitate dynamic standing balance in order to be able to return to prior level of living and return to prior level of skill performance. PT Evaluation and Plan of Treatment assessment record dated 12/29/25, indicated R95 required PT 3 times per week for a duration of 32 days. During interview on 2/11/26 at 10:44 a.m., Certified Occupational Therapy Assistant/Therapy Director (COTA/TD) stated when a resident was admitted with orders for PT or OT, they were seen by therapy staff within 2-3 days. COTA/TD stated it was a goal as a company to see all new residents within 3 days. COTA/TD confirmed R95 was admitted to the facility on [DATE] but was not seen by therapy staff until 12/29/25. COTA/TD stated she was unsure why there was a 7-day delay from admission to start of therapy services. There were no notes in R95's medical record that indicated a reason for delay. She went on to state she was unsure if facility staff communicated with R95 on any delays. During interview on 2/13/25 at 10:51 a.m., facility Associate Administrator (AA) stated when a new resident admitted to the facility, the AA was responsible for communication of the new resident's referral information to the care team, which included therapy staff. AA stated it was her expectation that residents who have a referral for therapy services were seen within 48 hours. AA stated it was important to start therapy as soon as possible for better outcomes and to reduce the risk of a negative outcomes like delayed recovery. An untitled facility policy with a published date of 11/18/25 and subtitle of Service Delivery Policies indicated the purpose to standardize the initial of therapy following referral, ensuring timeliness and proper authorization. It went on to indicate new referrals should be evaluated within 24-48 hours and to communicate plans with nursing staff and residents/family.

Based on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding quality of care, infection control, respiratory care, and resident call system which were also identified during this survey. This had the potential to affect all 92 residents residing in the facility.Findings include: Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F684 for quality of care on the surveys exited 11/2/23 and 1/9/25. See F684: Based on interview and document review, the facility failed to update the provider with insulin readings outside of parameters for 1 of 1 resident (R101) reviewed for physician parameters. Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F695 on the survey exited 1/9/25. See F695: Based on observation and interview, the facility failed to ensure oxygen orders were administered as ordered for 1 of 1 resident (R38) reviewed for oxygen therapy. Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F880 Infection Prevention and Control on the surveys exited 11/2/23 and 1/9/25. See F880: Based on observation, interview and document review the facility failed to ensure infection control measures were maintained when performing wound care for 1 of 1 resident (R61) reviewed for wound care. Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F919 on the surveys exited 11/2/23 and 1/9/25. See F919: Based on observation and interview, the facility failed to ensure a call light was within reach for 1 of 1 resident (R38) reviewed for call lights. On 2/13/26 at 3:09 p.m., the associate administrator stated previous citations were addressed with facility plan of correction which included audits, and once QAPI determined continued compliance based on audit results, the audits were decreased or suspended, but QAPI still discussed the concerns. The associate administrator stated staff were expected to notify providers per parameters to maintain residents' health, and staff were expected to maintain proper placement of oxygen was important to sustain resident oxygen saturations. Staff were expected to complete hand hygiene between glove changes for infection control, and staff were expected to ensure call lights were within resident reach to prevent potential negative outcomes if not available. The facility's QAPI Plan reviewed 9/25/25, indicated the performance improvement plan (PIP) project, once it has met its goals, will be reviewed in the following quarterly QAPI meeting to ensure the project is being sustained. If the QAPI committee identifies that the PIP project has failed to sustain itself, it will decide what the next steps are to improve and ensure sustainability of the goals. To ensure the PIP project is implemented and effective for sustaining projects, the committees will choose data and measurement tools that directly impact and is effective to meet the goals of the project. The measurements will be reviewed by the committees to ensure it is effective.

Based on observation, interview, and document review the facility failed to ensure infection control measures were maintained when performing wound care for 1 of 1 resident (R61) reviewed for wound care. Findings include: R61's admission Minimum Data Set (MDS) dated [DATE], indicated R61's cognition was intact and included diagnoses of pressure ulcer of left buttock-stage 3 (a severe, full-thickness wound extending through the skin to the subcutaneous fat layer, appearing as a deep crater), local infection of the skin and subcutaneous tissue, and morbid obesity. R61's historical care plan with a last review date of 12/5/25, included the following: Focus-resident is currently on Enhanced Barrier Precautions (EBP) relate to wound; Interventions- staff to follow enhanced barrier precautions, staff to don/doff personal protective equipment (PPE) per enhanced barrier precautions when providing high contact care. R61's order review history report signed/dated 2/1/26, indicated the following orders: Buttocks-1) Cleanse with generic wound cleanser 2) Apply skin prep thoroughly 3) Apply collagen to wound bed 4) Apply hydrocolloid dressing over areas 5) Change every 3 days and PRN every day shift related to pressure ulcer of buttock stage 3; and Follow EBP (Enhanced barrier precautions) while providing wound cares and other high contact care activities. During observation on 2/11/26 at 10:04 a.m., registered nurse (RN-D) was observed providing wound care. RN-D donned PPE (gown, gloves and surgical mask) gathered supplies and positioned R61 to lay on his left side exposing his buttocks. RN-D cleansed the wound with wound cleanser and clean 4x4 gauze; removed soiled gloves and applied clean gloves. RN-D did not perform hand hygiene before applying clean gloves. RN-D patted area dry with 4x4 gauze and removed soiled gloves, then applied clean gloves. RN-D did not perform hand hygiene before applying clean gloves. RN-D applied collagen powder into wound bed and calcium alginate, covered wound with hydrocolloid dressing, dated and initialed dressing and removed soiled gloves. RN-D applied clean gloves but did not perform hand hygiene. RN-D applied Vanicream to surrounding tissue, assisted R61 to his back and removed PPE and placed it in trash and then washed hands and exited room. During interview on 2/11/26 at 10:37 a.m., RN-D stated she should perform hand hygiene when entering the room, before applying gloves and when changing gloves. RN-D stated she should wash hands when they were visibly soiled and apply hand sanitizer after removing soiled gloves before applying clean gloves. RN-D stated she believed wearing two pairs of gloves was an acceptable alternative to performing hand hygiene between glove changes. RN-D stated she would remove the outermost glove and believed it was not necessary to perform hand hygiene as she believed the inner gloves would still be clean. During interview on 2/11/26 at 11:02 a.m., licensed practical nurse (LPN-C) stated hand hygiene was performed when you enter a resident room, when changing gloves from dirty to clean and upon exiting room. LPN-C went on to say hand washing should be done if hands were visibly soiled. During interview on 2/11/26 at 1:52 p.m., transitional care unit care coordinator (CC) stated staff should perform hand hygiene going into a resident room, between glove changes and when exiting a resident room. CC stated wearing two sets of gloves was not an acceptable alternative to hand hygiene when removing soiled gloves. The first set of gloves was basically like your skin. During interview on 2/13/26 at 11:28 a.m., Director of Nursing (DON) stated hand hygiene was completed after using bathroom, when entering or exiting a resident's room and after removing soiled gloves but before applying clean gloves. DON stated wearing two pairs of gloves was not a safe alternative to hand hygiene. DON stated it was her expectation that staff completed hand hygiene by washing hands or using hand sanitizer. DON stated it was important to accurately complete hand hygiene, so you were not introducing new bacteria or germs into an open wound, contaminating dressing supplies and reducing the risk of new or worsening infections with residents. Facility policy titled Infection Prevention and Control Program indicated the facility has established policies and procedures regarding infection control among employees and those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.

Based on interview and document review the facility failed to ensure 1 of 5 residents (R11) was offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations.Findings include: A CDC Adult Immunization Schedule by age topic dated 08/07/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had not received the complete series of pneumococcal vaccination (i.e., PPSV23, PCV20 and PCV13) or their history was unknown, then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20), 1 dose of PCV-15, or PCV-21. R11's undated face sheet, indicated R11 was [AGE] years of age, admitted to the facility on [DATE], and had the following diagnoses: bipolar disorder, post-traumatic stress disorder, weakness, hypertension (high blood pressure) and chronic kidney disease. R11's Minnesota Immunization Information Connection (MIIC) undated report, indicated R1 had received a pneumococcal vaccination on 4/3/2015, it did not indicate which variation. This made R11 eligible for a pneumococcal vaccination. R11's resident vaccine administration consent form signed 10/6/2025, indicated R11 gave consent to receive a Pneumococcal vaccination. R11's medical record lacked any evidence a vaccine was administered. On 2/13/26 at 1:47 p.m., the director of nursing (DON) stated they had offered R11 a vaccination approximately one month ago, but it had not been provided. The DON's expectation was vaccination eligibility was evaluated upon admission to the facility and provided after the resident's status was verified. The DON confirmed R11's vaccination had not been administered. The DON stated the importance of keeping the vaccination status of resident up to date to prevent the risk of respiratory complications. The facility Pneumococcal Policy last revised 2/2024, indicated prior to or upon admission to the facility (within 5 days), all residents will be assessed for current immunization status and eligibility to receive the pneumococcal vaccine. Within 30 days of admission, resident will be offered the vaccine, when indicated.

Based on observation and interview, the facility failed to ensure a call light was within reach for 1 of 1 resident (R38) reviewed for call lights.Findings include:R38's quarterly Minimum Data Set (MDS) dated [DATE], included R38 was cognitively intact, could understand others and could express ideals and wants. R38's diagnoses include heart failure, multiple sclerosis (a chronic condition that can lead to vision loss, numbness, fatigue and mobility issues), and respiratory failure. During observation on 2/10/26 at 9:28 a.m., R38 was in her wheelchair at the side of her bed. Feet were in footrests. R38 was leaning to the right, oxygen nasal cannula was out of nostrils. R38 stated she just got back from somewhere but could not remember where. R38 stated she was tired and looking forward to laying down. R38 stated her call light was somewhere over there while pointing to the opposite side of her bed. Call light cord was wrapped around bed rail on opposite side of bed and out of reach. On 2/10/26 at 9:35 a.m., business office manager (BOM) was seen entering R38's room. BOM stated she would get a nurse if there were any medical concerns when she answered a call light. BOM confirmed R38's oxygen nasal cannula was not in her nose, and her call light was on the opposite side of her bed, out of reach. BOM left R38's room without moving her call light within her reach. On 2/10/26 at 9:52 a.m., licensed practical nurse (LPN)-A entered R38's room and adjusted nasal cannula into nose. LPN-A stated she was unsure how long the oxygen was not properly in place. LPN-A check R38's oxygen saturation with a reading of 86%. LPN-A confirmed R38 was not showing any signs of respiratory distress, no gasping, confusion or bluing lips. During interview on 2/11/26 at 8:28 a.m., BOM confirmed R38 was unable to reach her call light the previous day when she was in R38's room. BOM confirmed she left R38's room without ensuring the call light was within reach. BOM stated she informed a nurse at the nurses' station that R38's oxygen nasal cannula needed to be adjusted after she left her room. During interview on 2/11/26 at 1:15 p.m., director of nursing (DON) stated a call light should always be within reach. DON stated every employee should be watching to ensure a call light was within reach. The DON stated if a resident was unable to reach a call light, they were unable to call for help when needed. No policy for call lights provided.

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 (R39, R51) reviewed for food palatability. This deficient practice had the potential to affect all 93 residents residing in the facility who consumed food from the facility main kitchen. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had intact cognition and required supervision to eat. R51's quarterly MDS dated [DATE], indicated R1 had intact cognition and was able to feed herself after staff set up her tray. During an interview on 1/6/25 at 1:43 p.m., R51 stated the food did not taste very good and the hot items were usually served cold and the cold items were served warm. During an interview on 1/6/25 at 2:08 p.m., R39 stated the hot food is always cold and the cold food usually is not cold. During an observation on 1/6/25 at 5:45 p.m., multiple trays were being placed on a cart from the main kitchen. At 6:08 p.m., as the last plates were being passed from the cart a test tray was requested from dietary aide DA-A. The meal consisted of a cold roast beef sandwich, mashed potatoes, gravy, and pureed corn. The tray was tested for temperatures and results were as follows: -cold roast beef sandwich was 158 degrees Fahrenheit (F). -mashed potatoes were 115 degrees F. -gravy was 129 degrees F. -pureed corn was 113 degrees F. Surveyor tasted the food from the tray: the cold roast beef sandwich was warm, the mashed potatoes, gravy, and pureed corn were cold. During an interview on 1/6/25 at 7:05 p.m., R39 stated the roast beef was not very cold and the mashed potatoes and gravy were cold. During an interview on 1/6/25 at 7:20 p.m., R51 stated the cold roast beef was not very cold and the mashed potatoes and gravy were so cold that they couldn't eat them. During an interview on 1/6/25 at 6:32 p.m., dietary aide (DA)-A stated the process is to plate the food, cover it, place it on a tray, and then the trays are passed to all residents who eat in their room. DA-A stated the holding temps of hot food should be at least 135 degrees F and cold food should be served no warmer than 41 degrees F. During an interview on 1/6/25 at 6:37 p.m., culinary director (CD) stated the normal process was to plate the food either from the steam tables in the dining room or from the main kitchen for residents who eat in their room, cover the food, and place on a cart for staff to pass to residents. CD stated the holding temp of cold food should be 41 degrees F and hot food should be at least 135 degrees F. Review of a facility policy titled Test Tray Evaluation Procedure undated, indicated facility would test last tray delivered, and identified cold food should have been at or below 50 degrees F and hot food at or above 140 degrees F.

Based on observation, interview, and record review, the facility failed to ensure a shared glucometer (blood glucose meter) was disinfected after use for one resident (R71), and failed to performed hand hygiene after removing soiled gloves and prior to donning clean gloves and completing clean tasks during perineal care for 2 of 3 residents (R10, R17) observed during change of incontinent product. Additionally, the facility failed to ensure staff performed hand hygiene between assisting multiple residents in the dining area for 3 of 5 residents (R71, R40, R49) observed in a dining area. Findings include: HH DURING PERINEAL CARE R10's admission Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition, required substantial and/or maximal assistance for toileting hygiene and partial and/or moderate assistance to roll left and right, and had diagnoses of cancer, heart failure, hypertension (high blood pressure), renal disease, diabetes mellitus, and respiratory failure. R17's quarterly MDS dated [DATE], indicated R17 had intact cognition, was dependent on staff for toileting hygiene, required substantial and/or maximal assistance to roll left and right, and had diagnoses of heart failure, urinary tract infection in the last 30 days, asthma, and respiratory failure. During observation on 1/7/25 at 3:55 p.m., nursing assistant (NA)-B and NA-C had gloves on and assisted R10 with perineal cares. R10 had a saturated incontinent product, and NA-C used wipes to provide perineal care to the front side and back side of R10. NA-C used the same gloves to tuck in clean linen used as a draw sheet and a clean incontinent product under R10. During observation on 1/7/25 at 4:10 p.m., NA-B and NA-C had gloves on and assisted R17 with perineal cares. R17 had incontinent bowel movement, and NA-B assisted R17 with perineal cares. NA-B had feces on gloves, removed gloves, did not perform hand hygiene, applied clean gloves, and moved R17's pillow to the wheelchair. NA-B tucked in the dirty bed linen under R17 and further cleaned bowel movement from R17. NA-B tucked the clean incontinent product under R17 with the same gloves. NA-B removed gloves, did not perform hand hygiene, and rubbed a towel against R17's back per request. NA-B left the room and performed hand hygiene prior to grabbing clean supplies from the supply closet. NA-B re-entered R17's room, applied gloves, and wiped the front perineal area of R17. NA-B did not change gloves or perform hand hygiene and velcroed R17's incontinent product, applied clean bed linen, repositioned R17, and placed a pillow behind R17's head. NA-B removed gloves and did not perform hand hygiene, pushed R17's bedside table towards R17, and brought bagged dirty items to the soiled linen room. During interview on 1/7/25 at 4:32 p.m., NA-C stated their gloves were not visibly soiled, so they did not change their gloves or perform hand hygiene between perineal care and tucking in R10's clean incontinent product. During interview on 1/7/25 at 4:44 p.m., NA-B stated they should have removed gloves and performed hand hygiene when gloves removed prior to touching clean items. During interview on 1/8/25 at 2:26 p.m., clinical manager (CM)-B, who worked with the director of nursing (DON) as the infection preventionist, expected staff to remove gloves and perform hand hygiene between dirty and clean tasks to prevent cross-contamination. During interview on 1/9/25 at 12:39 p.m., CM-A agreed staff needed to remove gloves and perform hand hygiene after dirty tasks and before clean tasks. The facility Gloves policy dated 12/19, directed staff to wash hands before applying gloves and wash hands after removing gloves. The Toileting Assistance policy dated 11/19, directed staff to gather incontinent supplies as needed, wash hands and apply gloves, change incontinence product as needed, perform pericares, assist with clothing and incontinence product adjustments as needed, discard soiled incontinence products, and remove gloves and wash hands. GLUCOMETER DISINFECTION R71's quarterly MDS dated [DATE], indicated R71 had severe cognitive impairment, required supervision or touching assistance with eating, and had diagnoses of hypertension, diabetes mellitus, cerebrovascular accident, dementia, malnutrition, and hemiplegia or hemiparesis. R71's order with start date of 11/23/23, directed staff to check R71's blood sugar before meals for DM II [diabetes mellitus two]. During observation on 1/7/25 at 5:08 p.m., licensed practical nurse (LPN)-B brought a bin with clean supplies, such as packets of alcohol wipes and bottle of test strips, into R71's room. LPN-B checked R71's blood sugar and placed the glucometer into a plastic cup which sat in the bin of clean supplies. LPN-B removed gloves, performed hand hygiene, and returned to the medication chart at the nursing station with the glucometer and supplies. LPN-B used a glove to remove the used test strip from the glucometer and placed the glucometer on top of the clean alcohol wipes without disinfecting. During interview on 1/7/25 at 5:33 p.m., LPN-B stated the glucometer and bin with supplies were shared between residents in station three. LPN-B stated they usually disinfected the glucometer after use inside the resident's room but rushed so they could write down items they needed to order before they forgot. During interview on 1/8/25 at 2:26 p.m., CM-B expected staff to disinfect glucometers after use before leaving the resident room or putting back in clean supply bin. IP stated it was important to prevent the spread of bloodborne pathogens. During interview on 1/9/25 at 12:39 p.m., CM-A stated glucometers were disinfected before placed back in a clean area. During interview on 1/9/25 at 1:48 p.m., the director of nursing (DON) expected staff to disinfectant and cover shared glucometers for two minutes after use to prevent spread of bloodborne illness. Infection Prevention and Control Program policy dated 11/24, indicated staff were to be educated and follow proper techniques and procedures for prevention of infection. The policy did not specifically address glucometer disinfection. HAND HYGIENE DURING MEAL ASSISTANCE R40's quarterly MDS dated [DATE], indicated R40 had severe cognitive impairment, required substantial and/or maximal assistance with eating, and had diagnoses of diabetes mellitus, cerebrovascular accident (stroke; when blood flow to the brain is interrupted), dementia, malnutrition, and hemiplegia or hemiparesis (complete loss of movement or weakness in one side of the body). R49's annual MDS dated [DATE], indicated R49 had severe cognitive impairment, required partial/moderate assistance with eating, and had diagnoses of atrial fibrillation (heart condition which causes an irregular and rapid heartbeat), hypertension (high blood pressure), diabetes mellitus, arthritis, dementia, and cerebrovascular accident. R71's quarterly MDS dated [DATE], indicated R71 had severe cognitive impairment, required supervision or touching assistance with eating, and had diagnoses of hypertension, diabetes mellitus, cerebrovascular accident, dementia, malnutrition, and hemiplegia or hemiparesis. During observation on 1/8/25 at 8:18 a.m., R71 sat in wheelchair at a dining room table and mixed their oatmeal with their spoon without eating more than a couple bites. LPN-A approached R71 and fed R71 the oatmeal with their spoon without wearing gloves. LPN-A brought juice up to R71's mouth, R71 refused to swallow, and LPN-A wiped R71's mouth with a napkin. LPN-A did not perform hand hygiene and approached R49, who was in a wheelchair at another table, wiped R49's mouth with a napkin and no glove, and assisted R49 to eat pancakes and eggs using R49's silverware. LPN-A did not perform hand hygiene and approached R40 at the same table and assisted R40 with their breakfast using R40's silverware. During interview on 1/8/25 at 8:31 a.m., LPN-A stated they washed their hands before assisting in the dining area and verified they did not perform hand hygiene between assisting residents. LPN-A stated they were touching bowls and utensils and had not touched the food so did not need to wash their hands. During interview on 1/8/25 at 2:26 p.m., CM-B expected staff to wash their hands between assisting different residents in the dining area or expected staff to use one hand to help one resident and the other hand to help the second resident. IP stated staff should avoid cross-contamination. During interview on 1/9/25 at 12:39 p.m., CM-A stated staff needed to use a different hand for each resident they assisted with eating in the dining area or perform hand hygiene between assisting residents or ask other staff for help. During interview on 1/9/25 at 1:48 p.m., the director of nursing (DON) expected staff to wash their hands prior to meal service and in between residents or designate one hand per resident. Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated 10/17, directed staff to wash hands after engaging in activities which contaminate the hands.

Based on interview and record review, the facility failed to provide ongoing monitoring, comprehensive assessment, and care planning, and needed care consistent with professional standards of practice, facility policy, and provider orders resulting in risk of serious illness or death related to complications of coronavirus disease 2019 (COVID-19) infections to 1 of 5 residents (R1) identified in Immediate Jeopardy. In addition to the resident in immediate jeopardy, the facility failed to update policies and procedures for comprehensive assessment, monitoring, developing, and revising person-centered care plans, and implement consistent interventions in accordance with professional standards of practice for all respiratory illnesses resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy for 4 out of 4 residents (R4, R6, R7, R8). The immediate jeopardy (IJ) began on [DATE] when R1 tested positive for COVID-19 and ongoing monitoring, comprehensive assessment, and care planning, and needed care was not provided for R1 and was identified on [DATE]. The administrator, associate administrator, director of nursing, and regional nurse consultant were notified of the IJ at 6:10 p.m. on [DATE]. The IJ was removed on [DATE], but noncompliance remained at the lower scope and severity level E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The facility's Covid Policy dated [DATE], included: Management After Identification . Monitoring of Residents: Regular monitoring of resident condition who test positive (VS [vital signs], etc.) should occur on each shift at a minimum in order to closely monitor resident condition and help determine when resident can be removed from isolation. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, diabetes, Bell's Palsy (one-sided facial weakness) hypertension (high blood pressure), and depression. R1 had a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment, was independent with toileting, transfers, and walking, utilized a wheelchair, was frequently incontinent of bowel and bladder, and needed set-up or clean-up assistance with eating. R1's care plan last dated [DATE], was not updated and did not include any focus or interventions related to R1's COVID-19 diagnosis. A progress note dated [DATE] at 2:41 p.m., indicated R1 tested positive for COVID-19 and R1's provider and family were updated. R1's provider order dated [DATE], indicated R1 was prescribed a five-day course of Paxlovid (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression). R1's treatment administration record (TAR), progress notes, and vital sign record from [DATE] to [DATE] did not include documentation of vital signs or monitoring of R1's COVID-19. R1's medication administration record (MAR) dated the month of [DATE], indicated R1 refused to take his morning dose of Paxlovid on [DATE] as prescribed. A progress note by licensed practical nurse (LPN)-D dated [DATE] at 5:36 p.m., indicated during report at the start of their evening shift (2:00 p.m. to 10:00 p.m.) LPN-D was told R1 was not doing well, and the provider and family had been updated. LPN-D documented R1's vital signs, which were a higher-than-normal, respiratory rate (RR) (breaths per minute) of 24, oxygen saturation level (O2 sat) (the amount of oxygen circulating in a person's blood) of 96%, and a heart rate (HR) (heart beats per minute) of 76. The note indicated LPN-D called the on-call provider, nurse practitioner (NP)-A, who ordered labs (blood work), pushing fluids (encouraging fluid intake), and vital sign checks every shift. R1's provider orders from NP-A dated [DATE], included labs and monitoring vital signs every shift for COVID-19 for three days including oxygen saturation levels. The faxed paper orders noted an electronic signature from NP-A at 3:37 p.m. and fax machine receipt time stamp at 1:37 p.m. Pacific Standard Time, equivalent to 3:37 p.m. Central Standard Time (the time zone from which the fax was sent and received). R1's vital signs record dated [DATE] at 6:30 p.m. indicated R1's temperature was 98 degrees Fahrenheit, and his blood pressure was ,d+[DATE]. A progress note by LPN-D dated [DATE] at 9:58 p.m., noted at 7:11 p.m. they checked on R1 and found him unresponsive and pulseless and confirmed his death at 7:30 p.m. R1's death certificate titled Minnesota Documentation of Death indicated R1 died on [DATE] at 7:30 p.m. at [AGE] years old. Causes of death included primary causes of dementia and cerebrovascular disease (conditions affecting blood flow to the brain) with COVID-19 listed under other significant conditions contributing to death. In an interview on [DATE] at 8:28 a.m., LPN-B stated R1 had been gradually declining from baseline since admission. R1 used to wheel themselves around in a wheelchair, transfer themselves, and have a good appetite. Over time R1 had stayed in bed more, was more lethargic and less communicative, did not want to eat or drink as much, and declined overall. In an interview on [DATE] at 9:03 a.m., LPN-A stated R1 was independent with minimal assistance needed on admission and walked with a walker at times. As time went by, he declined and his Parkinson's seemed to get worse with increased shaking, he could not feed himself and someone fed him, he slept most of the time or sat in his wheelchair and needed staff assistance of one to get up. In an interview on [DATE] at 12:57 p.m., NP-A stated she first found out R1 was diagnosed with COVID-19 when contacted by facility staff on [DATE]. The Paxlovid must have been prescribed by the on-call provider contacted on [DATE] when R1 tested positive. NP-A stated for a resident with COVID-19 or another respiratory illness like pneumonia or influenza she would expect vital signs to be taken at least every shift, residents to be monitored, and to be notified right away if there was any worsening of symptoms. NP-A indicated she believed the facility's orders for COVID-19 precautions included taking vital signs every shift and thought the facility did vital signs every shift for residents with either COVID-19 or another respiratory illness. In an interview on [DATE] at 4:58 p.m., LPN-B stated she was the day shift nurse on R1's unit on [DATE]. LPN-B stated on [DATE], she believed R1 was not eating, did not want to eat breakfast and did not want lunch if she remembered correctly, and R1 refused a meal. LPN-B stated R1 seemed sleepy and lethargic, but not more so than what had been his normal for about the last week since his diagnosis with COVID-19 on [DATE]. LPN-B did not remember what she told oncoming nurse LPN-D during report, but thought she said to keep an eye on R1. LPN-B stated someone could have called the provider during the day about R1's clinical condition, but she did not remember calling a provider about R1 on [DATE]. In an interview on [DATE] at 5:22 p.m., LPN-D stated she checked on R1 after receiving report and took his vital signs because she was told in report that R1 had COVID-19 and was not doing well. LPN-D heard R1 did not take his medications that morning because he had difficulty swallowing the pills, so they were held (not administered). LPN-D stated she contacted the on-call provider because of R1's increased RR and NP-A sent orders for labs and vital sign checks. In an interview on [DATE] at 11:55 a.m., NP-A stated a nurse called her on [DATE] but could not recall what time the facility called and was unable to locate documentation of the time of the call. NP-A stated the call could have been around noon, but she believes she sent the orders for labs and vitals electronically right away after the call and stated the orders were electronically signed at 3:37 p.m. on [DATE]. NP-A indicated she wanted staff to get lab work, do closer monitoring of vital signs, and push fluids to further assess R1's condition before determining if transfer to a hospital for treatment was appropriate. In an interview on [DATE] at 9:01 a.m., director of nursing (DON) stated for residents with COVID-19 staff put in a batch of orders including monitoring of O2 sat, respirations, and temperature that every shift is supposed to do and do any time there is a change in a resident's condition. The facility policy for monitoring is regular monitoring of resident condition including vital signs every shift at a minimum. For residents with a respiratory illness like influenza, pneumonia, or respiratory syncytial virus staff should be looking at vital signs every shift because they are looking for a change in condition. The DON stated the facility's standard for COVID-19 vital signs monitoring order did not adhere to facility policy or professional standards of practice because it only included RR, O2 sat, and temperature and did not include HR or BP. The DON stated R1 tested positive for COVID-19 on [DATE] and his vital signs were monitored once during his illness, on [DATE], the day he was found deceased . The DON stated this does not meet her expectations and it appears the facility was not monitoring R1 which does not follow facility policy or professional standards of practice. The DON stated staff would not have been able to notice a change in condition or identify when R1's condition changed due to lack of monitoring. DON stated there is nothing on R1's care plan related to COVID-19. R4's MDS dated [DATE], indicated R4 was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) affecting the right dominant side after a stroke, stroke, Alzheimer's disease, aphasia (loss of ability to understand or express communication), hypertension, hyperlipidemia (high cholesterol), malnutrition, and dysphagia (difficulty swallowing). R4 had a BIMS score of zero indicating severe cognitive impairment. R4 was dependent on staff for mobility in bed and wheelchair, transfers, bathing, toileting hygiene, and was always incontinent of bowel and bladder. R4's care plan last dated [DATE] included a focus on potential risk for exposure to the virus causing COVID-19 due to residing in a congregate living facility, co-morbid conditions, advanced age, and dependency on caregiver assistance. It did not include a focus or interventions related to R4's COVID-19 diagnosis. A progress note dated [DATE] at 10:33 a.m., indicated R4 tested positive for COVID-19. A second progress note at 10:43 a.m., indicated provider and family were updated and the provider was faxing over new orders. R4's provider orders dated [DATE], indicated prescription of a five-day course of Paxlovid to treat COVID-19 and COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours. A provider note dated [DATE], indicated R4 was at high risk for complications related to COVID-19. The documented treatment plan included monitoring R4's vital signs every shift with instruction to call provider if O2 sat was less than 90% or resident had a fever. R4's vital sign record included RR documented once on [DATE] and once on [DATE]. O2 sat and temperature were documented twice on [DATE], once on [DATE], and twice on [DATE]. HR and BP were documented once on [DATE] and once on [DATE]. A nursing progress note dated [DATE] at 2:28 p.m., indicated the writer assessed R4's vital signs including BP, HR, and RR. No other recorded vital signs were noted on R4's MAR, TAR, progress notes, or vital sign record between [DATE] and [DATE]. In an interview on [DATE] at 9:01 a.m., The DON stated R4's O2 sat had not been monitored every shift and the facility policy for monitoring was not being followed. The DON noted they did not see anything on R4's care plan related to COVID-19 except the risk for exposure to COVID-19. R6's MDS dated [DATE], indicated R6 was admitted [DATE] with diagnoses including acute and subacute hepatic failure (liver failure), alcoholic liver cirrhosis with ascites (alcohol-induced liver disease with abdominal fluid build-up), hyponatremia (low sodium level in the blood), malnutrition, depression, portal hypertension (high blood pressure in the major vein leading to the liver), muscle weakness, latent tuberculosis (tuberculosis bacteria in the body without symptoms of tuberculosis), and a thyroid disorder. R6 spoke Spanish, had some difficulty making themselves understood and understanding others, and had a BIMS score of nine indicating moderate cognitive impairment. R6 required supervisory assistance with transfers, ambulation, and toileting. A progress note dated [DATE] at 2:08 p.m., indicated R6 tested positive for COVID-19 and family and on-call provider were contacted. R6's provider orders dated [DATE], indicated prescription of a five-day course of Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) and COVID-19 monitoring including check temperature, O2 sat, and RR every four hours ending [DATE]. R6's care plan interventions last dated [DATE], included COVID-19 isolation precautions of infection control precautions per protocol, sign on resident's door, and treatment for current per order. R6's care plan did not include other interventions related to his COVID-19 infection. R6's vital sign record, MAR, TAR, and progress notes included RR, O2 sat, and temperature taken at least once per shift between [DATE] and [DATE]. R6's HR and BP were documented once on [DATE] through [DATE], zero times on [DATE], twice on [DATE], once on [DATE], twice on [DATE] through [DATE], and once on [DATE]. In an interview on [DATE] at 9:01 a.m., The DON stated R6's care plan included isolation precautions related to COVID-19, but no other interventions related to R6's COVID-19 diagnosis. She would not describe the care plan as individualized related to COVID-19. The DON stated professional standards of practice for a set of vital signs include BP, HR, temperature, RR, and O2 sat, and facility policy directed vital signs be monitored every shift for residents with COVID-19. The DON noted R6's vital signs were not monitored per facility policy and professional standards of practice and nursing staff were not monitoring him for a change in condition because there was not enough vital sign data to do so. R7's MDS dated [DATE], indicated R7 was admitted [DATE] with diagnoses including acute on chronic diastolic heart failure (an episode of worsened chronic heart failure), anemia, rheumatoid arthritis, acute and chronic respiratory failure with hypoxia (a condition where the respiratory system cannot provide enough oxygen to the body), and used supplemental oxygen. R7 had a BIMS score of 12 indicating moderate cognitive impairment, and was independent with toileting, ambulation, and transfers. R7's care plan last dated [DATE], did not include any focus or interventions related to R7's COVID-19 diagnosis. A progress note dated [DATE] at 11:00 a.m., indicated R7 tested positive for COVID-19. A provider note dated [DATE], indicated R7 was at high risk for complications related to COVID-19. The treatment plan included prescription of Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) for five days and instruction to monitor vital signs every shift and call provider if O2 sat was less than 90% or resident had a fever. R7's provider order dated [DATE] indicated COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours through [DATE]. R7's vital sign record, MAR, TAR, and progress notes did not include full sets of vital signs every 4 hours per provider orders between [DATE] and [DATE]. R7's HR was documented zero times on [DATE] and BP was recorded once. HR and BP were noted twice on [DATE] and [DATE], three times on [DATE] and [DATE], twice on [DATE], and three times on [DATE]. In an interview on [DATE] at 11:46 a.m., the DON stated R7's care plan was not updated and was not resident-centered regarding COVID-19. The DON stated R8's vital signs monitoring was missing some vital sign components and did not follow facility policy or professional standards of practice. R8's MDS dated [DATE], noted R8 was admitted on [DATE] with diagnoses including schizophrenia, diabetes, morbid obesity, obstructive sleep apnea (intermittent interruptions in breathing while asleep), acute and chronic respiratory failure, and utilized continuous supplementary oxygen. R8 had a BIMS score of 13 indicating no cognitive impairment, required substantial assistance with mobility in bed, and was dependent on staff for transfers, bathing, and dressing. The initial physician visit note dated [DATE], notes R8 was admitted to the facility after a hospitalization in December of 2023 for influenza and pneumonia with respiratory failure requiring intubation (severe respiratory failure requiring mechanical assistance to breathe). A progress note dated [DATE] at 1:11 p.m., indicated R8 tested positive for COVID-19. R8's care plan without date of last review due to R8's recent admission included interventions most recently added on [DATE] but did not contain any focus or interventions related to COVID-19. R8's provider orders dated [DATE], indicated COVID-19 positive monitoring including check temperature, O2 sat, and RR every four hours ending [DATE] and directed to update provider every shift with any changes in vital signs. A provider order dated [DATE], noted a prescription for Molnupiravir (an antiviral medication used to treat mild-to-moderate COVID-19 for adults at high risk of disease progression) for five days to treat COVID-19. R8's vital sign record, MAR, TAR, and progress notes did not include full sets of vital signs every four hours per provider orders. On [DATE], R8's RR, HR, BP, and temperature were each recorded once and O2 sat was recorded three times. On [DATE], RR, HR, BP, and temperature were each recorded twice, though O2 was recorded six times. On [DATE], RR, HR, BP, and temperature were each recorded once and O2 sat was recorded four times. In an interview on [DATE] at 11:46 a.m., the DON stated R8's care plan was not updated or resident-centered regarding COVID-19. The DON stated R8's vital signs monitoring did not follow facility policy or professional standards of practice. The facility's Care Planning policy dated ,d+[DATE], included: (2) A comprehensive care plan must be: A) Developed within 7 days after completion of the comprehensive assessment. B) Prepared by an interdisciplinary team, that includes but is not limited to: i)The attending physician; ii) A registered nurse with responsibility for the resident; iii) A nurse aide with responsibility for the resident; iv) A member of food and nutrition services staff; v) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan; vi) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. C) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive, quarterly, and significant change review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must: A) Meet professional standards of quality. B) Be provided by qualified persons in accordance with each resident's written plan of care. C) Be culturally-competent and trauma-informed. The IJ that began on [DATE], was removed on [DATE], when the facility updated order sets for residents with COVID-19 to include monitoring of full sets of vital signs every shift and implemented these orders for all residents affected, revised the process for activating these orders, integrated vital sign monitoring mandatory task into TARs, updated care plans for all residents with COVID-19 to include appropriate interventions, created skilled nursing progress note templates for residents with COIVD-19 and other respiratory illnesses to be completed every shift that include vital signs and assessment of clinical condition, provided nursing staff with education about the new processes and reinforced education about notification of providers for changes in condition, and implemented audits of charting and monitoring, but the noncompliance remained at the lower scope and severity level of E because the facility needs to update policies update policies and procedures for comprehensive assessment, monitoring, developing and revising person-centered care plans, and implementing interventions in accordance with professional standards of practice for all respiratory illnesses.

Based on interview and document review, the facility failed to ensure R1's safety when a mechanical lift was not used in accordance with the manufacturer's instructions resulting in life threatening injury for 1 of 3 residents (R1) reviewed who used mechanical lifts. This resulted in an Immediate Jeopardy (IJ) when R1 fell from the mechanical lift sling during a transfer, landing with his head on the mechanical lift legs, and his legs partially suspended in the air. The IJ began on [DATE] at 7:42 a.m. when staff were transferring R1 from his bed to his wheelchair using the mechanical lift. While transferring R1, staff did not ensure the sling loops were properly secured to the mechanical lift prior to removing him from his bed. R1 was partially suspended in the air when R1 fell from the sling landing on his head. The administrator and the director of nursing (DON) were informed of the IJ on [DATE] at approximately 8:05 a.m. The facility implemented corrective action as of [DATE], and the IJ was issued at past non-compliance. Findings Include: R1's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated R1 was admitted to the facility on [DATE]. R1's admitting diagnoses included pulmonary embolism, congestive heart failure, atrial fibrillation, dysphagia, and generalized muscle weakness. R1's care plan, dated [DATE], indicated R1 was only to be transferred using a mechanical lift. R1's facility Lift/Mobility Status form, dated [DATE], indicated R1 required a full body mechanical lift with the assistance of two staff for transfers. R1's significant change in status MDS assessment, dated [DATE], indicated R1 was dependent on staff for all transfers. R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating he was cognitively intact. R1's incident note dated [DATE], indicated R1 sustained a fall from a mechanical lift. R1 was hanging from the sling with his feet up in the air and his head was on the base of the of the mechanical lift. Family and EMS were immediately called. R1 was transported by EMS to the hospital. Video footage of R1 was reviewed with the administrator on [DATE] at 2:50 p.m., of the hallway outside R1's room. This video footage revealed the following: On [DATE] at 7:24 a.m., nursing assistant (NA)-A and NA-B brought the mechanical lift into R1's room and shut the door. At 7:42 a.m., NA-B opened the door and called for licensed practical nurse (LPN)-A to come to the room. LPN-A entered the room immediately and closed the door. NA-A and NA-B left the room to retrieve supplies and additional staff. Nursing staff ran into the room for support, and others began making phone calls to emergency medical services (EMS). At 7:47 a.m., LPN-A exited the room and paged a code blue (emergency staff response) then immediately returned to R1's room. Multiple staff ran to the room, brought an AED, and crash cart. EMS arrived at 7:53 a.m., and R1 was transported out of his room at 8:06 a.m. R1's hospital record dated [DATE] to [DATE], indicated R1 arrived at the hospital emergency department (ED) via EMS at 8:50 a.m. after he fell from a mechanical lift at his home facility on [DATE]. ED records indicated R1 presented with multiple lacerations to his head, extremities with altered mental status (AMS) following a loss of consciousness during the initial fall. R1 had age indeterminate fractures of the T12, L1 and L2 that were most likely acute as evidenced by characteristics of the fractures. R1 was awake and alert, without the ability to follow commands or answer all questions appropriately. R1's was admitted to the hospital for emergent interventions for life-threatening injuries. Palliative medicine was contacted and through discussion with family member (FA)-A, R1 was transitioned to partial comfort cares with medicinal interventions for comfort. Hospital nursing notes on [DATE], indicated R1 had become unresponsive and did not increase level of consciousness for the remainder of his hospitalization . R1's physician evaluation indicated R1 had a high probability of imminent life or limb-threatening deterioration due to closed head injury with AMS with multiple trauma from a fall. R1 was being treated for acute metabolic/toxic encephalopathy, and FM-A had transitioned to full comfort cares. R1 expired [DATE]. During an interview on [DATE] at 1:31 p.m., FM-A stated he was informed by hospital physicians R1 had passed away from injuries sustained during the fall on [DATE]. During an interview on [DATE] at 2:07 p.m., licensed practical nurse (LPN)-A stated she was called into R1's room by (NA)-A on [DATE] at approximately 7:40 a.m. LPN-A stated when she entered the room, she saw R1 partially suspended by his legs in the mechanical lift sling, and the right side of his head resting at an unnatural angle on the mechanical lift support legs. LPN-A stated all the sling clips on the left side were completely intact, and only two of the straps on the right side of the sling were attached to the mechanical lift. LPN-A stated she worked with NA-A and NA-B to reposition R1, and immediately noted a bloody laceration to R1's posterior scalp. LPN-A stated R1 was not responding to verbal or tactile stimuli and his face from the neck up was unnaturally cyanotic. LPN-A stated she had NA-A and NA-B retrieve additional staff and EMS were contacted. LPN-A stated she placed supplemental oxygen on R1 and activated a code blue. LPN-A stated she was aware R1 was DNR and activated a code blue at that time to get additional nursing staff to help her. LPN-A stated NA-A and NA-B could not explain to her what happened. LPN-A stated staff must always pause when using a mechanical lift and ensure all sling loops are engaged prior to transferring a resident away from a stationary surface. During an interview on [DATE] at 2:50 p.m., the Administrator stated NA-A and NA-B were immediately removed from the patient care following this incident. The Administrator stated NA-A had completed her mechanical lift competency upon hire in 2023 and NA-B was rehired within the last 30 days and had completed a lift competency for the facility in 2021. The Administrator stated following this incident, R1's sling was inspected and found to be without defect. The Administrator stated the mechanical lift from the incident was removed from patient care, inspected by maintenance, and had no functional defects. During an interview on [DATE] at 3:41 p.m., NA-A stated she had entered R1's room the morning of [DATE] with NA-B to provide bowel and bladder care and intended to transfer R1 to his wheelchair for breakfast. NA-A stated R1 had been incontinent of bowel that morning, and once they had completed with a brief change, they placed the sling underneath him. NA-A stated she attached all three loops on the left side of the sling, then verbally reminded NA-B to place all three loops on the right side of the sling into the appropriate clip. NA-A stated she turned to the side to use the bed remote to slightly lower the bed so they could use the scale function of the mechanical lift to obtain a daily weight on R1. NA-A stated NA-B then pulled the mechanical lift away from the bed and began to turn without communicating to NA-A. NA-A stated R1 fell out of the sling and she told NA-B to go get LPN-A. NA-A stated she did not check to ensure all loops were attached to the mechanical lift at any point. NA-A stated she had completed her mechanical lift competency during her orientation, and she knew she needed to check the loops for secure attachment prior to transferring a resident. During an interview on [DATE] at 3:54 p.m., NA-B stated she had entered R1's room the morning of [DATE] with NA-A to provide bowel and bladder care and intended to transfer R1 to his wheelchair for breakfast. NA-B stated after they had cleaned R1 up, she and NA-B placed the sling underneath R1 and attached the loops to mechanical lift. NA-B stated she attached all loops on the right side and did not notice one of them was not properly attached. NA-B stated when NA-A lowered R1's bed, NA-B slightly raised the lift. NA-B stated she did not notify NA-A of her intentions and pulled the mechanical lift away from the bed. NA-B stated R1 immediately fell out of the sling. NA-B stated she notified LPN-A of the fall immediately. NA-B stated she did not check to ensure all loops were attached to the mechanical lift at any point. NA-B stated she had completed her mechanical lift competency when she was originally hired in 2021, and she knew she needed to check the loops for secure attachment prior to transferring a resident. During an interview on [DATE] at 11:25 a.m., NA-C stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:29 a.m., NA-D stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:33 a.m., LPN-B stated prior to moving a resident with a mechanical lift, you must pause and ensure all loops are securely connected to the mechanical lift. During an interview on [DATE] at 11:55 a.m., the Director of Nursing (DON) stated NA-A and NA-B were immediately removed from direct patient care following the incident. The DON stated NA-B admitted she must not have attached one of the loops on the left side of R1's sling. The DON stated every time a mechanical lift is used to transfer residents, operating staff must ensure the sling loops are attached securely prior to continuing. An electronic communication from the DON on [DATE] at 11:20 a.m. indicated the facility does not have a mechanical lift policy, and directly follow the manufacturer instructions while training staff. An electronic communication from the administrator on [DATE] at 3:14 p.m., indicated NA-A completed her mechanical lift competency on [DATE], and NA-B completed hers on [DATE]. During an interview on [DATE] at 4:42 p.m., physician-A stated the injuries R1 sustained during his fall were lift-threatening and contributed to his decompensation and death. Physician-A stated she discussed the option of completing an autopsy with FA-A to determine R1's exact cause of death. A facility document titled Facility Competency 2.0 for Mechanical Lifts indicated step 7 for transferring a resident with a mechanical lift is to ensure all sling loops are secured appropriately prior to moving the resident. The Invacare Reliant 600 RPL,d+[DATE] Battery Powered Patient Lift User Manual, dated 2018, indicated each time the sling is used to transfer a resident, the operator must ensure the sling loops are securely attached prior to removing the resident from the original object. The past noncompliant immediate jeopardy began on [DATE] at 7:42 a.m. The immediate jeopardy was removed, and the deficient practice was corrected by [DATE], after the facility implemented a systemic plan that included the following actions: - The mechanical lift was removed from the unit for further inspection by maintenance staff - Both NA-A and NA-B were placed on administrative suspension during the investigation and their employment has been terminated by the facility - Facility removed and inspected all mechanical lifts in the building and completed any necessary repairs. - Facility completed an audit of all employee's mechanical lift competencies and ensured all staff and agency staff had current competencies before their next working shift. - Facility completed education for all applicable staff to focus on pausing over the original stationary object and ensuring the sling loops are secured before continuing. - Facility completed daily audits of staff using mechanical lifts on residents and will continue to do so five times per week. - Facility completed a thorough investigation which resulted in the identification of a root cause. As a result of the facility implementation, this will be issued at past noncompliance.

Based on interview and document review, the facility failed to ensure R1's safety when the mechanical lift was not used in accordance with the manufacturer's instructions resulting in risk of potential serious harm, injury, impairment, or death for 1 of 3 residents (R1) reviewed who use mechanical lifts. As a result, the lift tilted and fell to one side while the resident was suspended. R1 was held against the side of the bed until lowered to the floor and placed in a sitting position. The IJ began on 12/6/22, at 2:15 p.m. when staff were transferring R1 and moving R1 in the lift from chair to bed. While moving R1, staff did not open the legs of the Invacare mechanical lift. R1 was suspended in the air, the Invacare mechanical lift tilted and fell to one side. The administrator and director of nursing (DON) were informed of the IJ on 12/29/2022, at 2:15 p.m. The facility implemented corrective action as of 12/9/2022, and the IJ was issued as past non-compliance. Findings included: Minimum Set Data (MDS) assessment, dated 11/7/2022, indicated R1's diagnoses included severe morbid obesity, bilateral lower extremity lymphedema, chronic obstructive pulmonary disease, asthma, and myalgia. R1 required the assistance of two staff with transfers, bed mobility, and locomotion on the unit. R1's Brief Interview for Mental Status (BIMS) score was 15 of 15, indicating he is cognitively intact. R1's quarterly Fall Risk Evaluations, dated 6/20/2022 and 9/19/2022, indicated R1 was at high risk for falls related to their comorbidities. R1's quarterly Resident Transfer Ability Tool, dated 9/19/2022, indicated R1 required a sit-to-stand mechanical lift for transfer from bed to chair. R1's care plan, last updated 11/25/2022, indicated staff are to use a sit-to-stand mechanical lift while transferring R1. During an interview on 12/27/2022 at 12:58 p.m. R1 stated on the day of the incident he was sitting in his chair and staff weighed him using the mechanical lift. R1 stated that while he was suspended in the air, being weighed, he told the staff he wanted to go to bed and not return to the chair. As the staff moved him towards the bed the mechanical lift tipped over. During an interview on 12/27/2022 at 1:25 p.m., nursing assistant (NA)-C stated R1 had his own sling for use with the mechanical lift, R1 preferred to use the mechanical lift to transfer from chair to bed. NA-C stated training on the use of the mechanical took place for all staff after the incident. During an interview on 12/27/2022, at 1:35 p.m., registered nurse (RN)-A stated on the day of the incident, he heard a commotion and reported to R1's room where he saw R1 being pinned against the side of the bed by NA-A and NA-B. RN-A stated he assisted in lowering R1 onto the floor to a sitting position. Once sitting, R1 was assisted into a supine position. RN-A conducted a physical assessment and found no apparent injury. R1 complained of generalized pain. RN-A had staff call 911 for assistance. RN-A stated he had received additional training on the use of the lift after R1's fall. During an interview on 12/27/2022, at 2:20 p.m., clinical nurse manager (CNM)-B stated the root cause of the incident was the legs of the lift were not extended while moving R1 from chair to bed. CNM-B stated re-education had been done and she was conducting audits of staff using the mechanical lifts. During an interview on 12/27/2022, at 3:08 p.m., director of nursing (DON) stated she responded to the fall shortly after it occurred and began the investigation immediately after R1 was transported to the hospital by ambulance. The DON stated NA-A and NA-B re-enacted the event and stated the legs of the lift were not extended in attempt to ease the lift closer to the bed. DON stated she does not recall any similar incident with the use of the mechanical lift. Stated both NA-A and NA-B were re-educated prior to returning for another shift and all nursing staff were re-educated on proper use of the lift. During an interview on 12/27/2022 at 3:40 p.m., NA-A stated he and NA-B used the Invacare mechanical lift to move R1 from his chair to weigh him. During this time, R1 asked to be put into his bed. NA-A and NA-B moved R1 about five feet to the side of his bed. NA-A stated he did not extend the legs of the lift. Once near the bed, the lift began to tilt towards the bed. NA-A stated he and NA-B called for help and pinned R1 to the side of the bed to keep him from falling further. R1 did not fall to the floor. RN-A came in and they lowered R1 to the floor in a sitting position. NA-A stated he had received additional training on the use of the lift prior to returning to work. During an interview on 12/27/2022 at 3:55 p.m., NA-B stated once he and NA-A started moving the lift towards the bed, the lift began to tilt until it tipped over. NA-B stated he helped pin R1 to the side of the bed and then assisted in lowering R1 to a sitting position on the floor. NA-B stated R1 did not hit his head. When asked if the legs to the lift were extended prior to moving the lift, NA-B stated, I have been a CNA for [AGE] years and this has not happened to me before, I have moved residents in the lift without extending the legs. NA-B stated he had received additional training on the use of the lift prior to returning to work. During an interview on 12/29/2022 at 11:38 a.m. Invacare representative (IC)-A stated, if you move a patient in a lift with the legs drawn in, the lift will become unstable, this should never be done. The legs must always be extended when a patient is suspended. The only exception is moving under a bed and the patient is above the bed. You must never turn the lift without extending the legs. IC-A stated failure to follow the manufacture instructions of the lift equipment and open the legs of the lift to the maximum position prior to maneuvering the lift, impairs the stability of the lift and risks a serious adverse outcome to residents. According to the Invacare Reliant 450 RPL450-2 & Reliant 600 RPL600-2 Battery Operated Lift User Manual, published 10/2018; Page 9, section entitled Lifting the Patient, Warning, When using an adjustable base lift, the legs MUST be in the maximum Opened/Locked position before lifting the patient. Page 20, section entitled Introduction Warning, and page 24 section entitled Warning, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under the bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The past noncompliance immediate jeopardy began on 12/6/22, at 2:15 p.m. The immediate jeopardy was removed, and the deficient practice was corrected by 12/9/2022, after the facility implemented a systemic plan that included the following actions: -The mechanical lift was removed from the unit for further inspection by the manufacturer's representative. -Both NA-A and NA-B were placed on administrative suspension during the investigation and re-educated prior to their return to work. -Facility reviewed all residents who used mechanical lifts to ensure appropriate use and sling size. -Facility completed a thorough investigation which resulted in the identification of a root cause. -Based on the facility's findings of the investigation, the facility provided re-education to all nursing staff to ensure the appropriate use of the mechanical lifts and reinforcement of the mechanical lift transfer policy. As a result of the facility implementation, this will be issued at past noncompliance.

Based on interview and document review, the facility failed to prevent 2 incidences of physical and mental abuse for 1 of 1 resident (R1) reviewed for abuse. Further, the facility failed to ensure all staff were appropriately trained to the abuse policy and procedures for reporting suspected or known abuse immediately and complete a thorough investigation and protect 8 other residents, to include R1 who resided on that wing, for potential further abuse. This deficient practice resulted in an immediate jeopardy (IJ) when nursing assistant (NA)-A, NA-B, and the social worker (SW)-A failed to report abuse allegations immediately to the facility administration and/or to the State Agency (SA). The IJ began on 8/22/22, at 1:13 p.m., when it was identified yelling was overheard coming from the shower room. Social worker (SW)-A observed R1 yelling I do not want a shower . she grabbed my mouth. SW-A removed R1 from the situation while the director of nursing (DON) and assistant DON (ADON) interviewed staff. No actions to report the abuse to the administrator, or protect residents occurred at that time, leading to R1 having another subsequent incident of abuse on 9/28/22. In that instance, NA-A had yelled at R1 and had reportedly grabbed R1's face. It was during the investigation on 10/5/22, when the facility identified the previous abuse on 8/22/22 and subsequent abuse on 9/28/22 and implemented corrective action to prevent any such recurrence. The administrator and new interim director of nursing (DON) were notified of the IJ on 10/12/22, at 5:16 p.m., identified at the scope and severity of J- ISOLATED. The immediacy was corrected prior to the start of the survey and was therefore identified as PAST NON-COMPLIANCE. Findings include: Review of the report filed to the SA on 10/5/22 at 6:56 p.m., identified that same day at 5:30 p.m., R1's family member (FM)-A reported R1 was being physically and verbally abused by NA-A. FM-A advised the facility she had proof of the abuse. Staff involved were immediately suspended pending an investigation. Interview on 10/12/22 at 10:46 a.m., with R2 identified she overheard staff yelling at R1 on 9/28/22, got on the web camera app R1's family had given her access to, found the incident, and sent the recording to FM-A. R2 stated she did not notify any staff at the facility per the daughter's request. R2 forwarded the recording to survey staff with family permission. Upon review of the audio recording submitted to the survey team, dated 9/28/22 at 3:02 p.m., identified the conversation between R1 and NA-A could be heard as follows: R1: I don't feel good . please leave me alone. NA-A: Quit yelling put your hand down . do you want me to leave you alone or put you on the toilet? R1: Oww . get your hand off my mouth! NA-A: Stop yelling! Why are you yelling? R1: Something is going to happen to you [NA-A]. NA-A: What's going to happen to me, huh? You said something is going to happen to me Shut up! Shut up! Just hush [R1] . you're something! R1: You're going to find out. You're going to be in trouble. NA-A: You're the one going to be in trouble you're trouble . you're going to get in trouble! R1: How am I going to be in trouble? NA-A: For lying . all you do is cry, cry, cry. R1: Your mouth is going too much. NA-A: could be heard laughing. R1's progress note dated 8/22/22, at 1:13 p.m. indicated yelling was heard coming from the shower room. Social worker (SW)-A observed R1 yelling I do not want a shower; she grabbed my mouth. SW-A removed R1 from the situation while the director of nursing (DON) and assistant DON (ADON) further interviewed staff. There was no indication the SW, DON, or ADON had notified the administrator of the alleged abuse nor had the SA been notified , nor was an investigation begun. Interview on 10/12/22 at 12:31 p.m., with the interim director of nursing (DON) identified the allegation of physical abuse on 8/22/22 was identified during the 10/5/22 abuse investigation and was noted to have not been reported at that time to the SA, nor was staff suspended or the administrator notified. An immediate mitigation plan was put into place to prevent abuse from happening again after the administrator was made aware of the 10/5/22 allegation. The allegation of physical and mental abuse on 9/28/22 was not reported to administration until 10/5/22 by R1's daughter. The other NA (NA-B) who was in the vicinity at the time the 9/28/22 incident occurred had not reported the potential abuse at that time. The DON agreed R1 was subjected to mental and/or physical abuse. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 12/5/17, indicated R1 was vulnerable and at risk for abuse related to dementia, anxiety, and depression. Interventions directed staff to immediately notify the supervisor and complete incident report per facility and state guidelines. Observation and interview on 10/13/22, at 10:56 a.m. with R1 identified she was upset with NA-A and recalled the event of 9/28/22. R1 stated NA-A used to be so nice but had changed. R1 became tearful and stated, [NA-A] put her hands on my mouth . squeezed my cheeks . and was yelling at me. R1 stated that was upsetting and she didn't like how NA-A treated her. R1 acknowledged, she presently felt safe at the facility and had requested NA-A to not provide care to her anymore. Interview on 10/13/22 at 11:58 p.m., with NA-B stated on 9/28/22, she was assisting NA-A with R1. R1 was upset and was coming out into the hallway to get help to use the commode. NA-A told R1 to return to her room and wait for us. NA-A entered R1's room first. After a few moments, NA-B entered R1's room. R1 was observed crying and yelling she wanted help. NA-A was observed by NA-B to have told R1 Staff cannot come in and place you on the commode every ten minutes as there are other residents to assist. R1 stated she wanted to be left alone. NA-A continued assisting R1 after R1 asked staff to stop and proceeded to get her ready for the commode. NA-A told R1 this was the last time she was going to help R1. NA-B reported she overheard R1 and NA-A yelling back and forth. NA-B acknowledged NA-A should have stopped telling R1 this was the last time they were going to help her as it was upsetting R1. NA-B further stated NA-A's interaction with R1 made her feel uncomfortable. NA-B felt so uncomfortable she wanted to leave the room, but R1 was now on the commode. Once R1 was off the commode and back in her chair, both staff left the room. NA-B had not witnessed NA-A grabbing R1's face when providing cares. NA-B had not talked to facility staff about this incident until management asked her about it. NA-B stated she had not viewed the incident as abuse until talking with the management team and receiving further education. NA-B verified the incident should have been reported right away and she understands that now after having been re-trained. Interview on 10/13/22, at 12:44 p.m. with FM-A stated she had placed a camera in R1's room without the facility's knowledge. FM-A further stated there had been previous allegations of abuse by R1, but FM-A didn't have any proof and that was why the camera with audio was installed. FM-A stated she had audio of the incident on 9/28/22 but the camera was obscured by an object. She heard staff screaming at R1. Staff were laughing at her for crying. FM-A further heard R1 yelling for staff to let go of her mouth. R1 repeatedly yelled for staff to leave her alone. FM-A talked to R1 about it and all R1 did was cry. FM-A had not notified the staff about the incident until 10/5/22. A facility policy title Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/17, directed staff to monitor residents and will know how to identify potential signs and symptoms of potential abuse. Furthermore, the policy directed staff must always report any abuse or suspicion of abuse immediately to the administrator. The immediate jeopardy deficient practice was verified to have been corrected by 10/7/22, after the facility implemented a systemic plan that included the following actions: 1. On 10/5/22, the facility immediately suspended NA-A and NA-B pending the facility investigation upon administrator knowledge of the incident that occurred on 9/28/22. 2. Initiated and completed a thorough investigation of R1's alleged abuse. Their investigation discovered previous physical abuse of R1 and the lack of administrative and SA notification. 3. NA-A and SW-A were terminated and no longer employed by the facility. 4. Facility and pool staff education of facility abuse policies and reporting guidelines occurred on 10/5/22 and continued through 10/7/22. Any staff who were not present were to be trained before start of next shift. 5. It was also determined the interdisciplinary team (IDT) required re-education on reviewing resident progress notes daily during the work week to determine if potential abuse had occurred, and all policies and procedures were followed. 6. The facility began weekly auditing to determine staff knowledge of abuse and reporting guidelines and IDT review of resident progress notes. 7. All monitoring will be taken to QAPI on an ongoing basis. 8. Interventions were reviewed for R1 and added interventions for behaviors. R1 currently sees psych to promote her mental and psychosocial well-being. Verification of corrective action was confirmed on 10/12/22, by staff interviews and document review including training provided and an audit of medical records.

Based on interview and document review, the facility failed to provide emergency medical interventions for choking for 1 of 3 residents (R2) who was reviewed and was at risk for choking. The immediate jeopardy began on [DATE], at 1:00 p.m. when it was identified the facility failed to provide emergency intervention of finger sweep and abdominal thrusts to R2, when R2 wheeled herself to the nurse's station, was unable to talk (an indication of choking) and went unresponsive. The director of nursing (DON), regional director, and administrator were notified of the immediate jeopardy at 2:41 p.m. on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Non-compliance, as a result of immediate corrective action taken by the facility. Findings include: R2's Face Sheet undated, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Dysphagia List dated [DATE], indicated R2 had dysphagia. R2's Physician Advanced Directive Order dated [DATE], indicated R2 was a full code. Full code means if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. R2's Progress Note dated [DATE], indicated on [DATE], R2 received a regular meal, ate it unsupervised, and choked on her meal. R2 wheeled herself to the nurse's station, was unable to communicate, became unresponsive and turned blue in color. Licensed practical nurse (LPN)-C called a code blue (an alert for emergency situation), called 911, and prepared paperwork for emergency medical service (EMS). LPN-A, LPN-B, LPN-C, registered nurse (RN)-A, RN-B, RN-C, and RN-D took R2 to her room and assisted R2 to the floor. R2's Code Blue Record dated [DATE], indicated R2's oxygen saturations were monitored and R2's oxygen saturations went down to 32% on room air. RN-B assisted R2 to a sitting position as R2's condition worsened, and oxygen saturations dropped. R2's Code Blue Record indicated RN-C applied a non-rebreather oxygen mask (a device used to assist in the delivery of oxygen) with oxygen flow set at six liters per minute. R2 was positioned lying flat on the floor and R2's lips and fingers remained blue during the event. However, the Code Blue Record did not indicate if R2 had coughed; and R2 continued to be blue (no oxygen) and unresponsive until emergency medical service (EMS) arrived. The Code Blue Record indicated the administrator, three LPN's, and four RN's were present with R2 during this incident. The Code Blue Record lacked documentation of a airway assessment, respiratory assessment, full vital signs, or any immediate emergency medical intervention performed such as the mouth sweep, [MEDICATION(S)] maneuver or abdominal thrusts to open R2's airway. R2's emergency room (ER) notes dated [DATE], at 3:35 p.m. indicated R2 was brought to the ER via EMS (emergency medical services) during a choking episode at the nursing facility. The notes also indicated a large piece of meat was removed from the back of R2's throat and R2 was resuscitated with chest compressions and her oxygen saturations improved. A chest X-ray from the hospital on [DATE], suggested R2 had mild pulmonary [CONDITION(S)] (a buildup of fluid in the lungs) and pneumonia (infection in the lung). R2's hospital progress note dated [DATE], indicated R2 was hospitalized and diagnosed with aspiration pneumonia. A chest computerized tomography (CT) scan (x-ray images taken from different angles) dated [DATE], indicated R2's results included aspiration or infection in the right lung base. During an interview on [DATE], at 11:30 a.m. RN-B stated R2 wheeled herself to the nurse's station and became unresponsive. RN-B further stated R2's lips and hands were blue in color and her face was pale. RN-B stated R2 was unable to talk, cough, or reach out. RN-B stated she pushed R2 back to her room for privacy. RN-B stated she realized R2 had choked when there was meat missing from R2's sandwich while in R2's room during the incident. RN-B stated no RN's or LPN's initiated a finger sweep of R2's mouth, performed the [MEDICATION(S)] Maneuver or abdominal thrusts on R2. RN-B stated she was the incident commander for the day, and she was responsible for responding to any medical codes. RN-B stated she was unsure of who was doing what, no one was doing anything, and no one took charge of running the code. RN-B stated, it was like everyone was just standing around not doing anything. During an interview on [DATE], at 1:00 p.m. the administrator stated RN-B acted as the incident commander for R2's medical emergency. The administrator stated she responded to the code and had double checked R2's code status, which indicated R2 was a full code. The administrated stated she went to R2's room to move items out of the way for when EMS arrived. The administrator also stated when nursing staff attempted to lay R2 on the floor, R2's condition worsened, and a nurse put a non-rebreather oxygen mask on R2. The administrator stated her note on R2's code blue event dated [DATE], indicated while waiting for EMS to arrive, she had moved the items in R2's room and observed R2 had open-faced sub sandwich on the plate; only the meat was missing. All other items on the tray were still full or covered. The administrator also stated once EMS had arrived, she left R2's room. During an interview on [DATE], at 2:00 p.m. nursing assistant (NA)-B stated R2 choked on meat from a submarine sandwich. NA-B also stated she did not inform nursing that she noticed meat was missing from R2's submarine sandwich. During an interview on [DATE], at 11:21 a.m. the director of nursing (DON) stated LPN-C was given corrective action as LPN-C did not meet her expectations on how she responded to the incident when R2 choked. The DON also stated LPN-C, LPN-B, RN-A, LPN-A, RN-B, RN-C, and RN-D who responded to the code blue for R2's incident did not provide abdominal thrust to R2 during this event on [DATE]. DON, stated LPN-C should have taken charge of the code and given direction to other staff since she was in charge of the floor where the incident occurred. The DON stated LPN-C reported R2 was unresponsive but did not tell her R2 went limp and slump over in her wheelchair. The DON verified the definition of unresponsive is medically considered unconscious. Also, the DON stated LPN-C should have started abdominal thrust once R2 became unresponsive. During an interview on [DATE], at 12:35 p.m. R2's medical doctor (MD) stated she would have expected staff to initiate abdominal thrusts if R2 came out of the room, was changing color and staff noticed R2 was choking. R2's MD also stated staff should have imitated emergency treatment until emergency medical services arrived. During an interview on [DATE], at 1:30 p.m. LPN-C stated on [DATE], at approximately 1:00 p.m. she saw R2 propel herself to the nursing station where R2 became unresponsive and went limp, slumping over. LPN-C stated R2's lips and fingertips were blue. LPN-C stated she quickly took an oxygen saturation which indicated R2's oxygen level was 45% on room air. LPN-C stated she immediately called a code blue, grabbed the chart to look for R2's code status, and then called 911. LPN-C stated R2 was not able to talk, cough, or spit. LPN-C stated R2's condition worsened when R2 was laid flat on the floor; R2's oxygen saturations went down to 32%. LPN-C stated no other vital signs were documented. RN-C placed oxygen with a non-rebreather mask on R2, setting it to six liters per LPN-C stated R2 was then sat up and supported by staff until EMS arrived. LPN-C further stated they realized R2 had choked when she was cleaning up R2's lunch tray after the event and R2 left with EMS. The facility's Choking Education dated [DATE], indicated choking occurs when a foreign body (example: a mouthful of food) partly or completely blocks a person's airway making breathing difficult. The Choking Education indicated the signs and symptoms of choking in a resident included clutching at throat or neck, throat pain, inability to speak, breathe, cough, or swallow. The Choking Education further indicated signs of when a resident was choking included coughing, wheezing, gagging, unusual breathing sounds, chest pain, change in color (example blue lips or red face), or collapse. The Choking Education indicated common causes of choking included eating or drinking too quickly, swallowing food before it has been sufficiently chewed, swallowing small bones/objects, or inhaling small objects. Choking education further indicated when responding to a suspected choking incident to ask them to cough to remove the object, encourage them to relax and breathe deeply, if they cannot cough or talk, stand behind them and start [MEDICATION(S)] maneuver (abdominal thrusts), have someone check code status and call 911, if unable to dislodge object and resident loses consciousness, lay them on the floor, and do a mouth sweep, and start CPR. The facility's Code Responses & Disaster Plan Summary document undated, indicated for an medical emergency a code blue would be called when a medical condition called for additional nursing staff. Code Responses & Disaster Plan Summary document further indicated nurses would to report to incident as soon as possible, bring the emergency cart and automated external defibrillator (AED), check the resident code status, and begin CPR if full code & pulseless. The IJ began on [DATE], and the faciltiy immediately implemented corrective action and was in complinace by [DATE], at 2:30 p.m. when the facility implemented a systemic plan which included: - The facility reviewed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - The facility reviewed each resident's diet orders, level of supervision, and care plans for accuracy if identified to be at risk for choking. - The residents identified without a speech evaluation in the last 90 days were screened by speech therapy; and speech orders were obtained if needed. - The facility provided education to all staff (non-clinical and clinical) on choking, on how to recognize the signs and symptoms of choking, how to respond to a resident suspected of choking, and how to help prevent choking from occurring. This education was prior to staff working their next shift. -The facility provided risk versus benefit education to their interdisciplinary team. - The DON indicated the facility would continue to audit resident's diet orders and level of assistance to ensure the resident care plans are being followed. - The facility completd audits on risk versus benefits to ensure residents were educated on the risk when they did not wish to follow SLP recommendations.

Based on interview and document review the facility failed to prepare food in accordance with residents needs for 1 of 3 residents (R2) who required a modified texture diet and was at risk for choking were reviewed for accidents. This deficient practice resulted in an immediate jeopardy (IJ) situation when the facility did not provide R2 the diet recommended by speech language pathologist (SLP) and R2 choked. The IJ began on [DATE], when the facility failed to provide appropriate texture modifications for R2 who required mechanical soft texture. On [DATE], at approximately 1:00 p.m., R2 choked on her meal. The director of nursing (DON), administrator and regional director were notified of the IJ on [DATE], at 2:41 p.m. The facility implemented corrective actions and the immediate jeopardy was removed on [DATE], at 10:13 a.m. and remained at a lower scope and severity of D - isolated scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R2's face sheet dated [DATE], indicated diagnoses of oropharyngeal dysphagia (swallowing difficulty related to the oral cavity and throat) and moderate protein and calorie malnutrition. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition and was independent with eating. R2 had the ability to express ideas and wants and understood verbal content. R2's care plan dated [DATE], indicated R2 had a swallowing problem history and R2's goal was to not have a choking episode when eating. Staff were directed to provide and serve diet as ordered. R2's Physician Orders dated [DATE], indicated regular textured diet with thin liquids. R2's Interagency Physician Discharge Orders/Instructions dated [DATE], indicated R2 was hospitalized [DATE], until [DATE], as she choked on meat. A big piece of meat was removed from the back of R2's throat. R2 was treated for acute respiratory distress with acute hypercapnic (high levels of carbon [MEDICATION(S)] in blood) and hypoxic respiratory failure (not enough oxygen in your blood) due to obstruction by food/meat. R2's Provider Progress note dated [DATE], indicated R2 complained of difficulty with toast getting stuck. R2 did not want to see SLP-J but nurse practitioner (NP)-H told R2 she needed a screen to prevent bigger problems. According to the progress note, SLP-J saw R2 during lunch. R2 presented with decreased laryngeal elevation and mild signs and symptoms of aspiration on thin liquids. R2 refused speech therapy and the recommendation to downgrade diet to mechanical soft. There was no indication in the progress note that R2 was explained the risk versus benefits for refusing the diet recommendations. R2's Speech Therapy Evaluation and Plan of Treatment dated [DATE], indicated SLP- J saw R2 after a choking episode on toast. According to the Plan of Treatment, SLP-J recommended mechanical soft diet and thin liquids by cup. R2 refused the recommended diet and further skilled SLP services. The Speech Therapy Evaluation and Plan of Treatment also indicated without therapeutic intervention R2 had an increased risk for malnutrition, aspiration, depression, and social isolation. There was no indication in the Plan of treatment that SLP-J explained the risk of noncompliance with her recommendations to R2. R2's Nutrition High Risk Progress Note dated [DATE], indicated R2 received a regular textured diet with liquids. R2 had a problem chewing, swallowing and poor dentation. The progress note also indicated R2 was seen by SLP due to reports of difficulty swallowing toast but R2 refused to continue to work with SLP. There was no indication of follow up with R2's IDT team. R2's Nutrition High Risk Progress Note dated [DATE], indicated a regular textured diet and denied need or desire for a modified diet. R2 was seen by SLP-J on [DATE], due to a history of choking on toast. R2's Nutrition at Risk dated [DATE], indicated a nutrition at risk review occurred with therapy, licensed nursing staff, a dietitian, activities, and social services. The Nutrition at Risk lacked indication of follow up related to SLP-J's evaluation of R2 on [DATE]. R2's tray card dated [DATE], indicated a regular textured diet. R2's progress note dated [DATE], at 2:17 p.m. indicated R2 wheeled herself to the nurse's station from her room, went unresponsive and turned blue in color and was transferred to the hospital. The facility Assistance with Activities of Daily Living (ADL)'s-Eating list, undated, indicated R2 was to eat meals in the station five dining room. In an interview on [DATE], at 10:28 a.m. nursing assistant (NA)-C stated R2 ate independently and alone in her room. NA-C stated she did not think R2 had a swallowing problem prior to the incident on [DATE]. NA-C was not aware of R2's SLP recommendations made on [DATE]. In an interview on [DATE], at 11:17 a.m. NA-D stated R2 was very independent at meals. In an interview on [DATE], at 3:40 p.m. NA-F stated a resident who was independent did not need additional cues or monitoring. In an interview on [DATE], at 11:26 a.m. licensed practical nurse (LPN)- C stated on [DATE], R2 ate slow and was still eating when meals trays were picked up around 12:30 p.m. Shortly after 1:00 p.m. R2 propelled her wheelchair out of her room, tried to speak to LPN-C but could not and went unresponsive. LPN-C called a code blue and called 911. In an interview on [DATE], at 1:28 p.m. LPN-C stated she was not aware that R2 had a swallowing problem. LPN-C stated R2 ate independently alone. Also, LPN-C stated if she had been aware R2 had a swallowing issue she would have had increased monitoring at meals. LPN-C also stated she was thankful R2 came out of her room otherwise no one would have checked on her until 4:00 p.m.; later that day. In an interview on [DATE], at 1:47 p.m. registered nurse (RN)-B stated R2 appeared to have blue lips and was unresponsive when she arrived at the scene of the incident on [DATE]. RN-B stated she took R2 back to her room and realized R2 had choked when there was meat missing from her sandwich. In an interview on [DATE], at 2:38 p.m. SLP-I stated if a resident refused SLP recommendations she would go over a risk versus benefits with the residents. Additionally, SLP-I stated she would put other interventions, such as monitoring, in place to keep a resident safe if they refused recommendations. SLP-I also stated increased monitoring would make a difference for someone if they wanted to be on an upgraded texture. In an interview on [DATE], at 3:11 p.m. the registered dietitian (RD) stated NP-H referred R2 to speech therapy on [DATE], when R2 reported to NP-H she had choked on toast. The RD also stated on [DATE], SLP-J saw R2 and recommended to downgrade her textures to mechanical soft. SLP-J did not communicate her recommendations to the interdisciplinary team (IDT) after her evaluation on [DATE]. On [DATE], the RD noticed R2 had not received mechanical soft textures and called NP-H to clarify. The RD also stated she did not inform SLP-J or other interdisciplinary team (IDT) members that R2's diet texture was wrong until after the incident on [DATE]. Finally, the RD stated R2 continued to receive a regular textured diet until [DATE], when R2 choked on her meal. In an interview on [DATE], at 8:31 a.m. SLP-J stated she may have forgotten to communicate R2's diet recommendation to NP-H, RD, dietary manager (DM)-C, therapy department and RN-D after she completed the evaluation and recommended mechanical soft on [DATE]. SLP-J also stated she did not complete a risk versus benefits for R2 after her evaluation on [DATE]. Additionally, SLP-J stated R2 had been at risk to choke if she did not comply with SLP-J recommendations. SLP-J stated she should have completed a risk versus benefits with R2 and increased supervision if R2 refused the recommendations. SLP-J also stated, had the RD informed her of her oversight at the time of the RD evaluation on [DATE], she would have corrected R2's diet order, or explained the risk of noncompliance to R2. During an interview on [DATE], at 10:54 a.m. the RD stated she and registered nurse (RN)-D were responsible to update SLP recommendations in the care plan. The RD also stated she would document in the care plan if a resident refused interventions or had a risk versus benefits form in place. The RD also stated when SLP made recommendations, it should be the order until a risk and benefits form was completed. The RD verified R2 should have received mechanical soft textures since there was no risk versus benefits form completed after R2's evaluation on [DATE]. Finally, the RD verified the SLP recommendation on [DATE], were not in R2's care plan. During an interview on [DATE], at 11:11 a.m. the director of therapy (DT) stated SLP-J did not communicate to the IDT after her evaluation on [DATE]. During an interview on [DATE], at 12:29 p.m. R2's medical doctor (MD) stated when a resident refused SLP recommendations it was her expectation for staff to explain the risk. During an interview on [DATE], at 11:50 a.m. NP-H stated she was not aware that there was not a risk versus benefit completed with R2 when R2 continued to eat regular textures after the SLP evaluation on [DATE]. During an interview on [DATE], at 12:14 p.m. R2 stated she swallowed something and almost died . R2 stated she choked on a piece of meat and never wanted that to happen again. R2 also stated, can you please help me and make sure it doesn't happen again. Additionally, R2 stated, I didn't know that was going to happen if I ate that. I thought I was going to die. During an interview on [DATE], at 11:56 a.m. the director of nursing (DON) stated her expectation when a resident refused SLP recommendations would be to update the IDT team, complete a risk versus benefits with the resident and update the resident's care plan. Additionally, the DON stated she would increase supervision and monitoring if a resident refused recommendations for safety. The DON verified SLP did not communicate her recommendations to the IDT team and did not explain the risk to R2. The DON also stated her expectation would have been for the RD to update the entire IDT team when she noticed the issue with R2's diet order. The facility Food & Nutrition Services, Nutrition Therapy policy undated, indicated a mechanical soft diet was a modified diet and was used for residents with limited chewing ability. Mechanical soft foods should include ground moist meats, canned fruits and vegetables, well-cooked soft vegetables, finely chopped fruits and vegetables soft breads and desserts. The facility Nutritional Status Management policy dated [DATE], indicated the IDT team together with the resident and/or representative would identify, evaluate risk factors and individualize interventions to meet the nutritional needs of residents. The IJ was removed when R2's diet was downgraded and her plan of care was updated. In addition, the facility implemented a new process to communicate SLP diet recommendations. The facility provided risk versus benefit education to their interdisciplinary team. All facility staff received education on choking and how to recognize, prevent and respond to choking. The facility also reviewed residents who were at risk for choking for diet orders and their level of supervision. The DON or designee continued to audit resident diet orders and level of assistance matched their plan of care and were being followed. There were also audits completed regarding risk versus benefits to ensure residents were educated on the risk when they did not wish to follow SLP recommendations.

Based on interview and document review, the facility failed to ensure documentation of resident resuscitation status was consistent throughout the clinical record to ensure the resuscitation status reflected the resident's current resuscitation preferences, and failed to ensure staff were knowledgeable about what constituted the clinical signs of irreversible death. This resulted in an immediate jeopardy (IJ) for 1 of 7 residents (R5) whose resuscitation preference of cardio-pulmonary resuscitation (CPR) was not honored when R5 was found unresponsive and CPR was not performed. Additionally, this resulted in immediate jeopardy for 2 of 7 residents (R6, R7) who were at risk for serious harm or death when their resuscitation status were inconsistent in their clinical record. The immediate jeopardy began on [DATE], when R5's resuscitation preference changed to receive cardio-pulmonary resuscitation, and the change was not consistently changed throughout R5's medical record. The immediate jeopardy was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 6:43 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of G-isolated, actual harm that is not immediate jeopardy. Findings include: The American Heart Association's (YEAR) guidelines for cardio-pulmonary resuscitation indicated while the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION] (lack of pulse), there were a few exceptions where withholding CPR would be considered appropriate: -Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. -Obvious clinical signs of irreversible death (e.g., rigor mortis (stiffening of muscles), dependent lividity (pooling of blood in the lowest lying part of the body due to gravity), decapitation (separation of the head from the body), transection (cut across body causing body separation), decomposition (decay of the body). -a valid advanced directive, Provider Orders for Life-Sustaining Treatment (POLST), or order indicating do not attempt resuscitation R5's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R5 exhibited moderate cognitive impairment. Limited staff assistance with transfers, walking, dressing, and personal hygiene. R5's Admission Record form included [DIAGNOSES REDACTED]. R5's Order Summary for order date range [DATE] - [DATE] identified a [DATE] order Do Not Resuscitate (DNR). The order summary did not include any other code status orders. A [DATE] paper POLST directed Attempt Resuscitation/CPR (cardio-pulmonary resuscitation) if resident has no pulse and is not breathing. The POLST directed Full Treatment. This included: intubation, advanced airway interventions, mechanical ventilation as indicted and transfer to hospital and/or intensive care unit if indicated. The POLST further directed Follow these orders until orders change. These medical orders are based on the patient's current medical condition and preferences . Under Documentation of Discussion the POLST indicated Patient (Patient has capacity). The POLST was signed by R5. Under the physician signature section, the POLST indicated My signature below indicates to the best of my knowledge that these orders are consistent with the patient's current medical condition and preferences. R5's primary physician signed the POLST on [DATE]. Although R5's resuscitation status changed from do not resuscitate (DNR) to CPR on [DATE], R5's electronic medical record continued to identify R5's code status as DNR. -R5's electronic order remained DNR. -R5's electronic (MONTH) 2019 Medication Administration Record [REDACTED] Additionally, an untitled [DATE] and [DATE] paper form, used to communicate information about R5 during appointments outside of the facility indicated R5's code status as DNR, which was inconsistent with R5's POLST signed [DATE] for CPR. A progress note, dated [DATE], indicated R5 does not require supervision for safety. R5 transferred and walked independently. A progress note, dated [DATE], indicated R5's discharge was extended to [DATE], pending a [DATE] appointment. A progress note, dated [DATE], at 6:59 a.m. indicated licensed practical nurse (LPN)-A entered R5's room at 4:45 a.m. to administer intravenous medication. R5 was found unresponsive, all extremities cold to touch, lips blue. 911 called, paramedics did not attempt resuscitation, .patient has expired. Last seen alive at 1:30 a.m. The progress note lacked documentation that CPR was initiated and lacked documentation of obvious clinical signs of irreversible death. During an interview on [DATE], at 3:00 p.m. LPN-A stated when she entered R5's room, she put her hand on R5's chest and found R5 not breathing. LPN-A stated R5 looked pale. LPN-A stated she went to the nursing station and returned with a stethoscope. LPN-A stated she attempted, but was unable to find a heartbeat with the stethoscope. LPN-A stated she called 911, then looked up R5's code status in the electronic point click care system (PCC). LPN-A stated the electronic system showed R5 was DNR. LPN-A stated she did not start CPR. LPN-A stated she informed the paramedics when they arrived R5 was DNR and the paramedics stated there was nothing they could do. When asked about the clinical signs of death, LPN-A stated R5's extremities were cold. LPN-A stated she notified the director of nursing (DON) of R5's death as well as R5's family. LPN-A stated, after her shift ended, she was completing some documentation and found a paper POLST in R5's chart. LPN-A stated she could not recall what the directive on the POLST was, but went on to say she recalled the the POLST did not match the information in the electronic PCC. LPN-A stated if R5's PCC would have directed CPR, she would have started CPR on R5. LPN-A stated she informed the DON and a few of her fell ow nurses that R5's PCC and POLST form did not match and was directed to check both places from now on to find the code status. LPN-A stated prior to this, she was directed to look in PCC to find a resident's code status. During an interview on [DATE], at 4:23 p.m. the DON, after reviewing R5's electronic record, stated she received a call from LPN-A. The DON stated LPN-A told her she went into R5's room to hang an IV. The DON stated LPN-A told her she found R5 unresponsive, cold to the touch, and lips were blue. The DON stated she believed they reviewed the code status. The DON added she questioned LPN-A why she called 911 as R5 was DNR. The DON stated LPN-A believed 911 needed to be called, even when DNR. The DON stated she educated LPN-A 911 did not need to be called for DNR residents. The DON stated staff are directed to refer to the paper POLST in the chart to determine code status. The DON reviewed R5's POLST stating the POLST directed CPR and the PCC directed DNR. The DON stated they did not match. The DON stated she was not aware of the inconsistency. The DON referred to the facility's policy stating CPR would not be done for obvious signs of clinical death, rigor mortis, dependent lividity, decapitation, transection, and decomposition. When asked if R5 had any of these signs the DON stated no, adding these were examples. The DON stated cold to the touch would be another sign of obvious death and CPR would not be initiated. The DON stated she would not expect staff to initiate CPR on a resident that was cold to touch and CPR should not have been initiated for R5. R6 R6's admission MDS, dated [DATE], indicated severe cognitive impairment. R6 was independent with walking and dressing. R6's [DATE] [DIAGNOSES REDACTED]. R6's medical record contained inconsistencies with resuscitation code status: R6's Order Summary Report from PCC, printed on [DATE], indicated an active [DATE] order Do not intubate (DNI)/Do not attempt resuscitation (DNAR if pulseless and apneic (not breathing)). -R6's paper POLST, located in R6's paper chart under the advanced directive tab on [DATE] indicated Attempt Resuscitation/CPR Full treatment. The POLST was dated [DATE], 4 days after the electronic PCC DNR order. The POLST was signed by R6 and the provider. A provider note, dated [DATE], indicated Full Code (full attempts at resuscitation including intubation), POLST completed on this date: [DATE] She understands and is clear wants full code. R7 R7's admission MDS, dated [DATE], indicated R7 was cognitively intact. R7 required extensive assistance with dressing and personal hygiene. R7's Admission Record, printed [DATE], included [DIAGNOSES REDACTED]. R7's record contained inconsistencies with resuscitation code status: -R7's Order Summary Report from PCC, printed on [DATE], indicated an active [DATE] order Full code, Do Not Intubate. -R7's paper POLST, located in R7's paper chart under the advanced directive tab on [DATE], indicated DNR/DNI (do not resuscitate, do not intubate). The POLST was signed by the the resident. The POLST was undated and not signed by the provider. During an interview on [DATE], at 2:37 p.m. R7 stated when he was admitted he informed staff he did not want tubes and that kind of stuff, but if he had a [MEDICAL CONDITION] wanted them to do something. R7 stated he wanted chest compressions to be done if his heart stopped. R7 stated staff talked to him again yesterday and told the staff the same thing. During an interview on [DATE], at 4:19 p.m. licensed practical nurse (LPN)-B stated if a resident was unresponsive she would check in PCC for code status, then check the chart. LPN-B stated if the code status's did not match she would call the supervisor. During an interview on [DATE], at 4:22 p.m. registered nurse (RN)-A stated if a resident was unresponsive someone would check the code status in both the paper chart and PCC. RN-A stated if there was a discrepancy the MD would be called. During the interview on [DATE], at 4:23 p.m. the DON reviewed R6's and R7's PCC order and paper POLST. The DON stated the order entered in PCC and paper POLST directives did not match on either R6 or R7. The DON stated the code status in PCC and on the POLST need to match. The DON added Looks like we are going to need to do a sweep on the code status. The DON stated every resident in the building's code status will be reviewed. The DON stated when a resident is admitted to the facility, the resident usually comes with admission orders [REDACTED]. Once at the facility, staff ask the resident what their code status preference is. The DON stated if the resident expresses different wishes from the order, for example, order is DNR and resident wishes to be full code, staff call the provider and obtain a new order to match the residents wishes. The DON stated the POLST form gets brought up at admission. The facility's policy CPR-Cardio-pulmonary Resuscitation, dated [DATE] directed It is the practice this facility will provide basic life support, CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care during a witnessed or unwitnessed event, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. Nursing staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: -A valid Do Not Resuscitate order is in place -Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present -Initiating CPR could cause injury or peril to the rescuer. The policy did not identify cold extremities as an obvious sign of clinical death. The objective of CPR guideline is to provide basic life support based until emergency medical services arrives, consistent with the resident advance directives, in the absence of an advanced directive or Do Not Resuscitate Order and if the resident does not show signs of clinical death. Prompt initiation of CPR is essential as brain death begins four to six minutes following [MEDICAL CONDITION] if CPR is not initiated within that time. The procedure for CPR directed staff to obtain the resident record and review resident directives. If the resident has a valid advance directive, a POLST (Physician order [REDACTED]. If no DNR order/advance directive exists or if advance directive does not indicate Do Not Resuscitate, begin resuscitation efforts: The policy lacked direction of the process of obtaining orders and POLST and a process to ensuring both match. The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility had implemented an acceptable removal plan including review of all residents' code status' to ensure accuracy; review and revision of policies with staff education provided- included review of clinical signs of irreverisble death (rigor mortis, dependent lividity, decaption, transection, decomposition). The facility also developed a procedure to ensrue all staff were trained prior to their next shift; and the provider developed an audit system to ensure compliance.

Based on observation, interview, and document review, the facility failed to provide care and services to ensure pain was managed for 1 of 3 residents in the sample (R10) with identified pain, for 1 of 1 resident with a history of bowel obstruction (R30), and 1 of 3 residents reviewed for non-pressure related skin issues (R53). Findings include: R10 had severe unmanaged pain that resulted in actual harm to the resident. At 6:02 p.m. on 4/22/12, R10 was interviewed in her room. She reported, "I have pain all over," and felt staff were rough with her. She stated, "It hurts bad. It hurts most when I'm getting dressed." At 3:35 p.m. on 4/23/12 a nursing assistant (NA-C) entered R10's room and the resident expressed to the NA she was experiencing pain. NA-C informed R10 that the nurse recently gave her pain medication. R10 stated, "I should get [MEDICATION NAME] instead they give me that stupid [MEDICATION NAME] that does not do anything for me." NA-C informed R10 that she was there to provide some care for her. R10 continued to express pain. NA-C told R10 she could come back later to assist her, if that would be better for the resident. She told the NA she preferred the assistance "now." NA-C told the resident she would return with help from another staff person. At 3:50 p.m. NA-C returned to R10's room and again reported she would return with another staff person to assist her. At 3:56 p.m. NA-C returned to R10's room with NA-D and the nurse manager. At 3:57 p.m. R10 was heard yelling at the NA's, "Stop you are hurting me! I am in pain! Ouch my legs hurt! My legs hurt real bad!" At 10:30 a.m. on 4/25/12 R10 told the trained medication assistant (TMA-A) that she was waiting for a NA to assist her. At 10:47 a.m. TMA-A offered to assist NA-E with R10's cares. R10 was heard screaming while she was assisted with cares, "I am in mortal pain! That hurts! That hurts real bad! This is barbaric!" At 11:05 a.m. on 4/25/12, an interview was conducted with TMA-A. The TMA reported R10's last dose of pain medication of [MEDICATION NAME] 1.5 milliliters (ml) was given at 3:30 p.m. on 4/24/12. TMA-A also verified that R10's order was for [MEDICATION NAME] every four hours as needed for pain and in addition R10 had a pain patch. TMA-A gave R10 another dose of [MEDICATION NAME] 1.5 ml at 11:15 a.m. on 4/25/12. TMA-A was unaware R10 had orders for anti-anxiety medication. The TMA did, however, verify the resident had an order for [REDACTED]. At 9:45 a.m. on 4/26/12, R10 was observed during a.m. cares. NA-F and NA-G were observed assisting R10 with grooming, hygiene, dressing and repositioning. During cares, R10 yelled out "Be careful! Double ouch! You're killing me! You're rubbing me raw! That hurts bad! I still have mortal pain! My legs hurt bad!." The NA's informed R10 that they would inform the nurse about her pain. At 10:38 a.m. on 4/26/12, R10 was heard yelling out "Can I get some pain medication? I am in pain." At 10:45 a.m. on 4/26/12, licensed practical nurse a (LPN-A) verified R10 was able to express and rate her pain level. During the interview R10 said she had a headache and her legs were hurting really bad. LPN-A informed her she would get her some Tylenol (the resident had orders for no Tylenol) and repositioned her feet and legs with a pillow. At 11:20 the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R10's quarterly Minimum Data Set (MDS) and pain assessment was completed on 3/6/12. The resident had [DIAGNOSES REDACTED]. The pain assessment indicated the resident was able to communicate pain. She experienced recent pain in the previous five days that she rated 8 out of 10 (on a 0-10 scale). The pain made it hard to sleep at night and limited her day to day activities. The assessment noted the resident was prescribed [MEDICATION NAME]es and and a non-medication approach of repositioning. The questions on the assessment, "Describe administration patterns, any side effects and effectiveness" as well as "Describe interventions and effectiveness" were left blank. Pain was identified as an ongoing issue for R10 as noted on previous MDS assessments where the resident rated her pain severity as 4 out of 10 on 12/13/11, 10 out of 10 on 9/16/11, and 8 out of 10 on 6/20/11. R10 was prescribed [MEDICATION NAME] 125 microgram (mcg) patch apply and change every 72 hours (order date for 25 mcg 1/6/12 and for 100 mcg 2/6/12), [MEDICATION NAME] 30 milligrams (mg) every four hours as needed (order date 1/16/12), [MEDICATION NAME] 60 mg daily for depression and chronic pain (order date 12/8/10), [MEDICATION NAME] 0.5 mg for anxiety/nausea/shortness of breath (order date 12/30/11), and Oragel 10% gel to affected areas as needed for pain (order date 11/11/11, "affected areas" not specified, and medication not used in 3/12 or 4/12). The resident was administered prn [MEDICATION NAME] approximately 22 times in both 3/12 and 4/12 for reports of "mortal pain, headache, pain all over, leg pain" that the resident rated in each instance between 7/10 and 10/10. In 3/12 positioning and music were often attempted, however, in 4/12 the majority of days non-pharmacological interventions was either "0" or was left blank. The effectiveness of the medication was generally noted as "effective, helped, sleeping." Target behavior monitoring was scored "0" on all days in 3/12 and 4/12 for resisting cares, yelling, etc. Psychology progress note dated 12/19/11, indicated R10 was "referred for services due to yelling at caregivers, particularly for pain medications. She makes frequent complaints of having 'mortal pain' and will scream at caregivers especially if they are touching her lower extremities." She was able to recall some recent and remote events with accuracy. It was noted there were indications of hypersensitivity which could be due to the [DIAGNOSES REDACTED]. The psychologist noted and recommended: 1) Presence of pain is likely, but at least somewhat manageable. 2) The resident was provided with a copy of "Coping With Depression," although would likely need it read to her. 3) "Given that PRN [MEDICATION NAME] seems helpful," it was suggested staff consider assessing for pain prior to cares, offer PRN pain meds, and then providing cares 30-60 minutes later. "[MEDICATION NAME] may help her tolerate cares better by reducing anxiety." 4) Offer proactive check-ins that are not related to her hollering out and not based on cares. 5) Direct reassurance, e.g. "'I know that you have a lot of pain and I am going to be gentle as I can.'" 6) Occupying her time with other residents and volunteer, try books on tape or CD and she used to play Solitare. 7) Give a lot of reassurance with the Hoyer lift such as, "'I've double checked everything, we're right here, you're going to be fine, etc.'" Although the care plan directed staff to "provide emotional support to resident/family as needed in regards to pain and dementia process," the recommendations made by the psychologist were not reflected on R10's care plan nor on the nursing assistant assignment sheet. The care plan dated 1/24/12, indicated [REDACTED]. The goal for R10 was to report a pain level decrease within 30 minutes of intervention through the next assessment period. Interventions included administering pain medications as ordered as well as "as needed" pain medication for breakthrough pain, and to assess for medication effectiveness. Staff were to acknowledge the presence of pain and discomfort, listen to the resident's concerns, document/report complaints and non-verbal signs of pain, implement relaxation techniques to assist with pain control, and offer music or television. A practitioner note dated 1/30/12, indicated R10 used [MEDICATION NAME] 17 times so far and usually once per day. The note further indicated R10 would continue to see the psychologist to assist staff with managing behaviors, hypersensitivity and pain. A progress note dated 4/15/12, noted R10 complained of "mortal pain" during activities of daily living (ADL'S) and R10 was given as needed [MEDICATION NAME] and [MEDICATION NAME] with good effect and resident noted to be resting comfortable. A progress note dated 4/19/12, noted R10 complained of "mortal" pain rated 10/10 all over and [MEDICATION NAME] 30 mg had been given at 5:00 p.m. The note indicated that upon re-check, R10 stated it did not help, no non-verbal signs and symptoms of pain were noted, and the resident appeared comfortable. The Pain Management Policy dated 10/23/09, was reviewed. The policy indicated that each resident was to be assessed and monitored for effective pain management. Pain level was to be monitored and documented weekly by a nurse. Requests for as needed (un-scheduled) pain medication were to be given only by a nurse. The nurse "must evaluate" the resident's pain before giving interventions and the effectiveness of the interventions after they were provided. The charge nurse and nurse manager were responsible to monitor for implementation of care plan interventions and changes in a resident's condition. Nursing assistants were to be trained on how and when to report any complaints of pain or discomfort to the charge nurse. R30 was admitted to the hospital with [REDACTED]. The facility failed to complete a comprehensive bowel assessment for R30, despite having knowledge of the resident's recurrent bowel obstructions, which resulted in numerous hospitalization s. R30 was admitted to the facility, from another nursing home on 12/8/11 with [DIAGNOSES REDACTED]. Documentation received from the transferring nursing home included the following: A hospital history and physical (H&P) revealed R30 had been admitted to the hospital twice for bowel obstructions from 10/14 to 10/19/11, and again from 10/30 to 11/9/11. hospitalization s were due to small and large bowel obstruction, with a large ventral hernia, which were resolved. The H&P also indicated R30 had occasional incontinence of bowel, and the large broad ventral hernia contained portions of the small bowel and colon, as well as part of the liver. Despite this information, no bowel assessment was completed for R30 by the facility. The admission Minimum Data Set (MDS) completed on 12/15/11, revealed R30 was frequently incontinent of bowel and was not on a bowel program. Nurses notes from 12/8/11 to 12/27/11 addressed changes in bowel status, where bowel movements were soft or loose in consistency; and there were changes in medications. However, no comprehensive bowel assessment was completed during this time period. The resident was admitted to the hospital on [DATE]. A social service note dated 1/5/12, indicated R30 was admitted to the hospital on [DATE] with a bowel obstruction and 4500 milliliters of fecal matter had been removed from R30's stomach. R53 had brusing to the arms and hands, but the facility failed to provide the appropriate treatment and services to minimize bruising. A comprehensive non-pressure related skin assessment was not completed for R53 despite documentation of having had large bruises of unknown origin. The most recent revised care plan dated 3/1/12, did not address R53's potential for bruising. At 10:21 a.m. on 4/24/12, a black and purple skin bruise, measuring approximately six inches long by four inches wide was noted on the back of R53's left hand, extending up to the wrist. When asked how the bruise occurred, the resident did not respond. Although she was dressed in a long sleeved sleeved shirt, there was not protection padding on R53's hands. A review of the incident report indicated that at 8:00 a.m. on 4/23/12, staff, "noted a 5 x 3 centimeter (cm) dark red bruise on back of left hand. Cause not known. Resident stated that it did not hurt and she did not know how it happened." The report indicated the possible cause may have been the wheelchair or grab bars. A review of R53's record indicated that at 5:20 p.m. on 3/19/12, bruising of the right wrist was noted. A review of the incident report revealed staff noted a purple bruise measuring 6 cm long by 4.3 cm wide on R53's right wrist, that extended from the wrist up to the elbow. A review of the facility's Incident Report and Incident Report/Review indicated the facility did not know how the bruise had occurred and that R53 had fragile skin. Interventions identified were to remind staff to keep R53's arms covered with sleeves. However, there was no indication this was the only appropriate intervention as a comprehensive non-pressure related skin assessment had not been completed. At 1:40 p.m. on 4/25/12, RN-A was questioned regarding a skin assessment addressing R53's tendency toward bruising. RN-A stated the facility did not have an assessment for non-pressure related skin conditions.