Every finding on record at Victory Health and Rehabilitation Center

Based on interviews and document review the facility failed to investigation an allegation of mistreatment for 1 of 1 resident (R6) reviewed for mistreatment.Findings include: R6 R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, impairment in both lower extremities, dependence upon staff for assistant with toileting hygiene and activities of daily living (ADL), and an ostomy (a surgical opening on the abdomen that allows stool to leave the body). R6's diagnoses included multiple sclerosis (a chronic disease that affect the nervous system), a neurogenic bladder (nerve damage disrupts communication between the brain, spinal cord and bladder), paraplegia, and depression. R6's care plan indicated the following:8/18/25- there was a potential for abuse due to being a vulnerable adult with interventions that included: implemented 8/18/25, don't have R6 near others who disturb him; implemented 8/18/25, remove from potentially dangerous situations; implemented 2/25/26, and ensure safety around others who might take advantage of R6's confusion.8/27/25- alteration in gastrointestinal status related to colostomy with interventions to change the colostomy per orders.11/28/25- needed assistance with ADLs and mobility with interventions that indicated substantial assistance for toileting hygiene. R6's provider orders dated 12/1/25, indicated empty the colostomy bag every shift. R6's progress notes lacked mention of the alleged incident. During an interview on 8/14/26 at 3:14 p.m., R6 stated after R6 exchanged words about changing his colostomy bag, with a nurse he didn't know on 8/12/26, the nurse left the privacy curtain open when she was changing his ostomy bag and told R6 it smelled bad in the room. R6 stated he asked the nurse for privacy and the nurse told him she couldn't stand the smell, threw his new ostomy bag towards him, told him he should learn to change the ostomy bag himself, took her gown off and put it on the corner dresser. Then the nurse returned and wadded up the gown and threw it at R6's face. R6 stated the nurse provided the required cares until the dirty ostomy bag was removed and the stool and site were cleaned. Then the nurse hollered for another nurse (LPN-A) to come to finish the task. R6 stated he informed the LPN-A what happened, and after the LPN-A applied the new ostomy bag, the LPN-A left the room and stated she was going to get the director of nursing (DON). The DON was gone so another nurse, identified by R6 as the RN-C, came into the room to take his statement. R6 stated he told the LPN-A, the RN-C, and the social worker (SW)-A about the incident. During an interview on 8/14/26 at 3:31 p.m., the LPN-A stated the nurse involved in the incident was RN-E. On 8/12/26, RN-E was caring for R6 and had trouble changing R6's colostomy bag because it was causing her to gag. When the RN-E came out of R6's room, after providing care, the RN-E was crying. The LPN-A stated R6 did not tell her the RN-E wadded up the used gown and threw it at him, but if he had she would have reported it as an allegation of abuse. The LPN-A stated a nurse should not tell a resident they smell, should not tell a resident to provide their own cares, and should have called for help and not gagged in front of the resident. If the RN-E said the things R6 alleged, the RN-E should not care for R6 again. The LPN-A was not aware of any investigation into the incident.During an interview on 8/14/26 at 4:28 p.m., The SW-A told the Governing Body it was an allegation of abuse, and the Governing Body said it was not. The SW-A stated the Governing Body said he was going to ask the RN-E about what happened but was unsure if that occurred. Further, the SW-A stated she normally helped with investigations, but was not asked to do this one, so she didn't think it was investigated. During an interview on 8/18/26 at 2:30 p.m., the DON stated she did not have a file about the incident with R6. The DON stated it was not reported to her until 8/14/26, she thought the Governing Body was going to investigate the incident but had no evidence it was investigated. During an interview on 8/19/26 at 2:37 p.m., the administrator stated he was aware of the incident alleged by R6 but was not present in the building or notified by staff about it until days later. The administrator stated he did not have an investigation file about the incident and further stated it should have been reported and investigated by the Governing Body but was not. If the reason it was not investigated was because no one was hurt, that was not a valid reason to not investigate or report. The administrator stated the Governing Body was not available for an interview. The Abuse Investigation and Reporting policy dated 7/17 indicated if an incident or suspected incident of resident abuse or mistreatment was reported, the Administrator would assign the investigation to an appropriate individual for investigation.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded, with the potential for inaccurate resident care planning and a language barrier in assessments and care for 1 of 3 residents (R4) reviewed for communication.Findings include: R4's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition, Vietnamese as R4's race, and English as the primary language. R4's diagnoses included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations. R4's care plan dated 4/29/26, indicated no cultural preferences with an intervention to review cultural preferences quarterly and as needed. The care plan did not identify how to communicate with R4, that Vietnamese was R4's preferred language, or to provide information in a language R4 understood. During an interview on 8/18/26 at 2:30 p.m., the director of nursing (DON) stated she thought R4 could understand basic English but didn't think he could understand medical assessment. From the time of admission, the facility should have planned for an interpreter for better comprehension of nursing assessments and information, and documents should have been provided in a language he understood. The DON stated she was not sure why R4's MDS indicated his primary language was English because it was not and the MDS was inaccurately coded. The Resident Assessments policy dated 3/22 indicated all persons who have completed any portion of the MDS must sign the document to attest to the accuracy of the assessment.

Based on interviews and document review, the facility failed to report allegations of mistreatment and abuse to the State Agency (SA) within the required timeframe for 2 of 2 residents (R6 and R1) reviewed for allegations of mistreatment and abuse.Findings include: R6 R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, impairment in both lower extremities, dependence upon staff for assistant with toileting hygiene and activities of daily living (ADL), and an ostomy (a surgical opening on the abdomen that allows stool to leave the body). R6's diagnoses included multiple sclerosis (a chronic disease that affect the nervous system), a neurogenic bladder (nerve damage disrupts communication between the brain, spinal cord and bladder), paraplegia, and depression. R6's care plan indicated the following:8/18/25- there was a potential for abuse due to being a vulnerable adult with interventions that included: implemented 8/18/25, don't have R6 near others who disturb him; implemented 8/18/25, remove from potentially dangerous situations; implemented 2/25/26, and ensure safety around others who might take advantage of R6's confusion.8/27/25- alteration in gastrointestinal status related to colostomy with interventions to change the colostomy per orders.11/28/25- needed assistance with ADLs and mobility with interventions that indicated substantial assistance for toileting hygiene. R6's provider orders dated 12/1/25, indicated empty the colostomy bag every shift. R6's progress notes lacked mention of the alleged incident. During an interview on 8/14/26 at 3:14 p.m., R6 stated after R6 exchanged words about changing his colostomy bag, with a nurse he didn't know on 8/12/26, the nurse left the privacy curtain open when she was changing his ostomy bag and told R6 it smelled bad in the room. R6 stated he asked the nurse for privacy and the nurse told him she couldn't stand the smell, threw his new ostomy bag towards him, told him he should learn to change the ostomy bag himself, took her gown off and put it on the corner dresser. Then the nurse returned and wadded up the gown and threw it at R6's face. R6 stated the nurse provided the required cares until the dirty ostomy bag was removed and the stool and site were cleaned. Then the nurse hollered for another nurse (LPN-A) to come to finish the task. R6 stated he informed the LPN-A what happened, and after the LPN-A applied the new ostomy bag, the LPN-A left the room and stated she was going to get the director of nursing (DON). The DON was gone so another nurse, identified by R6 as the RN-C, came into the room to take his statement. R6 stated he told the LPN-A, the RN-C, and the social worker (SW)-A about the incident. During an interview on 8/14/26 at 3:31 p.m., the LPN-A stated the nurse involved in the incident was RN-E. On 8/12/26, RN-E was caring for R6 and had trouble changing R6's colostomy bag because it was causing her to gag. When the RN-E came out of R6's room, after providing care, the RN-E was crying. The LPN-A stated R6 did not tell her the RN-E wadded up the used gown and threw it at him, but if he had she would have reported it as an allegation of abuse. The LPN-A stated a nurse should not tell a resident they smell, should not tell a resident to provide their own cares, and should have called for help and not gagged in front of the resident. If the RN-E said the things R6 alleged, the RN-E should not care for R6 again. During an interview on 8/14/26 at 3:57 p.m., the RN-C stated he went to R6's room to hear his statement about the incident at the request of the LPN-A. The RN-C stated R6 alleged when the RN-E provided ostomy cares on 8/12/26, the RN-E stated it smelled like, shit when the air came out of the ostomy bag. RN-E then opened the door to R6's room to let it air out. R6 asked the RN-E to close the door, and the RN-E wanted the odor to leave the room before continuing to provide the ostomy cares. R6 and the RN-E exchanged curse words, and the RN-E left the room stating she was getting someone else, smashed up her gown, and threw it at his face while swearing at him. The RN-C stated when he talked to the RN-E about the incident, she said the same thing; when she opened the ostomy bag the gas came out and she needed to step out of the room and leave the door open because she was going to throw up. The RN-C stated he did not know if the RN-E told R6 she had to leave because she was going to throw up. The RN-C stated the SW-A was also in the room when R6 was telling him about the incident. R6 reported the RN-E threw a gown at his face. The RN-C stated he apologized to R6 for what happened, and that the facility would work on educating the RN-E and would not assign her to his care again. The RN-C stated after he heard R6's story, the LPN-A and the SW-A went with him to the office of the Governing Body to report the incident. The SW-A told the Governing Body, it was abuse and should be reported to the State Agency as an allegation of abuse. The Governing Body disagreed, stating R6 had a history of making allegations against staff, R6 had no physical marks, and the Governing Body wouldn't consider the allegation abuse. The RN-C stated he had not heard R6 make any allegations about staff before and had no behaviors. The RN-C stated the Governing Body did not want staff to report the incident because the Governing Body had already determined the allegation was not considered abuse. During an interview on 8/14/26 at 4:28 p.m., the SW-A stated she talked to R6 on 8/12/26 at about 5:15 p.m. R6 reported he exchanged words and the RN-E, and she had left the door open, but R6 wanted it shut for privacy. The nurse cussed at R6, took off her gown, crumbled it up, and threw it at R6 and the gown hit R6 in the face. The SW-A stated she went to get the RN-C to hear the allegation because it sounded like abuse. Then, The SW-A and the RN-C went to the Governing Body to ask him to report it. The SW-A told the Governing Body it was an allegation of abuse, and the Governing Body said it was not. The SW-A stated the Governing Body said he was going to ask the RN-E about what happened but was unsure if that occurred. Further, the SW-A stated she normally helped with investigations, but was not asked to do this one, so she didn't think it was reported or investigated. During an interview on 8/18/26 at 2:30 p.m., the DON stated she did not have a file about the incident on 8/12/26, between R6 and the RN-E. The DON stated it was not reported to her until 8/14/26, she thought the Governing Body was going to investigate the incident but had no evidence it was investigated or reported. During an interview on 8/19/26 at 2:37 p.m., the administrator stated he was aware of the incident alleged by R6 but was not present in the building or notified by staff about it until days later. The administrator stated he did not have an investigation file about the incident and further stated it should have been reported and investigated by the Governing Body but was not. If the reason it was not investigated was because no one was hurt, that was not a valid reason to not investigate or report the incident. The administrator stated the Governing Body was not available for an interview. R1's R1's quarterly MDS dated [DATE], indicated R1 was cognitively intact. R1's diagnoses included paraplegia, lung disease, and anxiety.The Nursing Home Incident Report filed on 7/27/26 at 5:53 p.m., identified staff were aware of an incident 7/27/26 at 2:49 p.m., in which R1 reported staff assaulted her the weekend prior (7/25/26). The report indicated on 7/25/26, R1 reported hearing a cracking sound and pain when a staff member grabbed her arm during assistance with repositioning and having her hair pulled when two staff assisted with adjusting her pillow and blanket. R1 reported she felt the actions of the two staff were intentional. During an interview on 8/14/26 at 3:05 p.m., the administrator stated the report to the State Agency was late. The Administrator stated the facility had a new director of nursing (DON) at the time, and the Governing Body, who identified as the chief operating officer (C.O.O.), thought the DON was going to file the report but hadn't. When the Governing Body realized the DON had not filed the report, the Governing Body filed the report, but it was after the required two-hour reporting deadline. The Abuse Investigation and Reporting policy dated 7/17 indicated if an incident or suspected incident of resident abuse or mistreatment was alleged, the facility would report the allegation to the State Agency immediately, but not later than two hours after receiving the report.

Based on interview and document review the facility failed to develop and implement a baseline care plan to properly communicate with 1 of 3 residents (R4) reviewed for baseline care plan. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, Vietnamese race, and English as the primary language. R4's diagnoses included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations. R4's care plan dated 4/29/26, indicated no cultural preferences with an intervention to review cultural preferences quarterly and as needed. The care plan did not identify how to communicate with R4, that Vietnamese was R4's preferred language, or to provide information in a language R4 understood. R4's hospital discharge notes dated 4/30/26, indicated during a consultation by a physician on 5/3/26 at 10:38 a.m., the hospital utilized an interpreter. During a physical therapy session on 5/4/26 at 12:15 p.m., the therapist utilized an interpreter. During an interview on 8/13/26 at 4:59 p.m., R4 answered his phone speaking in a language other than English. R4 stated he was on his way home and to call back later. He stated he did not understand what the call was about. During an interview on 8/13/26 at 3:42 p.m., the licensed practical nurse (LPN)-A stated the method of communication should be included in the baseline care plan, especially if a resident's preferred language is not English. During an interview on 8/18/26 at 8:35 a.m., the LPN-C stated she did not use an interpreter to communicate with R4, English was not R4's primary language, but R4 could respond some in English while she was providing care. The LPN-C stated any communication issues should be added into the care plan on the day of admission so staff would know how to communicate correctly with the residents. During an interview on 8/18/26 at 8:59 a.m., with an interpreter using the Vietnamese language, R4 stated the facility tried to communicate with an interpreter phone that didn't work because there was no cellular phone service in the building. His facility medical provider spoke to him only in English and R4 stated he answered the questions he thought he understood but wasn't sure if he answered correctly. During an interview on 8/18/26 at 2:30 p.m., the director of nursing (DON) stated she thought R4 could understand basic English but didn't think he could understand medical assessments. The DON stated R4's baseline care plan should have contained information about cultural preferences including R4's primary language, and that the facility staff should use an interpreter for communication. The Baseline Care Plans policy dated 3/22 indicated a baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within 48 hours of admission.

Based on interview and document review the facility failed to obtain informed consent for a room change for 1 of 1 resident (R4) reviewed for notification of change.Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, Vietnamese race, and English as the primary language. R4 diagnoses included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations. R4's electronic health record census data indicated room changes on 7/2/26, from room [ROOM NUMBER] to 155 and then on 7/3/26, from room [ROOM NUMBER] to room [ROOM NUMBER]. R4's Room Change Notice dated 7/1/26, indicated a room change from room [ROOM NUMBER] to 155 with a reason listed as other but not specified. The medical record lacked documentation of a room change consent for the room change dated 7/3/26, from room [ROOM NUMBER] to room [ROOM NUMBER]. During an interview on 8/14/26 at 4:28 p.m., the SW-A stated R4 had two room changes and should have had a notice for each. On 7/2/26, R4 was moved from room [ROOM NUMBER] to 155 and then on 7/3/26, was moved from room [ROOM NUMBER] to room [ROOM NUMBER]. The SW-A acknowledged she completed R4's Room Change Notice for the room change dated 7/1/26, and did not put the reason for the change on the form, but should have. The SW-A stated she did not know why she omitted the reason, but each room change should indicate a reason. During an interview on 8/18/26 at 8:59 a.m., with a Vietnamese language interpreter, R4 stated he had been in three rooms during his stay at the facility and didn't know why he had to change rooms. The last move was better because he was then in a room by himself. During an interview on 8/19/26 at 1:53 p.m., the director of nursing (DON) acknowledged R4 received a room change notice for the room change from room [ROOM NUMBER] to room [ROOM NUMBER], but it did not include an explanation. R4 did not receive a documented room change notice for the room change from 155 to 106. The DON stated the expectation was that each resident would be notified of each room change in advance, with an explanation. The Room-to-Room Transfer policy dated 12/16 indicated the documentation for a room transfer included the date and time the transfer was made, the name and title of the individual who assisted in the move, all assessment data obtained during the move, how the resident tolerated the move, and the person and title of the person recording the data. If the resident refused the move, the reason would be documented. The policy lacked indication the reason for the move should be included in the documentation.

Based on observation, interview and document review, the facility failed to ensure bathing/shower assistance was provided for 2 of 3 residents (R4, R7) reviewed for activities of daily living (ADLs).Findings include: R4 R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, impairment in both lower extremities with the use of a wheelchair for mobility. R4 required touch assistance for ADLs, R4's the ability to bathe was not assessed. R4 was incontinent of bowel, required a catheter for urination, and had diagnoses that included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations. R4's July 2026 Treatment Administration Record (TAR) lacked orders for a weekly bath. R4's care plan dated 4/24/26, indicated assistance of one staff for showering/bathing. R4's weekly bath assessments indicated he received a shower on 5/12/26; 5/25/26; and 6/22/26. R4 received bed baths on 5/19/26; 5/24/26; 6/2/26; and 6/30/26. R4 refused a shower on 6/15/26 but allowed a skin assessment. During an interview on 8/14/26 at 4:28 p.m., the social worker (SW)-A stated on 7/10/26, R4 told her he wanted a shower. The SW-A told a nurse R4 wanted a shower, but R4 didn't get a shower and should not have to go a week or more without a shower. During an interview on 8/18/26 at 12:52 p.m., registered nurse (RN)-A acknowledged the SW-A told her R4 wanted a bath on 7/10/26. The RN-A told a nursing assistant (NA) R4 wanted a shower but didn't recall who she told. The RN-A stated R4 should have gotten a shower when he requested it. During an interview on 8/18/26 at 8:59 a.m., with an interpreter for the Vietnamese language, R4 stated he had not gotten baths for over a month, and his skin was, so itchy. In the three months R4 was at the facility, staff helped him shower one time. R4 stated he told staff repeatedly he wanted a shower, and he was given a non-committal response. R4 then told management staff he wanted a shower and still did not get assistance. R4 stated he didn't know who he spoke to about wanting showers, he didn't know their names. R4 stated he heated water in his room from the sink and washed his face and the front of his body but could not wash the back of his body. Staff brought him pans of water, but he really wanted a shower. R4 stated his family did not want to visit him because they said he smelled too bad. During an interview on 8/18/26 at 2:30 p.m., the director of nursing (DON) acknowledged R4 didn't get any showers after 7/13/26, and didn't know why. Prior to 7/13/26, R4 only received showers on 5/12/26, 5/25/26 and 6/22/26. If showers were his preference or if R4 asked for showers, he should have gotten them weekly and as needed. During an interview on 8/19/26 at 9:25 a.m., the NA-A stated she cared for R4 sometimes. When R4 wanted a bath, she would bring two pans of water and a washcloth to his room for him to give himself a bath. The NA-A stated she was unsure why R4 didn't get a shower. She would give R4 a shower when he asked but the NA-A did not offer a shower. The NA-A stated she saw R4 wash with pans of water once and just thought that was how he liked to bathe but acknowledged she didn't ask how R4 preferred to bathe. Each resident has a weekly time assigned for a bath, and if they refused, the NA was expected to reapproach two-three times and then tell the RN. The RN was responsible for documenting if a bath or shower is refused. During an interview on 8/19/26 at 12:28 p.m., the NA-E acknowledged R4 did not get showers weekly but should have. R7 R7's quarterly MDS dated [DATE], indicated R7 had moderate cognitive impairment, required supervision for transfers from surface to surface, and set-up or supervision for activities of daily living. R7's diagnoses included malnutrition, depression and high blood pressure. R7's July 2026 TAR lacked orders for weekly bath audits. R7's August 2026 TAR lacked orders for weekly bath audits. R7's care plan dated 6/24/26, indicated an ADL self-care deficit related to activity intolerance and dementia with interventions to supervise with shower or bath. R7's weekly bath audits indicated one bath since admission on [DATE]. No other baths were documented. R7's progress notes dated 7/13/26, indicated a weekly bath audit was completed. The progress notes lacked mention of other baths provided. During an interview on 8/13/26 at 3:42 p.m., the licensed practical nurse (LPN)-A, stated each resident was supposed to be offered a shower weekly. If the resident refused, staff would reapproach and offer a shower again. The care plan should indicate if the resident refused bathing and what else to try to encourage bathing. The LPN-A acknowledged R7 had one documented bath and there was no further documentation to support other baths were offered or refused. During an interview on 8/18/26 at 2:30 p.m., the DON acknowledged R7 was supposed to get a weekly shower and had only one, on 7/13/26, and didn't know why. The DON expected each resident to get assistance with a weekly bath or shower. During an interview on 8/19/26 at 9:39 a.m., the NA-B stated she had a list of showers she was required to give during her shift, and each resident was assigned a specific day to shower. If the resident refused a shower, she would report it to the nurse. The nurse would try to intervene and offer one and then document if the resident still refused. During an interview on 8/19/26 at 10:05 a.m., family member (FM)-A stated R7 was not getting regular baths and often had body odor when she visited. R7 could not shower herself. The Activities of Daily Living policy dated March 2018 indicated appropriate care and services would be provided for residents who were unable to carry out ADLs independently in accordance with the plan of care including appropriate support and assistance with bathing.

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR) accurately reflected the resident's medication and treatment administration for 1 of 1 resident (R4) reviewed for accuracy of record.Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, Vietnamese as R4's race, and English as the primary language. R4's diagnoses included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations.R4's provider orders included the following:6/9/26 acetaminophen 500 milligrams (mg) oral tablet, give two (2) tablets by mouth (po) three times daily6/9/26 atorvastatin (used to treat high cholesterol) 20 mg oral tablet, give 20 mg po at bedtime6/9/26 betamethasone dipropionate external cream (used to relieve itching) 0.05%, apply to hands, chest, and abdomen topically twice daily6/9/26 carvedilol (used to treat high blood pressure and heart failure) 3.125 mg oral tablet, give three (3) tablets po twice daily, in the morning and bedtime6/9/26 fexofenadine hydrochloride (HCl) (antihistamine to treat allergies) 60 mg oral tablet, give one (1) tablet po twice daily, in the morning and in the afternoon6/9/26 gabapentin (used to treat nerve pain) 300 mg oral capsule, give 1 capsule po at bedtime6/9/26 methocarbamol (muscle relaxer) 500 mg oral tablet, give 1 tablet po three times dally6/9/26 simethicone (used to treat excess gas in the stomach) 80 mg oral tablet, give 1 tablet four (4) times daily 6/9/26 sucroferic oxyhydroxide (used to treat high blood phosphate levels in patients with chronic kidney disease on dialysis) 500 mg oral tablet, give 1 tablet po three times daily with meals6/9/26 torsemide (used to remove excess fluid from the body) 100 mg oral tablet, give 1 tablet po twice daily, in the morning and afternoon6/9/26 triphocaps (complex vitamin) 1 mg, give 1 mg po, one time a day in the afternoon6/9/26 trazodone HCl (antidepressant) 100 mg oral tablet, give 1 tablet po at bedtime6/10/26 lactulose (used to lower ammonia levels in the body with people who have liver disease)10 gram (gm) /15 milliliter (ml), give 30 ml po in the evening6/10/26 patiromer sorbitex (used to treat high potassium levels) 8.4 gm oral packet, give 1 po in the evening 6/13/26 pantoprazole sodium (used to treat stomach acid) 40 mg oral tablet delayed release, give 40 mg po twice daily, in the morning and evening R4's July 2026 MAR/ TAR indicated on 7/14/26 the following medications were administered when R4 was no longer in the facility:4:00 p.m., doses of fexofenadine HCl, simethicone, and torsemide 5:00 p.m., doses of lactulose, patiromer sorbitex calcium packet, pantoprazole, triphrocaps 8:00 p.m., doses of acetaminophen, atorvastatin, betamethasone dipropionate, carvedilol, gabapentin, methocarbamol, simethicone, sucroferic oxyhydroxide, trazodone The MAR further indicated a Lidocaine patch could not be applied on 7/14/26 at 12:00 p.m., because the resident was documented as code 3, out of the facility. R4's progress note dated 7/14/26 at 11:11 p.m., indicated R4 was out of the facility. The electronic health record lacked a note indicating what time R4 left the facility. During an interview on 8/19/26 at 11:56 a.m., the trained medication aide (TMA)-B stated she was aware R4 left the faciity on 7/14/26 around 3:00 p.m. and acknowledged she charted medications were administered after that time. The TMA-B stated it was a mistake and she didn't know why she charted them as administered when they were not. During an interview on 8/19/26 at 12:28 p.m., the TMA-A stated R4 left the faciity on 7/14/26 after he had his morning medication, R4 was no longer in the facility by noon. The TMA-A stated she informed the registered nurse (RN)-C and the nursing assistant (NA)-C, R4 left and was not available for afternoon medications. The TMA-A stated the RN was supposed to document in the MAR that R4 was out of the facility for the medications the RN was supposed to administer. The RN was also supposed to document in the progress notes that R4 was out of the facility. The TMA-A reviewed R4's MAR, TAR, and progress notes for July 14, 2026, and noted many medications were marked as administered after R4 left the facility. The TMA-A stated any medication documented on the MAR with a code 3, indicated R4 was out of the facility. The TMA-A stated she left her shift at 3:00 p.m., and R4 was already gone. The TMA-A stated any mediations and treatments documented as administered on 7/14/26 after 3:00 p.m., were falsified and inaccurate. The TMA-A stated the medications that could not have been administered included: acetaminophen; atorvastatin; betamethasone dipropionate; carvedilol fexofenadine HCl; gabapentin; lactulose; methocarbamol; patiromer sorbitex calcium packet; pantoprazole; simethicone; sucroferic oxyhydroxide; torsemide; triphrocaps; and trazodone. During an interview on 8/19/26 at 1:53 p.m., the director of nursing (DON) stated any medications and treatments that were documented as administered after R4 left the faciity on 7/14/26 after 3:00 p.m., were a falsification of records and did not occur. The Charting and Documentation policy dated 7/17 indicated treatments and services performed were documented in the medical record. Documentation in the medical record will be accurate.

Based on interviews and document review, the facility failed to provide a means to communicate in the resident's preferred and primary language for 1 of 1 resident (R4) reviewed for communication. Additionally, the facility policy indicated the language services availability would be conditional. Findings include: R4's initial nursing assessment dated [DATE], indicated R4 spoke English and lacked mention of R4's primary language, Vietnamese. R4's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, Vietnamese race, and English as the primary language. R4 diagnoses included heart failure, kidney disease, diabetes, depression, and bilateral below the knee amputations. R4's care plan dated 4/29/26, indicated no cultural preferences with an intervention to review cultural preferences quarterly and as needed. The care plan did not identify how to communicate with R4, that Vietnamese was R4's preferred language, or to provide information in a language R4 understood. R4's hospital discharge notes dated 4/30/26, indicated during a consultation by a physician on 5/3/26 at 10:38 a.m., the hospital utilized an interpreter. During a physical therapy session on 5/4/26 at 12:15 p.m., the therapist utilized an interpreter. R4's psychology services provider note dated 6/12/26, indicated R4 may have some cognitive issues, but language could also be a barrier. R4's psychology services provider note dated 7/3/26, indicated recommendations to have an interpreter available to ensure comprehension was of value and it may be possible to use publicly available resources to translate important information into R4's primary language and provide it in writing. R4's progress notes dated 7/23/26 at 5:39 p.m., indicated per the psychology provider note on 7/3/26, when available, having an interpreter available to ensure comprehension was of value. During an interview on 8/13/26 at 4:59 p.m., R4 answered his phone speaking in a language other than English. R4 stated he was on his way home and to call back later. He stated he did not understand what the call was about. During an interview on 8/13/26 at 3:42 p.m., the licensed practical nurse (LPN)-A stated if the admissions coordinator had reviewed the hospital discharge paperwork and had seen the hospital had used an interpreter to communicate with R4, the facility also should have used an interpreter because R4's primary language was not English. During an interview on 8/14/26 at 9:34 a.m., the receptionist (RC)-A at R4's dialysis provider stated when he communicated with R4 he used an interpreter. When the nurses at the dialysis provider explained a procedure to R4, they also used an interpreter. During an interview on 8/14/26 at 10:10 a.m., the registered nurse (RN)-C stated when he communicated with R4 he spoke more slowly than usual because he knew English was not R4's primary language and did not think R4 could understand medical processes in English. The RN-C stated he had not had training about how to access an interpreter at the facility and had not seen staff utilize an interpreter with R4. Further, the RN-C stated if previous providers noted they used an interpreter with R4, the facility should have too. During an interview on 8/14/26 at 11:43 a.m., the RN-B from R4's dialysis provider stated R4 could have a simple conversation with staff, but when she provided education to R4, she used an interpreter to ensure he understood. During an interview on 8/14/26 at 1:11 p.m., the hospital social worker (SW)-B stated they used an interpreter with R4 to communicate because R4 did not understand English well. The SW-B stated R4 knew general English words, but the hospital staff did not attempt to communicate in English because R4 could not carry on a medical conversation in English. During an interview on 8/14/26 at 4:28 p.m., the SW-A stated R4's primary language was Vietnamese and the facility did not have an interpreter service arranged to communicate with R4. The SW-A stated she tried to use an application on her phone but didn't know if it was reliable. R4 could understand some English, but complex medical conversations should have occurred in a language R4 understood. During an interview on 8/18/26 at 8:35 a.m., the LPN-C stated she did not use an interpreter to communicate with R4, English was not R4's primary language, but R4 could respond some in English while she was providing care. During an interview on 8/18/26 at 8:59 a.m., with an interpreter using the Vietnamese language, R4 stated the facility tried to communicate with an interpreter phone that didn't work because there was no cellular phone service in the building. R4's family couldn't call because of the lack of cellular service in the building. R4 stated he felt deaf and mute and couldn't communicate with anyone unless he went to the street in front of the building. R4 stated he understood when the staff asked him if he felt sick or hurt. His facility medical provider spoke to him only in English and R4 stated he answered the questions he thought he understood but wasn't sure if he answered correctly. During an interview on 8/18/26 at 2:30 p.m., the director of nursing (DON) stated she thought R4 could understand basic English but didn't think he could understand medical assessments. From the time of admission, the facility should have planned for an interpreter for better comprehension of nursing assessments and information, and documents should have been provided in a language he understood. The Translation and/or Interpretation of Facility Services policy dated 5/17 indicated the language access program will ensure individuals with limited English proficiency would have meaningful access to information and services provided by the facility. The policy indicated the language services would only be available if the population of the of the LEP group was large enough in the facility to support the need, would depend upon the nature and/or importance of the information or service that needed to be conveyed, the frequency with which the particular LEP population was in contact with the facility, and the resources (funds and personnel) available to ensure the provision of language access services to LEP individuals.

Based on interview and document review, the facility failed to perform complete and thorough investigations of allegations of abuse for 3 of 3 residents (R1, R2, R3) who were involved in resident-to-resident altercations. Findings include:A Nursing Home Incident Report (NHIR) dated 5/26/26 at 8:20 p.m., indicated at approximately 6:25 p.m., when R2 and R3 were both in the dining room, R2 struck R3 in the chest and face. Facility initiated 15-minute safety checks. The incident was witnessed by activity staff. A NHIR dated 5/26/26 at 10:30 p.m., indicated at 7:39 p.m., R2 and R1 were involved in a physical altercation in which R2 hit and scratched R1. Staff intervened and separated the residents, and staff performed monitoring and safety checks. Review of the investigative files on 6/1/26 of each of the two incidents revealed the investigations did not include interviews with other residents to ensure the other residents did not also have allegations of abuse by R2. During an interview on 6/2/26 at 12:09 p.m., the director of nursing (DON) stated during an investigation for abuse, other residents other than those involved in the incident, should be interviewed to determine if other residents had also been abused and acknowledged that had not occurred for either incident. A policy for abuse investigations was requested but not provided.

Based on interview and document review the facility failed to ensure a safe environment was maintained and monitoring was implemented as indicated in the medical record for 2 of 3 residents (R1, R3), and as ordered for 1 of 3 residents (R2) after resident-to-resident altercations.Additionally, the facility failed to ensure ongoing assessment and monitoring for 2 of 2 residents (R1, R3) after R1 was hit and scratched by R2, and R3 was hit in the torso and slapped by R2, which had the potential to result in unmonitored decline for R1 and R3.Findings include:A Nursing Home Incident Report (NHIR) dated 5/26/26 at 8:20 p.m., indicated at approximately 6:25 p.m., when R2 and R3 were both in the dining room, R2 struck R3 in the chest and face. Facility initiated 15-minute checks. The incident was witnessed by activity staff. A NHIR dated 5/26/26 at 10:30 p.m., indicated at 7:39 p.m., R2 and R1 were involved in a physical altercation in which R2 hit (did not indicate where ) and scratched R1. Staff intervened and separated the residents, and staff performed monitoring and safety checks. R1R1's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no behaviors, and diagnoses that included anxiety, depression, and Post Traumatic Stress Disorder (PTSD). R1's care plan indicated the following:5/19/25- safety- [R1] is at risk for potential abuse due to chemical dependency, mental illness, and intrusive thoughts. Intervention included to not have R1 near residents who disturb him and remove from potentially dangerous situations. 7/28/25- vulnerable adult due to mental health, cognition, physical impairment and nursing facility placement. The diagnoses list on the care plan indicated alcohol dependence and other stimulant use.R1's progress notes indicated the following:5/26/26 at 10:25 a.m., R1's bath audit was completed with no skin concerns noted. 5/26/26 at 8:01 p.m., activity staff informed the licensed practical nurse (LPN)-B R1 was involved in a physical altercation with R2; R2 hit and scratched R1. R1 was noted to have scratches on the chest, abdominal area, and arm following the incident. Staff performed monitoring and safety checks. 5/27/26 at 7:19 a.m., 15-minute checks continued. The progress notes lacked a comprehensive assessment of the scratches, their length, depth, and width, description of the color, shape, and margins, and if there was any drainage from the wounds. Also, the progress note lacked mention of the treatment provided, a pain assessment, and indication of ongoing monitoring of R1's injuries. R1's Incident Audit Report dated 5/26/26 at 9:38 p.m., indicated the LPN-B was informed by activity staff, R1 and R2 were involved in a physical altercation, R2 hit and scratched R1 over a money conflict. Male resident [R1] noted with scratches to chest, abdominal area, and arm following the incident. The residents [R1 and R2] were separated, and safety checks were initiated. The director of nursing (DON), administrator, provider, police, and psychologist were notified. R1's care plan was reviewed and updated, first aid care was performed for R1's scratches, and a PTSD screen and Vulnerable Adult assessment were completed. Referrals were sent to R1's psychology clinic for onsite evaluation and to the onsite substance abuse counselor. Monitoring and safety checks continued. R1's 15-Minute Check Sheet indicated 15-minute checks were implemented on 5/26/26 at 8:30 a.m., and continued through 5/28/26 at 7:00 a.m. The Check Sheet further indicated the 15-minute checks were omitted during the following time frames:5/27/26 from 12:15 a.m., through 6:15 a.m.5/28/26 from 8:15 a.m., through 2:15 p.m.5/28/26 from 7:15 a.m., through the end of the 72-hour monitoring periodR1's orders lacked mention of 15-minute checks. During an interview on 6/1/26 at 2:18 p.m., R1 stated he did not remember the incident with R2, but he had scratches on his arms and chest and was kicked by R2; staff told him about the incident. R1 stated he was not on safety checks, and the only time his VS were checked was twice daily when he had been drinking. R2R2's quarterly MDS dated [DATE], indicated intact cognition, no behaviors, and diagnoses that included traumatic brain injury, depression, anxiety, and PTSD. R2's care plan indicated the following:1/13/26- at risk for abuse due to being a vulnerable adult with an intervention dated 1/16/26 to not allow R2 to be near other residents who disturbed her.3/19/26, updated 5/27/26- Impaired thought process related to substance abuse and dependence of alcohol dated, with an intervention dated 5/27/26 to initiate the facility alcohol and substance abuse policy.5/27/26- potential to be physically aggressive after a resident to resident altercation with interventions to monitor and document for increase in behavior, specifically ( ), The care plan lacked indication of the behaviors the staff were supposed to monitor and was left blank.), and monitor, document, and report as needed (PRN) any signs and symptoms posing danger to self and others. The diagnoses list on the care plan indicated current alcohol use. R2's progress notes indicated the following:5/26/26 at 4:17 p.m., social worker (SW)-A went outside to schedule Care conference with another resident and R2 was passing a jug of liquor around to other residents. Staff asked to take the bottle, but R2 would not give up the bottle. Staff let nursing staff know the resident was drinking.5/26/26 at 7:35 p.m., at approximately 6:30 p.m., activity staff informed LPN-A that R2 attempted to hit R3, and R2 initially stopped, but when activity staff turned to assist another resident R2 struck R3 in the chest and face. 15-minute safety checks were initiated. The police, DON, and administrator were notified. 5/26/26 at 9:04 p.m., R2 continued to exhibit signs of intoxication, including slurred speech and mood changes, medication on hold, and her medical provider was notified. The progress notes lacked mention of R2's second altercation, between R2 and R1, on 5/26/26 at 7:39 p.m. R2's 15-Minute Check Sheet indicated 15-minute checks were implemented on 5/26/26 at 6:30 p.m., and further indicated the 15-minute checks were omitted during the following time frames:5/27/26 from 2:45 p.m., to 5/28/26 12:00 a.m.5/28/26 from 6:30 a.m,. to 5/28/26 8:00 a.m.5/28/26 from 1:15 p.m., through the 72-hour monitoring periodR2's provider orders dated 5/27/26, indicated 15-minute safety checks every shift, fill out the paper form. The provider order did not have an end date and was not entered until the day after the safety checks were implemented. During an interview on 6/1/26 at 3:46 p.m., R2 stated R3 called her a racist name and, a bitch. R2 told R3 to stop, but R3 didn't. R2 didn't recall the incident with R1, only that something happened. R2 stated she is able to hide from staff and staff couldn't keep up with her to check on her. During an interview on 6/1/26 at 3:00 p.m., the LPN-B stated both R1 and R2 were on 15-minute checks after the incident, which were completed on paper forms, usually for 72 hours after an altercation. The LPN-B stated she did not see R1's wounds up close but when R1 went outside, she saw them, and they were, not gushing blood. R1 was angry and the LPN-B was afraid to approach him to assess the wounds more closely. The LPN-B stated staff should have continued to monitor and check on the wounds for signs of infection and was unsure is staff had. R3R3's quarterly MDS dated [DATE], indicated severe cognitive impairment, no behaviors, and diagnoses that included malnutrition and visual problems. R3's care plan indicated the following:10/10/24- no cultural preference. The care plan lacked interventions for known racism/racist comments. 5/13/25- impaired thought processes with an intervention dated 10/8/21, closely supervise activities and interactions with others. 11/5/25- safety- was at risk with a potential for abuse due to cognition and physical impairment with an intervention dated 10/24/25 to ensure safety around others who may take advantage of R3, and an intervention dated 3/7/23, do not allow R3 to be around others who disturbed her. The diagnoses list on the care plan indicated symptoms and signs involving cognitive functions and awareness, depression, and adjustment disorder with anxiety. R3's progress notes indicated:5/26/26 at 7:24 p.m., indicated R3 was hit in the face by another resident, and the nurse conducted a head-to-toe assessment and found no swollen or open areas. VS were taken, and within normal range. Resident was placed in 15-minute checks. The progress note lacked values of the VS. 5/27/26 at 11:47 a.m., indicated the LPN-C was notified by other residents, R3 was slapped by R2. The LPN-C performed a head-to-toe assessment, VS were taken and were within normal range, the resident denied pain or discomfort, and R3 was placed on 15-minute checks. The provider and R3's FM were updated. 5/28/26 at 11:47 a.m., indicated the progress note created on 5/27/26 at 11:47 a.m., was not indicative of a new incident, but was instead a follow up note from the incident that was noted on 5/26/26. R3 remained stable and maintained on 15-minute checks. The progress notes lacked the VS values after the incident and lacked ongoing assessment after R3 was struck in the face by another resident. R3's Incident Report Audit dated 5/27/26 at 11:02 a.m., indicated an incident occurred 5/26/26 at 5:50 p.m., between R2 and R3. The Report indicated R2 slapped R3 in the face and a head-to-toe assessment was completed. Resident placed on 15-minute checks. The assessment lacked indication of VS values. R3's care plan was reviewed and updated, and a PTSD screen and VA assessment were completed. R3 was referred to on the onsite psychologist. R3's 15-Minute Check Sheet indicated 15-minute checks were implemented on 5/26/26 at 6:30 a.m., and continued through 5/30/26 at 8:00 a.m. The Check Sheet further indicated the 15-minute checks were omitted during the following time frames:5/27/26 from 12:15 a.m., through 6:15 a.m.5/28/26 from 8:15 a.m., through 2:15 p.m.R3's orders lacked mention of 15-minute checks.During an interview on 6/1/26 at 3:20 p.m., the activity aide (AA)-A stated she noticed on 5/26/26 after 6:00 p.m., R1 was shirtless, looked agitated, and had bloody scratches on his chest, a bloody handprint on his left arm, and the knuckles on both hands were bleeding. R1 walked towards his room but stopped where R2 was talking to another resident in front of R1's door and talked about how R1 went to the store for them, and came back with no money and no merchandise. R1 went into his room and walked out with a razor and threatened the other resident with it, and the AA-A hollered down the hallway for help. The AA-A asked R1 for the razor, but R1 walked outside instead. R2 picked up her walker and tried to hit R1 with it, but the AA-A redirected R2. The AA-A was discussing the incident with nursing staff (the AA-A didn't recall which nursing staff) and then walked outside to observe and saw R1 and R2 were hugging and appeared to be friendly again. Further, the AA-A stated she saw R2 hit R3 in the chest because R3 called R2 a racist name, and the AA-A hadn't heard the name-calling but the AA-A redirected R2 to keep her hands off R3. The AA-A stated she went to help someone else and came back and saw R2 had slapped R3's glasses off, and R3 said ow, that hurt. The AA-A stated she reported the incidents to a nurse, but didn't recall who, but the AA-A reported R2 first punched R3 in the chest and later slapped R3 on the face. During an interview on 8/2/26 at 8:56 a.m., the LPN-C stated 15-minute checks required an order, the checks were typically completed for 72 hours, and if the order did not have an end date, the checks should continue. The LPN-C acknowledged the 15-minute check order for R2 was still active, and the checks should have continued but did not and further acknowledged the 15-minute checks for R1, R2, and R3 were not completed fully. The LPN-C stated a change in condition could occur and if staff were not performing checks, staff would not know about the change in condition. During an interview on 6/2/26 at 9:34 a.m., the LPN-D stated R2 had two incidents on 5/26/26 when R2 was intoxicated with alcohol. The LPN-D stated she expected to see more of an assessment for R1's scratches, if they were old or new, if they required treatment, and if they were cleansed. The LPN-D stated she did not see any follow-up in the medical record about the scratches later but should have to ensure they were healing. The LPN-D acknowledged 15-minute checks were not completed fully for R1, R2, and R3., and if the checks were not completed, further incidents could occur. The checks were used to know the location of the residents, know they were safe, and to keep residents who had altercations away from each other while they are still upset. If the checks were not completed, staff would not know if the residents were in a safe situation. During an interview on 6/2/26 at 10:37 a.m., the nursing assistant (NA)-A stated staff were doing some15-minute checks on R3, but acknowledged staff did not do all the checks they were supposed to do, every 15 minutes for 72 hours. During an interview on 6/2/26 at 10:55 a.m., R3 did not recall the incident with R2. During an interview on 6/2/26 at 10:58 a.m., NA-B reviewed the 15-minute check sheets for R1, R2, and R3 and did not recognize the forms, and did not know their purpose. During an interview on 6/2/26 at 11:44 a.m., the family member (FM)-A stated R3 was racist, swore at staff and residents, and raised her middle finger often to them, and thought staff was protecting R3 as best they could.During an interview on 6/2/26 at 1:20 p.m., the LPN-A stated she was aware of the incidents between R1 and R2, and R2 with R3. The LPN-A stated that when residents are assaulted, the nursing staff assessed each resident for injuries and implemented 15-minute checks to ensure the residents were not in the same place at the same time. The LPN-A stated a skin assessment was documented for each resident in the progress notes, and VS should be recorded. If a resident is injured, nursing staff would keep monitoring to ensure the resident's condition did not worsen. During an interview on 6/2/26 at 12:09 p.m., the DON stated she was notified of both incidents. Staff were expected to separate the residents after an altercation, start 15-minute checks, perform skin assessments and VS, and notify family, the DON, and administrator. The DON stated she saw the progress noted on 5/26/26 at 8:01 p.m., in which a skin assessment was noted with scratches, but the nurse did not describe the scratches, the treatment that was administered, record the VS, or perform a pain assessment, but should have. The DON further acknowledged R3's incident progress noted indicated VS were assessed, but the progress note lacked the VS values. Additionally, the DON acknowledged 15-minute checks were supposed to have been completed for 72 hours for R1 and R3, but were not completed as long as they should have been, and were not completed every 15 minutes as they should have been. Also, R2's order for 15-minute checks had no end date, so R2 should have remained on 15-minute checks until the order was discontinued. The DON stated the 15-minute checks were implemented for the safety of each resident, and if they were not completed, another incident could occur. The DON further stated 15-minute checks were in the facility's batch orders, and each resident on 15-minute checks should have an order for them, but R1 and R3 did not. The Resident-to-Resident Altercation policy dated December 2016 indicated if two residents were involved in an altercation staff would document in the resident's clinical record all interventions and their effectiveness and complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record.

F880Based on observation, interview and document review the facility failed to store soiled linens, and transport linens to prevent the spread of infection. This had the potential to affect all 65 residents whose personal laundry was done at facility.Findings include: An observation on 1/14/26 at 8:16 a.m., laundry assistant (LA) carried an arm load of clean laundry on hangers, draped over arm, up against scrubs and brought into an unidentified resident's room.An observation on 1/14/26 at 8:19 a.m., on the outside laundry room door, a yellow sign stated: NURSING STAFF 1. Soiled linen MUST be bagged and taken to laundry room. Placed in proper container/bin, at the end of every shift. 2. Outgoing laundry must be put in blue bag, placed in proper bin in soiled room [ROOM NUMBER]. DO NOT put any soiled linens on the floor. Inside of the laundry room, there were large containers for facility laundry, empty blue fabric bags on a table, and two filled blue bags sitting on the floor in front of containers. There were four plastic bags filled with mop heads and rags, on the floor by the door leading into the washing and drying room. Also, multiple used cleaning rags and 3 dirty mop heads were unbagged and laying on the floor. By the back wall were two plastic bags filled with resident's clothes on the floor. A container for resident's clothes was labeled. A sign on the inside of laundry room door stated, PUT FACILITY LAUNDRY INTO BLUE BAG AND PLACE INSIDE OF BIN, NOT ON FLOOR.A tour of the laundry room and interview on 1/14/26 at 8:28 a.m.LA stated they were the only employee for the laundry department in the facility. The facility laundered all 65 resident's personal clothing and linens were shipped out and done off site. LA confirmed the items on the floor in the soiled laundry room and stated she relied on the staff to place the items in proper bags and containers. Soiled items in or out of bags were not permitted on the floor. Lastly, she stated the clean laundry was transported to the resident room was done incorrectly. The items should have been covered on a cart, while in transport. The rationale was to decrease infections in the facility.During interview on 1/14/26 at 9:01 a.m., with infection preventionist (IP) confirmed the observations in the laundry facility, the soiled items on the floor, stated that was against the policy and procedure for handling laundry. IP confirmed the signage and recognized that all staff were responsible for the proper handling of soiled linen. Soiled laundry on the floor was an infection control issue and proper storage, and transport of laundry decreased the risk of contamination and infection to be spread. The expectation of staff was to follow the policy and procedures of handling laundry.During interview on 1/15/26 at 10:30 a.m., trained medication aide (TMA)-A stated they were educated on the policy and procedure of laundry, that the soiled resident's linen was to be in a plastic bag, closed, and placed into bin in the soiled laundry room area, not on the floor, to decrease infections in the facility.During interview on 1/15/26 at 11:28 a.m., the director of nursing (DON) stated that IP oversees the laundry facility, however, the DON was involved in the role of proper handling of laundry by nursing staff. The expectation was to follow the policy and procedures for laundry. Laundry was to be handled using standard precautions, soiled laundry was to be bagged and placed in proper containers, the rationale for proper laundry handling was to decrease infections.A facility policy titled Laundry and Bedding, Soiled dated 9/2022, directed staff to transported and process laundry according to best practices for infection prevention and control. furthermore, staff should handle laundry using standard precautions and with minimum agitation to avoid the contamination of air, surfaces, and persons. Soiled laundry was to be bagged and placed in proper containers.

Based on interview and document review the facility failed to allow active resident and resident representative participation in the development and review of care plans for 4 of 4 residents, (R3, R25, R30, R14) reviewed for care planning and coordination of services while residing at the facility. Findings include: R3 R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, no adverse behaviors, and was dependent on staff for wheelchair mobility. R3's medical record identified the most recent care conference was held on 8/20/25, and no additional care conferences were held. R3 had an additional quarterly MDS completed on 11/9/25, There was no indication in the progress notes or medical record of any care conference held at the time of this assessment. During an interview on 1/13/26 at 8:22 a.m., R3's representative (RR)-A stated he was not invited to a recent care conference, and he had concerns about communication with the facility. R25 R25's quarterly MDS dated [DATE], identified intact cognition, no adverse behaviors, and was independent with wheelchair mobility. R25's medical record identified the most recent care conference was held on 8/19/25, and no additional care conferences were held. R25 had an additional quarterly MDS completed on 11/9/25, There was no indication in the progress notes or medical record of any care conference held at the time of this assessment. During an interview on 1/12/26 at 1:24 p.m., R25 stated he was not invited to a recent care conference, and he would have wanted one to bring up some concerns. R30 R30's admission MDS dated [DATE], identified R30 had moderate impaired cognition, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. In addition, MDS indicated R30 communicated needs, and understood direction and conversation. Furthermore, MDS indicated R30 exhibited no adverse behaviors. R30's medical record lacked documentation of any care conferences. During interview on 1/15/26 at 1138 a.m., the director of nursing (DON) verified the medical record did not have a care conference documented at any time for R30. The expectation for care conferences were to be completed within the first 48 hours of admission, quarterly and as necessary. R14 R14's quarterly MDS dated [DATE], indicated intact cognition and diagnoses of acute transverse myelitis in demyelinating disease (inflammation of the spinal cord that damages myelin), type II diabetes, and legal blindness. It further indicated R14 required partial assistance with most ADL's and supervision with mobility. R14's medical record indicated the most recent care conference was held on 8/18/25. R14's medical record showed no additional care conferences since 8/18/25. R14's progress notes (since admission on [DATE]), lacked documentation that a care conference had been completed. During interview on 1/12/2026 at 2:12 p.m., R14 stated he had not had a care conference since being admitted to the facility. During interview on 1/15/25 at 9:27 a.m., the DON stated the social worker was responsible for completing care conferences and they should be completed upon admission (within 48 hours) and then quarterly. The DON verified R14's last care conference was on 8/18/25, R25's was on 8/19/25, and R3's was on 8/20/25. He stated all 3 residents should've had another care conference in December and he expected care conferences to be completed quarterly following admission. A facility policy titled care conferences dated 9/2013, did not address how often care conferences should be completed.

Based on interview and document review, the facility failed to obtain and document an informed consent including explanation of risk and benefits, for 1 of 1 newly admitted resident (R80) reviewed for use of psychotropic medications.Findings include:R80's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition, no adverse behaviors and moderately severe depression. R80 was dependent on staff for bed mobility and had a diagnosis of complete paraplegia (complete loss of sensation and movement from the chest down). Medications included antianxiety and antidepressant.R80's Medication Administration Record (MAR) dated 12/30/25 through 12/31/25, identified alprazolam (antianxiety medication) 1 milligram (mg) by mouth as needed (PRN) for anxiety was given twice on 12/31/25, and documented as E which meant effective.R80's MAR dated 1/1/26 through 1/15/26, identified PRN alprazolam was given twice on 1/1/26, twice on 1/4/26, once on 1/5/26, twice on 1/6/25, once on 1/7/26, once on 1/8/26 and once on 1/9/26. All administrations were documented as E which meant the PRN was effective.R80's MAR dated 1/1/26 through 1/15/26, identified on 1/1/26, escitalopram (antidepressant medication) 20 milligrams (mg) by mouth was added one time a day for depression and was given daily.R80's Doctor's Order Sheet dated 1/9/26, identified: Discontinue alprazolam (antianxiety medication) and add clonazepam 1 mg as needed (PRN) maximum of two per day. End date 3/2/26, for diagnosis of major depression.R80's MAR dated 1/9/26 through 1/15/26, identified a new medication clonazepam 1 mg by mouth every 6 hours as needed for major depression until 3/6/26. The PRN clonazepam was administered daily on 1/10/26 through 1/14/26 and documented as effective.R80's medical record including progress notes, provider orders and assessments was reviewed and lacked evidence consent for use of the medication was obtained. Further, the record lacked evidence the risks or expected benefits of the medication regimen had been reviewed or discussed prior to initiation of the medications.During an interview on 1/15/26 at 9:01 a.m., R80 stated no one has explained the risks and benefits to the medications he was put on for his mental health. R80 stated he would like to know and felt like everything was rushed. During an interview on 1/15/26 at 9:02 a.m., licensed practical nurse (LPN)-A stated she was not sure about consent when a resident started on a psychotropic medication and would have to talk to her boss.During an interview on 1/15/26 at 9:02 a.m., the infection preventionist (IP) stated she was not sure about a consent or risk benefit discussion when a resident started on a psychotropic medication and would have to ask the director of nursing (DON).During an interview on 1/15/26 at 9:04 a.m., the DON provided a psychotropic medications policy and stated consent with risk and benefit discussion was a verbal discussion with the residents and their prescribers. There was not a process for the facility to document the details. The DON stated surveyor should reach out to Medical Doctor (MD)-A.A phone call was placed to the MD-A on 1/15/26 at 12:54 p.m., and voicemail left with call back instructions. A return call was not received.The facility's Psychotropic Medication policy dated 4/25/25, identified antidepressants and antianxiety medications were considered psychotropic medication and were subject to prescribing, monitoring and review requirements specific to psychotropic medications.

Based on observation, interview and document review, the facility failed to follow standards of practice to provide resident education and update the provider for 1 of 1 resident (R33) who routinely refused their diuretic medication.Findings include:R33's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, no adverse behaviors, was independent with meals and hygiene and had a diagnosis of chronic systolic (congestive) heart failure (CHF).R33's care plan dated 11/8/25, identified he was on a diuretic medication related to CHF. Interventions included administer diuretic medications as ordered by physician and monitor/document/report adverse reactions to diuretic therapy.R33's orders identified start date of 2/20/25, for bumetanide 1 milligram (mg) tablet, give two tablets two times a day related to CHF.R33's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25, identified bumetanide was refused 45 out of 60 opportunities. The MAR dated 12/1/25 through 12/31/25, identified bumetanide was refused 55 out of 62 opportunities. The MAR dated 1/1/26 through 1/15/26, identified bumetanide was refused 26 out of 29 opportunities.R33's nursing progress notes dated 11/1/25 through 1/15/26, lacked documentation of rationale for the refusal or that the risks and consequences had been discussed.R33's nurse practitioner's visit noted dated 11/12/25, and physician's visit note dated 12/1/25, lacked documentation of diuretic refusal.During an interview on 1/14/26 at 7:40 a.m., trained medication aide (TMA)-B stated R33 refused his diuretic and if a medication was refused the TMA should update the nurse.During an observation on 1/14/26 at 8:20 a.m., TMA-B prepared R33's morning medications, minus the bumetanide and brought the medications into his room.During an interview on 1/14/26 at 9:47 a.m., R33 stated he had not wanted his diuretic because it made him go to the bathroom too often.During an interview on 1/14/26 at 9:55 a.m., licensed practica nurse (LPN)-B stated a diuretic was an important medication and if a resident refused that medication more than one to three times, the providers should be updated. LPN-B stated that it would not necessarily be documented in a nursing progress note if a provider was updated on a medication refusal and to check the provider's notes instead.During an interview on 1/15/26 at 9:15 a.m., Medical Doctor (MD)-B stated if a concern about a medication was brought up to the provider group and it would be in the visit notes. MD-B declined to acknowledge awareness of R33 refusing diuretic medication, however acknowledged there was no documentation his notes or the nurse practitioner notes. MD-B stated if a medication was refused the patient should know the risk and benefits and the provider should be updated if the resident had a change in condition.During an interview on 1/15/26 at 12:39 p.m., the director of nursing (DON) stated medications should be given as ordered for safety purposes and to help the residents regain health. A diuretic was a high-risk medication, and residents had the right to refuse, however, nursing should have provided and documented education on risks and consequences of diuretic refusal.The facility's Medication Administration policy dated 4/2018, identified if a drug was refused the individual administering the medication shall be coded as indicated on the MAR space provided for that drug and dose. Additionally, as required or indicated for a medication the individual administering the medication would record in the resident's medical record any complaints or symptoms for which the drug was administered and any results achieved and when those results were observed.

Based on interview and document review the facility failed to communicate with a resident's emergency family contact when they were hospitalized and subsequently discharged from the facility for 1 of 2 residents (R1) reviewed for discharge process.Findings include:R1's electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and discharged on 9/13/25.R1's progress note, dated 9/13/25, indicated R1 was not redirectable and walking towards traffic and sent to the emergency department (ED) due to safety concern to self.R1's EMR lacked any evidence the facility communicated with R1's family about any potential safety concerns, his hospitalization, and discharge from the facility. During an interview on 11/10/25 at 9:50 a.m., R1's emergency contact and family member (FM)-A stated she was not informed of any incidents regarding R1 walking outside in traffic and was never informed he was hospitalized . FM-A stated she arrived at the facility on a Wednesday or Thursday to bring R1 some tobacco, and when she could not find him at the facility, she was informed he had been sent to the hospital on Saturday. FM-A stated staff at the facility were not able to tell her what happened only that the paramedics took him. FM-A stated when R1 was ready to discharge from the hospital, the social worker (SW)-A at the hospital was having a hard time getting ahold of the facility. FM-A stated she stopped by the facility to discuss in person R1's plans to return to the facility and was told by the administrator that R1 had been discharged from the facility, and she was handed a box of R1's belongings to take with her. During an interview on 11/10/25 at 11:12 a.m., the facility social worker (SW)-B stated it was expected that family be informed when a resident discharged from the facility or was sent to the ED. SW-B stated he was not the SW for R1, that particular SW was no longer with the facility, however had heard that R1 was officially discharged from the facility when he was civilly committed at the hospital.During an interview on 11/10/25 at 11:19 a.m., the facility administrator stated R1 was discharged from the facility after he was civilly committed at the hospital as he was unsure if a [NAME] was also in place, stating if that was the case they would not be able to readmit R1. The administrator confirmed R1's EMR lacked any notes of communication with the family regarding R1 hospitalization and discharge, unable to confirm if family was contacted or not.During an interview on 11/10/25 at 12:01 p.m., R1's emergency contact and family member (FM)-B also confirmed she had not been informed of R1 hospitalization and discharge from the facility. FM-B stated R1's family had not been contacted about any potential safety concerns such as leaving the facility or wandering off in traffic.A facility policy on discharge was not received.

Based on interview and document review the facility failed to ensure a written notice of transfer and bed hold was given to a resident and/or their family upon hospitalization for 1 of 2 residents (R1) reviewed for discharge. Findings include:R1's electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE] and discharged on 9/13/25.R1's progress note, dated 9/13/25, indicated R1 was not redirectable and walking towards traffic and sent to the emergency department (ED) due to safety concern to self.R1's EMR lacked any evidence R1 and/or family had received a written notice of transfer and information on the facility's bed hold policy when R1 was hospitalized on [DATE].During an interview on 11/10/25 at 9:50 a.m., R1's emergency contact and family member (FM)-A stated she was not informed when R1 was sent to the hospital, did not received a written notice of transfer or any information on the facility bed hold policy.During an interview on 11/10/25 at 11:12 a.m., the facility social worker (SW)-B stated it would be expected that family be informed when a resident discharged from the facility or was sent to the ED. SW-B stated the facility would give a verbal notice of transfer and information on the bed hold policy which should be documented in a progress note. SW-B was unaware of any specific facility policy regarding a written notice of transfer.During an interview on 11/10/25 at 11:19 a.m., the facility administrator stated it would be expected that a written notice of transfer was uploaded in the resident's EMR when they are transferred to the hospital, along with the bed hold policy. The administrator confirmed these were not in place for R1.A bed hold and written notice of transfer policy was not received.

Based on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed for 1 of 1 resident (R2) observed with medication at their bedside.Findings include:R2's quarterly minimum data set (MDS) dated [DATE] indicated intact cognition with diagnoses included morbid obesity and asthma.R2's self-administration of medications assessment dated [DATE] indicated R2 did not want to self-administer any medicationsR2's current provider orders on 10/21/25 included albuterol sulfate inhalation solution. 1 puff inhale orally every 4 hours as needed for shortness of breath due to asthma. R2's care plan dated 9/8/25 did not identify R2 did not identify a focus and/or interventions for self-administration of medication. During an observation and interview on 10/21/25 at 12:41 p.m., an inhaler was observed in a bowl on R2's bedside table. R2 stated he kept the inhaler next to his bed so he could use it as needed a couple of times a week. R2 did not tell staff when he used the inhaler.During an interview on 10/21/25 at 1:24 p.m., licensed practical nurse (LPN)-B confirmed R2 had an albuterol inhaler at his bedside. LPN-B stated when a nurse saw a medication in a resident room, the medication should be placed in the nurse's cart then an assessment needed to be completed. If the resident was deemed safe to self-administer the medication, an order needed to be obtained from the provider. LPN-B confirmed R2 had an order for an albuterol inhaler but did not have a self-administration order for the inhaler. During an interview on 10/21/25 at 11:29 a.m., the director of nursing (DON) stated if a resident asked to self-administer a medication the nurse needed to complete an assessment and if the resident was deemed safe, a provider order was obtained. The assessment was important to confirm the resident was capable and safe to self-administer the medication.During an interview on 10/21/25 at 12:13 p.m., the medical director stated if a resident requested to keep an inhaler at their bedside, the nurse should assess if the resident could use the inhaler properly, recognize when to use the inhaler, and how often they could use it. If the resident was deemed safe to self-administer, a provider order to keep the medication at the bedside should be obtained. The assessment was important to confirm the resident used the inhaler appropriately.The Self-administration of Medications policy dated 2/2021 instructed the interdisciplinary team to assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate. If the resident is deemed safe and appropriate to self-administer medications, this would be documented in the medical record and the care plan.

Based on observation, interview and document review, the facility failed to accommodate resident needs by ensuring call light buttons were within reach for 1 of 2 (R3) residents reviewed for call light usage.Findings include:R3 quarterly minimum date set (MDS) date 7/31/25 indicated severe cognitive impairment with diagnoses included schizoaffective disorder, bipolar type and catatonic schizophrenia.R3's care plan dated 9/8/25 instructed to be sure resident's call light is within reach and encourage resident to use it.During an observation and interview on 10/20/2025 at 2:41 p.m., R3 was lying in her bed. A cord was coming out of the wall near the head of the bed, but no call button was observed. R3 stated she did not have a call button. If she needed help, she would wave at staff as they walked by or would say help me. During an observation and interview on 10/20/2025 at 2:51 p.m. licensed practical nurse (LPN)-A confirmed R3's call light was lying on the floor under her bed. LPN-A stated the call light should have been attached to R3's bed where she could reach it. Resident's call lights needed to be within reach so the resident could receive help when needed.During an interview on 10/20/2025 at 2:57 p.m. nursing assistant (NA)-A stated before leaving a resident room, a staff person should make sure the resident has their call light and other needed items within their reach.During an interview 10/21/2025 at 11:29 a.m., director of nursing stated staff member need to be sure a resident has their call light within reach before leaving a resident's room. The call light is the resident's tool to communicate with staff.The Answering the Call Light policy dated 9/2022 instructed staff to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and document review the facility failed to monitor temperature and intravenous access (IV) site for 1 of 1 resident (R3) following electroconvulsive therapy (ECT).Findings include:ECT is a procedure done under general anesthesia. During this procedure, small electric currents pass through the brain, intentionally causing a brief seizure. ECT seems to change brain chemistry, and these changes can quickly improve symptoms of certain mental health conditions. Electroconvulsive therapy (ECT) - Mayo Clinic R3 quarterly minimum date set (MDS) date 7/31/25 indicated severe cognitive impairment with diagnoses included schizoaffective disorder, bipolar type, and catatonic schizophrenia.R3's care plan dated 9/8/25 indicated R3 had ECT treatment 2 times a week on Tuesday and Thursday. Following treatment R3 should be monitored for extreme headache, nausea, vomiting, confusion, temperature greater than 100.5, redness, swelling, and drainage or pain at the IV site lasting more than 24 hours.R3's ECT discharge orders and information dated 10/2/25, 10/7/25, 10/9/25, 10/14/25, and 10/16/2025 instructed what to report after ECT: Extreme headache, nausea, vomiting, confusion, Temperature greater than 100.5, Redness, swelling, and drainage or pain at the IV site lasting more than 24 hours, Major increase in depression or mania. R3's electronic physician orders included the aforementioned orders however did not include monitoring for temperature greater than 100.5 and redness, swelling, and drainage or pain at the IV site lasting more than 24 hours after ECT. The orders transcribed into the record included the following. -Physician order dated 5/14/24 instructed to monitor behaviors after ECT every shift on Tuesdays and Thursdays.-Physician order dated 7/31/25 instructed to monitor resident for extreme headache, nausea, vomiting, and confusion every shift on Tuesdays and Thursdays.-Physician order dated 7/16/24 instructed to complete vital signs every 4 weeks on Tuesday.R3's provider orders lack indication of R3's October treatment administration record (TAR) indicated R3 had ECT on 10/2, 10/7, 10/9, 10/14, and 10/16/2025. R3's temperature was checked on 10/7/25 and documented under the monthly vital sign check order. R3's TAR lacked temperature monitoring for 10/2, 10/9, 10/14, and 10/16/25.R3's nurse's notes for the month of October 2025 indicate R3's vital signs were checked one time on 10/14/25. R3's notes lack documentation of temperature monitoring on 10/2, 10/9 and 10/16. R3's notes lack documentation of IV site monitoring on 10/2, 10/7, 10/9, 10/14, and 10/16/2025.During an interview on 10/20/25 at 2:51 p.m., licensed practical nurse (LPN)-A stated if a resident needed additional monitoring an order would pop up in the TAR. Vital signs were supposed to be monitored as ordered in the TAR or if a resident was not feeling well. R3 had additional monitoring for behaviors, headache, and vomiting after ECT. Her vital signs were checked monthly.During an interview on 10/21/25 LPN-B stated all special monitoring for a resident was documented on the TAR. Resident's vital signs were checked according to provider orders, usually once a month and as needed if a resident was not feeling well. LPN-B confirmed R3's monitoring following ECT included behaviors and extreme headache, nausea, vomiting, and confusion. LPN-B could not find an order to monitor for temperature greater than 100.5 and redness, swelling, and drainage or pain at the IV site lasting more than 24 hours after ECT.During an interview on 10/21/25 at 11:29 p.m., director of nursing (DON) stated the symptoms nurses should be monitoring would be placed in the TAR. DON confirmed R3 had ECT 5 times in October 2025. Her temperature was taken 1 time and there was no documentation of IV site monitoring. It is important to monitor a resident so if they start feeling unwell staff can intervene timely.During an interview on 10/21/25 at 12:13 p.m., the medical director (MD) stated nurses should follow the patient instructions for monitoring sent with the resident following ECT treatment. Staff need to be monitoring for increased temperature and headache. Temperature should be taken when the resident returns from ECT. Monitoring should be completed to catch any problems early.The Behavioral Assessment, Intervention and Monitoring policy dated 3/2019 instructed if the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will see and document any improvements or worsening in the individual's behavior, mood, and function.

Based on interview and document review, the facility failed to ensure an allegation of potential abuse for 2 of 2 residents (R1, R2) who were involved in a resident-to-resident physical altercation, was reported immediately but no later than 2 hours to the State Agency (SA).Findings include:A Facility Reported Incident (FRI) submitted to the SA indicated on 8/29/25 at approximately 11:00 p.m. a verbal altercation between R1 and R2 occurred and R1 allegedly struck R2 in the face. The report was submitted to the SA on 9/3/25 at 11:45 a.m.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had no behaviors. R2's modification of significant change MDS dated [DATE], indicated R2 was cognitively intact, and had verbal behaviors 1-3 days in the 7-day look-back period.R2's hospital Discharge summary dated , 8/30/25 indicated a diagnosis of a dislocation of left side of jaw that was reduced, able to open but not close fully, contusion right chest wall.Prescribed oxycodone 5 mg, 1 tab every 8 hours as neededDuring an interview on 9/5/25 at 3:40 p.m., licensed practical nurse (LPN)-B stated she did not report the incident between R1 and R2 to the SA; she only reported it to the director of nursing (DON), but was supposed to report to the administrator, who reports to the SA. During an interview on 9/8/25 at 10:20 a.m., LPN-C stated abuse was reported in less than 24 hours and was not aware how to report to the SA but stated there was a book with instructions somewhere in the nurses' station. During an interview on 9/8/25 at 10:37 a.m., the DON stated abuse reporting was important because each resident should feel free from abuse and residents should receive high quality of care in a safe model. The DON stated abuse should be reported to the SA within 2 hours, and staff could report themselves, but should also inform the DON and administrator of abuse allegations. During an interview on 9/8/25 at 11:21 a.m., the administrator stated any staff could report abuse but should still inform the DON and administrator of abuse allegations. The administrator stated abuse was supposed to be reported to the SA within 2 hours and was not for this incident because the incident happened over the weekend, staff were not correctly informed, and it was reported as soon as the administrator was aware of the oversight. Additionally, the facility had begun retraining staff as of 9/3/25.The Abuse Investigating and Reporting policy dated July 2017, indicated an alleged violation of abuse will be reported immediately, but not later than two hours.

Based on interview and document review, the facility failed to prevent abuse of 3 of 3 residents (R1, R2, R3) reviewed for abuse. This resulted in an immediate jeopardy (IJ) when R1, R2, and R3 assaulted one another and the assualts resulted in R1 sustaining a fracture of his left small finger. The IJ began on 4/27/22, when R1 wanted a cigarette from R2. R2 told R1 no, and R1 and R2 had a verbal argument, but were separated by staff. Later the same day, R1 approached R2 and attacked R2, hitting him with his reacher. R2 grabbed a yellow Wet-Floor sign to defend himself, and also used the sign to hit R1. R3 attempted to break up the fight, but was knocked to the ground. Licensed practical nurse (LPN)-A eventually broke up the fight and separated the residents. During the altercation, R1 sustained a fracture of his left small finger. The administrator and director of nursing (DON) were notified of the IJ at 3:26 p.m. on 5/16/22. The facility implemented corrective action to prevent recurrence by 4/29/22, so F600 was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had a below the knee right leg amputation. R1's Care Plan obtained on 5/16/22, indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] R2's quarterly MDS dated [DATE], indicated R2 was cognitively intact. R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had bilateral above the knee leg amputations. R2's Care Plan obtained on 5/16/22, indicated R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] R3's significant change MDS on 4/2/22, indicated R3 was cognitively intact. R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Plan obtained on 5/16/22, indicated R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/27/22, at 10:40 p.m. a progress note for R1 indicated on 4/27/22, at approximately 7:30 p.m. there had been an altercation between R1 and R2. R3, who was R1's roommate, attempted to separate them, and in the process R1 pushed R3 who fell to the floor hitting his head on the fall. LPN-B called 911. R3 suffered a bump to his right forearm and the back of his head. R1 suffered bruising on his forearms and hands, and was given an ice pack to apply to the affected area. R1 and R3 were roommates, and R3 was placed in another room. On 4/27/22, at 10:50 p.m. a progress note for R2 indicated on 4/27/22, at approximately 8:00 p.m. R2 and R1 had a physical altercation related to a cigarette issue. LPN-A and other staff separated the residents and took them to their rooms. Police were called. No bruising or redness noted for R2, and he denied pain. A message was left for the nurse practitioner (NP)-A, the director of nursing (DON) was updated, and families were informed. On 4/28/22, at 5:29 a.m. a progress note for R1 indicated R1 had been up since the beginning of the shift and still wanted to go after R2 and R3. R1 was offered an ice pack and pain medication, but he refused. On 4/28/22, at 10:31 a.m. a progress note for R1 indicated R1 woke up, wasn't feeling well and asked to go to the hospital. R1 denied pain. (NP)-A was contacted and requested a detailed assessment. On 4/28/22, at 11:19 a.m. a progress note for R1 indicated after the assessment NP-A was called, and R1 was sent to the hospital by ambulance. On 4/28/22, at 1:54 p.m. the administrator's progress note for R1 indicated R1 was returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/28/22, a handwritten interview note conducted by the administrator with R1 indicated the fight started over cigarettes. R1 borrowed a cigarette to R2, then later saw R2 with an unlit cigarette. R1 stated he asked R2 for the cigarette because R2 owed him one. R2 told R1 he didn't have a cigarette for him, which made R1 upset. R1 went to grab the cigarette out of R2's hand and R2 swung at R1, and fists began flying. Staff tried to break them up but R2 just kept coming after R1. R3 then joined the fight. R1, R2, and R3 were then sent back to their rooms, R3 had to go to another room. On 4/28/22, a handwritten interview conducted by the administrator with R2 indicated the fight started over a cigarette. R1 stated told R2, I gave you a cig over a week ago. I need it back. R1 hit R2 in the chest. R1's reacher hit R2 on the head. R2 tried to get away, but R1 kept going after R2. R3 tried to break them apart. R1 then hit R3 over the head several times with a grabber. On 4/28/22, a handwritten interview conducted by the administrator with R3 indicated R1 went off on R2. R1 and R2 were arguing. R2 and R3 ordered a Lift (a ride) and left the facility. When R2 and R3 came back to the facility, R1 attacked R2. R3 tried to stop R1, but R1 pushed R2 and R3, and both fell to the floor. R3 hit his head. The police were called. R1 had hit R3 in the head with his reacher. On 5/16/22, at 9:27 a.m. R1 was interviewed and stated the incident started due to a cigarette. R1 stated he had asked to borrow a cigarette from R2, but R2 told him no. R1 stated he became upset because he could see R2 had an unlit cigarette in his hand, and R2 owed him a cigarette. R1 stated he went to take the cigarette out of R2's hand, R2 then swung at him. They both began punching each other, then R3 hit him in the hand with a stick or a cane. R1 said his hand was broke by it. R1 stated staff tried to break up the fight, but R2 and R3 kept going after him. R3 hit R1 over the head a few times with the stick or cane. On 5/16/22, at 10:15 a.m. R2 was interviewed and stated R1 had given him a cigarette a few days prior, but he had not asked for it. R2 stated a few days later he was heading for the front door with a cigarette in his hand and R1 tried to grab R2's cigarette and they had an argument and scuffle. R1 stated LPN-A broke them apart. R2 stated R1 later attacked him again and R3 stepped in to help him. R2 stated R1 was hitting him over the head with his reacher so hard it bent the reacher and gave R2 bruises. R2 stated R3 had a cane but doesn't recall if he hit R1 with it. R2 stated he picked up a yellow Wet-Floor sign off the ground and began using it as a shield and to hit R1 with it. R2 stated R1 had his hands up to protect himself after he had dropped the reacher, and he thought was when R1's hand was hurt. On 5/16/22, at 10:35 a.m. R3 was interviewed and stated he did not have his cane with him at the time of the incident. R3 stated there had been an argument earlier in the day between R1 and R2, but wasn't sure on the details. R3 stated later in the day, R1 was entering the facility and R2 was going out to smoke. R3 stated he saw the scuffle starting. R1 had a reacher and started hitting R2 over the head with it, and R2 grabbed the yellow Wet-Floor sign off the floor and started to defend himself with it and was hitting back at R1. R3 stated he tried to step in and stop the fight, but R1 started hitting him with the reacher also. R3 stated LPN-A came to help break up the fight. R3 stated he was knocked to the floor by R1. R3 stated he and R1 were roommates at the time, but the staff moved him to a different room. On 5/16/22, at 11:04 a.m. the DON was interviewed and stated R1 and R2 had a verbal confrontation in the front of the building at the receptionist area. The DON stated he was present for the this, and R1 and R2 were separated by LPN-A. R2 and R3 then left the facility. The DON stated R1 was the instigator and was more difficult to calm down. The DON stated later in the evening, R2 and R3 came back to the facility around 7:30 p.m. and that is when the physical altercation took place. The DON stated she was not present for that. The DON stated R1 and R2 began to fight again, and R3 tried to break up the fight. R3 was pushed to the floor during the exchange. The DON stated he was told LPN-A called the police. R1, R2, and R3 were told to stay in their own separate wings. The DON stated the next day R1 complained of pain in his left hand, he was sent to the hospital where they found out R1 had a broken finger. On 5/16/22, at 11:20 a.m. the administrator was interviewed. The administrator stated she had heard about the altercation when R1 wanted a cigarette back from R2. R1 and R2 argued then R1 knocked the cigarette out of R2's hand. The administrator stated R2 and R3 then left the facility grounds. The administrator stated when R2 and R3 returned to the facility, there was a second confrontation and fight between R1, R2, and R3. The administrator stated R1 and R3 were roommates, and R3 was moved to a different room. The facility had contacted her on 4/27/22, about the encounter, but she was told it was a verbal confrontation. The administrator stated the next day she found out it was a physical altercation. The administrator stated R1 told her he couldn't move his fingers and had pain, so R1 was sent to the hospital. The facility abuse policy titled Abuse Investigation updated on 9/4/20, identified abuse as abuse, neglect, mistreatment, exploitation, or injury of unknown source. The facility implemented corrective action to prevent recurrence by 4/29/22, when the facility implemented a systemic plan that included the following actions: R1, R2, and R3 were all interviewed on 4/28/22, staff interviews were conducted on 4/28/22, resident interviews were conducted on 4/28/22, staff education was completed for the majority of staff on 4/28/22, and 4/29/22 ,and ongoing until all staff have been educated. R1, R2, and R3 were put on 15 minute checks immediately after the incident on 4/27/22, through 4/28/22. R3 was moved to another room, Associated Clinic of Psychology (ACP) was contacted and completed a follow up visit with R1. R1 was sent to the hospital for his injuries, NP-A was notified of the incident, and behavior contracts were signed by R1, R2, and R3 on 4/29/22.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R2) reviewed for diabetic management were provided adequate care in accordance with current standards of practice and facility standing orders. This practice included lack of monitoring of low diabetic blood glucose (sugar) readings and interventions. This resulted in actual harm for R2 when he was found unresponsive due to low blood glucose and required emergency medical care at the hospital. Additionally, based on observation, interview and document review, the facility failed to implement interventions including completion of dressing changes as ordered with the administration order of Eucerin cream for 1 of 3 residents (R5) with non-pressure related wounds Findings include: R2's facility Admission Record, dated 10/14/21, indicated R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition, exhibited no behaviors or rejection of care, and received insulin injections. R2's MDS further indicated R2 required supervision for eating and drinking during meals. R2's care plan revised 5/2/22, indicated R2 had IDDM and directed staff to monitor and document side effects and effectiveness of medications. Additionally, R2's care plan lacked interventions to reduce the risk for hypoglycemic (low blood sugar related) events, monitor for signs and symptoms [CONDITION(S)] (low blood sugar) which included slurred speech, loss of consciousness, confusion, increased lethargy, sweating, increased thirst and urination after R2 was sent to the emergency department on 3/3/22 following an episode of blood sugars becoming dagerously low. During interview on 5/4/22, at 12:06 p.m. R2 stated the staff at the facility had a difficult time managing his blood sugars from going to low and giving insulin as ordered. R2 further stated he recently required emergency medical services for the provision of emergency [CONDITION(S)] care, was subsequently sent to the emergency room and received emergency treatment several times since admission to the facility for low blood glucose and going into a diabetic coma. He further stated his meals vary when they are delivered to the room anywhere from 7:30 a.m. to 8:30 a.m. R2 stated no staff had followed up with him on his episodes of [CONDITION(S)] or developed a plan to help monitor for low blood sugars. R2 further stated he was aware when his blood sugars were low and attempted to notify the staff, but staff would take too long to respond. R2 stated he was tired of going to the hospital for his low blood sugars and it could be avoided if staff would monitor or provide better diabetes management. R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medication order dated 3/1/22, directed staff to give [MEDICATION(S)] (insulin) 100 unit/milliliter (ml) pen, inject 10 units subcutaneously (injection given under the skin) three times a day before meals. R2's Order Summary, dated 5/3/22, indicated R2 was ordered: - on 10/18/21, consistent carbohydrate (mild diabetic) diet. - on 4/26/22, check blood sugar before meals. - on 3/8/22, Basglar KwikPen (diabetes management medication) 100 unit/ml inject 48 units subcutaneously at bedtime. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Insulin [MEDICATION(S)] (long acting insulin) 48 units subcutaneously at bedtime for diabetes and was given on 3/1/22, 3/2/22, and 3/3/22 at bedtime. - Boost Glucose Control twice a day was to start on 3/26/22. R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - Administer insulin with meals and indicated, if you do not see the meal do not administer the insulin for risk for [CONDITION(S)]. - Check blood glucose three times a day, only check prior to meals, and as needed if R2 became symptomatic. - Continue correction scale of 1:50 greater than 150 (one unit per 50 for a blood sugar of 150) every shift for diabetes. - [MEDICATION(S)] Solution, (Insulin [MEDICATION(S)]) inject 10 unit subcutaneously three times a day for diabetes. Give base dose 10 units if pre-meal blood sugar is greater than 70. - [MEDICATION(S)] Solution injection at sliding scale subcutaneously (injection under the skin) before meals for DM and continue correction scale of 1:50 greater than 150 started on 3/3/22. - 70-150 give 10 units - 151-200 give 11 units - 201-250 give 12 units - 251-300 give 13 units - 301-350 give 14 units - 351-999 give 15 units - 351 and over give 13 units Review of R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's nurse PN dated 3/3/22, at 12:12 p.m. indicated R2 was sent to hospital after being unresponsive. R2's nurse PN dated 3/3/22, at 1:22 p.m. indicated R2 was found around 10:45 a.m. unresponsive with a blood sugar of 45 and R2's nurse gave [MEDICATION(S)] injection and called 911. R2's nurse PN, dated 3/3/22, at 5:14 p.m. indicated Resident BG check before breakfast was 344 around 8 am. As per orders this resident was given 14 units. Resident was given breakfast (scrambled eggs,oatmeal, milk and one piece of toast). Writer returned to check on the resident at 1045 AM and found him not responding. Resident was checked 45 minutes later BS was 45. Immediately help was requested, another nurse who gave [MEDICATION(S)] injection immediately. Writer noticed that the resident didn't eat any food item on his tray. After about 15 minutes the BG level was 103. Paramedics arrived checked his BP 156/105, P99 and he was taken for evaluation. Hospital called that he will be back today. Progress note did not include interventions or assessments were done between insulin administration and R2's unresponsiveness episode at 10:45 a.m. and the blood sugar check 45 minutes later. R2's hospital Discharge Summary (DS), dated 3/3/22, indicated on emergency medical services arrival (EMS) to the facility R2's blood sugar was 62 and EMS administered D10 ( dextrose - emergency low blood surgar medication) 10 grams and R2 became more responsive enroute to the emergency department (ED). R2's DS indicated he was brought to the ED by EMS related to being hypoglycemic after administration of insulin. R2's DS further indicated R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Following hospitalization the following new sliding scale insulin orders were started: - [MEDICATION(S)] Solution (Insulin [MEDICATION(S)]) Inject as per sliding scale subcutaneously (injection under the skin) before meals for DM start date 3/8/22 indicated, if 151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units If greater than 400 units, give 10 units and call TCP R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's blood sugar reading at 11:00 a.m. indicated his blood sugar was 37. R2's nurse PN dated 4/1/22, at 11:59 a.m. indicated Residents BS at 11 am is 37 mg/dl. Pt appears unresponsive, diaphoresis noticed and skin is clammy to touch. Nurse administered glucogon and alerted paramedics at 11:15 a.m. of Pt's current state. Resident's BS level at 11:15 a.m. is 49 mg/dl. Paramedics arrived at facility at 11:25 a.m. and attempted resuscitating resident via the use of IV [MEDICATION(S)]. Resdient [sic] became responsive and was transported to the hospital via paramedics. Nursing alerted NP about patient's status. Will continue to monitor. R2's nurse PN dated 4/1/22, at 12:31 p.m. indicated R2 was returned to the facility without hospital admission on 4/1/22, after paramedics resuscitated R2 using glucogon. R2's provider PN dated 4/1/22, indicated R2 was unconscious on 4/1/22 due to a low blood sugar of 37 from not eating enough for breakfast after insulin was administered. R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's nurse PN dated 4/4/22, at 2:49 p.m. indicated Resident's finger stick glucose level at 11 am was 37 mg/dl. Resident had symptoms like tremors, cold clammy skin, diaphoresis, increased heart rate and respiratory rate and resident was not alert. Paramedics were notified and arrived at 11:25 a.m. IV dextrose was administered. Writer updated NP about the incident. Resident was later educated about safety measured, importance of eating regular meals and snacks, causes of [CONDITION(S)] and importance of maintaining a normal blood glucose level. Nursing will continue to monitor. R2's provider PN dated 4/8/22, indicated R2 was seen by nurse practitioner (NP) by request of staff for review of multiple orders for R2's blood sugar management. R2's PN indicated R2 had two episodes in the last week of unresponsiveness due to low blood sugars. During interview on 5/2/22, at 8:18 a.m. family member (FM)-A stated she had concerns regarding the care provided by facility of the diabetes management of R2. FM-A further stated R2 had multiple hospital and emergency room visits due to [CONDITION(S)] which could be avoided with proper management of insulin, meals, education, and follow up assessment to ensure R2 was eating his meals. During interview on 5/3/22, at 11:45 a.m. family member (FM)-A stated R2 had been sent to the emergency room two to three times related to going into a diabetic coma and [CONDITION(S)]. FM-A further stated the staff would administer R2 insulin, and not follow-up to make sure he had eaten, or he had side symptoms of [CONDITION(S)]. FM-A stated she was concerned for R2 and the frequent hypoglycemic events. During interview on 5/3/22, at 9:20 a.m. LPN-B when asked about the incident on 3/3/22, responded what did my progress note state, that is what I did. LPN-B further stated, I gave the medications when I documented. LPN-B further stated he got busy with providing blood sugar checks for other residents, and did not provide an explanation why there were no interventions for 45 minutes following first finding R2's unresponsiveness episode on 3/3/22 at 10:45 a.m During interview on 5/2/22, at 3:00 p.m. nurse practititioner (NP)-B stated R2 had bottomed out twice. NP stated she was not aware R2 was not assessed by nursing staff for his blood sugar at 10:45 a.m. on 3/3/22, when he was first found unresponsive. During interview on 5/3/22, at 10:06 a.m. nurse practitioner (NP)-A stated R2 is a type one diabetic with history of [CONDITION(S)], and R2's insulin should be administered within 15 minutes before or 15 minutes after a meal. NP-A further stated she was also concerned regarding R2 was observed unresponsive at 10:45 a.m. and was not checked on again until 45 minutes later, when R2's blood sugar was taken. NP-A stated she expected staff to check R2's blood sugar at 10:45 a.m., administer [MEDICATION(S)], and continue to check a blood sugar every 15 minutes until R2's blood sugar was up to 80 or higher. During interview on 5/3/22, at 12:30 consulting pharmacist (CP) stated [MEDICATION(S)] is a rapid acting insulin and becomes active within the bloodstream as soon as 15 minutes and peaks in one hour. CP stated nursing staff should have assessed and treated R2 for [CONDITION(S)] when he was first found not responding and had a full uneaten meal tray on 3/3/22, at 10:45 a.m. and should not of waited. Additionally, CP stated nursing staff need education on diabetes management, monitoring a resident who is diabetic and receives insulin, monitoring intake, blood sugars, and when to use [MEDICATION(S)]. During interview on 5/2/22, at 3:15 p.m. acting director of nursing (DON) verified R2's blood sugar was 344 when checked on 3/3/22, 6:58 a.m. and R2 was given his scheduled 10 units of [MEDICATION(S)]. DON further stated R2 was given 14 units of [MEDICATION(S)] for his sliding scale insulin at 7:03 a.m. Additionally, DON stated R2 was sent to the emergency roiagnom on [DATE], when he was found unresponsive with a blood sugar of 45. DON stated R2 had multiple hypoglycemic events since the beginning of this year which required treatment. DON further stated the nurse should have assessed and treated R2 on 3/3/22 at 10:45 a.m. when R2 was found unresponsive and not waited to recheck R2 45 minutes later. DON stated all staff need education on diabetes, insulin, and diabetes management. During interview on 5/3/22, at 1:58 p.m. acting DON stated he had provided education to nursing staff on [CONDITION(S)], where to locate the [MEDICATION(S)] and when to administer. DON further stated he provided the education because of the incident with R2 who had a hypoglycemic event and nursing staff were not aware of where to find the [MEDICATION(S)] which delayed the administration. A facility policy titled Management of [CONDITION(S)], dated 9/30/21, indicated symptoms of [CONDITION(S)] included weakness, restlessness, [CONDITION(S)], excessive perspiration, irritability, blurred vision, headaches, unconsciousness, or coma. Level three [CONDITION(S)] was classified when altered mental and or physical status required assistance for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy directed staff if a resident had a level three [CONDITION(S)] and is unresponsive, to call 911, administer [MEDICATION(S)], notify the provider immediately, remain with the resident, place resident in a comfortable and safe position and monitor vital signs. R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the MDS identified R5 had moisture associated skin damage and required staff to provide application of nonsurgical dressings and ointments. R5's MDS lacked indication R5 had behaviors of refusing cares. R5's care plan, revised date 3/14/22, identified R5 had skin alteration, a fluid filled blister on his right lower leg and fluid leakage from both legs. R5's care plan directed staff to administer treatments as ordered and monitor for effectiveness. R5's Wound Evaluation and Management Summary dated 4/26/22, indicated R5 had four wounds which incorporated his right and left lower extremity and recommended for R5 to elevate his legs and wound care to be completed daily. R5's dressing treatment plan included applying Eucerin cream to intact skin, cover lower legs with xeroform gauze, absorbant pad, and wrap with secondary gauze dressings. - Site one was described as a full thickness lymphedemic (tissue swelling caused by an accumulation of protein-rich fluid) wound of the right distal anterior leg which measured 1 centimeter (cm) x 1 cm x 0.1 cm with serous exudate (clear, thin, watery fluid). - Site two was described as a full thickness lymphedemic wound of the right distal medial (lower inside) leg which measured 1 cm x 1 cm x 0.1 cm with light serosanguinous exudate (composed of red blood cells and serous fluid, known as blood serum), 50 percent slough (dead tissue), 50 percent granulation (healing) tissue, and a fluid filled blister. R5's wound was described as in an [CONDITION(S)] stage and unable to progress to a healing phase because of presence of a biofilm (can affect the healing). R5's wound was noted as unchanged and required surgical excisional debridement to establish viable tissue margins and remove necrotic tissue. - Site three was described as healed. - Site Four: lymphedemic wound of the left shin which was full thickness which measured 0.3 cm x 0.3 cm x 0.3 cm with light serosanguinous exudate, 50 percent slough and 50 percent granulation tissue. R5's wound was described as in an [CONDITION(S)] stage and was unable to progress to a healing phase because of presence of a biofilm, had no change in healing status and required surgical excisional debridement to remove necrotic tissue and establish the margins viable tissue. R5's treatment administration record (TAR) dated 5/22, indicated R5's daily wound care orders for the right distal and anterior leg, left calf and shin included: - Cleanse wounds with normal saline. - Apply Eucerin cream to intact skin on lower legs. - Apply xeroform gauze over lower legs, cover with absorbent dressing and wrap in gauze. On 5/2/22, at 11:30 p.m. R5 stated each nurse would complete the wound care differently or not at all. He further stated, some staff will not use all the supplies or apply the cream to my legs, and the wound care is not consistent. R5 stated his bandages fall off after a few hours and the nurses do not reapply them. He stated he had significant swelling in his legs and his legs would leak fluid out of them causing further skin irritation. During observation on 5/2/22, at 12:46 p.m. R5 was observed with no bandages on his lower extremities. R5's bilateral lower extremities from the knees down to toes were edematous, found to have areas of a thick build-up of skin scaling in areas, and slight red color to his lower legs. Additionally, R5's was found to have wounds located on his right anterior lower leg, right distal lower leg and at R5's left shin. During wound care registered nurse (RN)-B sprayed each leg with a wound cleanser and patted tehm dry. RN-B proceeded with applying xeroform directly onto the skin covering the wounds and non-affected skin. RN-B then covered R5's lower extremities with highly absorbent dressings and wrapped them with a secondary dressing of gauze rolls. During observation of R5's wound care, RN-B did not apply the ordered Eucerin cream. During interview on 5/2/22, at 1:10 p.m. RN-B stated R5 had wounds on both of his lower legs which required daily wound care. RN-B did not respond when asked why he did not apply Eucerin cream to R5's legs prior to application of the xeroform gauze as directed by the R5's physician orders During interview on 5/3/22, at 2:30 p.m. acting director of nursing (DON) stated his expectation for nursing staff would be to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Acting DON further stated if RN-B did not apply the Eucerin cream as ordered, he did not follow the wound care as ordered. A facility policy on wound care was requested but was not provided.

Based on observation, interview, and document review, the facility failed to ensure a do-no-resuscitate (DNR) order was accurately reflected throughout the medical record for 1 of 2 residents (R41) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R41 who would had received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], at 3:30 p.m. when R1's Provider Orders for Life-Sustaining Treatment (POLST) identified R41 had an active do-not-resuscitate order, however, the electronic health record (EHR) indicated R41's was to be administered CPR. The administrator was notified of the IJ at 3:30 p.m. on [DATE]. The IJ was removed on [DATE], at 10:56 a.m. but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R41's Admission Record printed [DATE], indicated R41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's significant change Minimum Data Set (MDS) dated [DATE], indicated R41 was cognitively intact. R41's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's care plan dated [DATE], indicated R41 was Full Code, with a goal of Resident's Advanced Directives will be honored. Staff were directed to review R41's code status on a quarterly basis and as needed. R41's POLST signed by and R41 and the medical provider on [DATE], indicated DNR. R41's Care Conference Summary 1 - V2 dated [DATE] and [DATE], indicated R41's code status was Full Code. R41's Social Service Note dated [DATE], at 3:43 p.m. identified R41's code status was Full Code. During interview on [DATE], at 2:15 p.m. registered nurse (RN)-A stated both the EHR and paper chart would be reviewed (in the event a resident did not have a pulse or respirations). If the information did not match CPR would be initiated. During interview on [DATE], at 2:17 p.m. licensed practical nurse (LPN)-A stated in the event of [CONDITION(S)], both the EHR and paper chart would be reviewed. If a discrepancy existed CPR would be initiated. During interview on [DATE], at 2:18 p.m. LPN-B stated in the event of [CONDITION(S)], both the EHR and paper chart would be reviewed. If a discrepancy existed CPR would be initiated. R41's EHR banner observed on [DATE], at 4:10 p.m. indicated R41 was Full Code; athough R41's POLST identiifed DNR. During interview on [DATE] at 4:13 p.m. R41 confirmed his code status was DNR and he had signed the appropriate forms. During interview on [DATE], at 4:14 p.m. RN-B stated he reviewed the both EHR banner and the signed POLST in the paper chart to determine whether to provide CPR. If there was a discrepancy, he would initiate CPR. RN-B confirmed R41's EHR banner indicated Full Code and R41's POLST indicated DNR. RN-B stated the electronic documentation should have been changed when R41's new POLST was completed, or staff would perform CPR on him when he did not want it. During interview on [DATE], at 4:39 p.m. director of nursing (DON) verified the EHR indicated R41 was identified as Full Code, however, the signed POLST in the paper chart indicated R41 was DNR. The DON stated the discrepancy existed for approximately three months and he would have treated R41 as a Full Code. He re-affirmed if there was any doubt he would save the life. During interview on [DATE], at 8:51 a.m. director of social services (DSS) stated if a resident wanted to change a POLST she would meet with the provider, a nurse, and the resident (or resident representative), fill out the POLST, and have the resident (or representative) sign it. Once completed she gave a copy to the resident and placed the document in the paper chart. She communicated any changes in code status verbally at a daily team meeting, and a nurse or a social worker changed the care plan. She did not change the banner or the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If she noticed a conflict, she would check with the nurse manager, but expected staff would proceed with a Full Code. During interview on [DATE], at 9:14 a.m. social worker (SW)-A stated she typically was not involved in the POLST process, however, recalled reviewing the POLST with R41 and, after he signed it, she gave it to the DON. She stated if the code status in the paper chart and the EHR didn't match she anticipated staff would have performed CPR because of the lack of clarity, but it would have been against R41's wishes. During interview on [DATE], at 10:25 a.m. administrator stated when the POLST was completed the order should have been changed in the EHR and the banner updated. He stated he did not know why R41's code status was not updated in the EHR, but when the physician placed the order, it should had been changed. During interview on [DATE], at 11:49 a.m. physician (MD)-A stated code status must be addressed at each resident admission and re-admission, and he expected any change in status to be accurately communicated with staff. He stated the POLST must reflect the resident's choice, and staff must respect the resident's decision. He stated once a POLST was signed by the resident and the physician he gave it to the facility staff to put into the chart, and he considered the POLST a physician order. His expected staff to follow the orders on the paper copy of the POLST to ensure resident's wishes were respected. During interview on [DATE], at 1:38 p.m. R41 stated he changed his code status a few months ago after a visit with the provider, and the social worker at the time had him sign a form. He verified his understanding of DNR versus Full Code by stating DNR meant if your heart stops, they make no attempt to get it going again, and full code is when they do what they can to get you going. He further stated he changed his code status because he didn't want to have any chance of being brain damaged. The facility Advance Directives policy updated [DATE], indicated resident's code status would be obtained either verbally from the resident, hospital medical record or resident advanced directive documents. This information would be entered into the Electronic Medical Record for physician review and signature. Social Services reviews and updates the Advance Directives upon readmission and as needed but at least quarterly in conjunction with the plan of care. POLST information would be added to all resident charts upon admission. The policy Emergency Procedure - Cardiopulmonary Resuscitation revised ,d+[DATE], identified if the resident's DNR status was unclear, CPR would be initiated until it was determined that there was a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The IJ was removed on [DATE], at 10:56 a.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review. - All residents records were reviewed to ensure the electronic banner, physician orders, and advance directive care plans reflected the most current POLST and orders on [DATE]. - Seven LPNs and five RNs were educated on POLST completion, order entry and facility policy on [DATE], as evidenced by the Education Sign In Sheet. - A process was implemented to ensure all other nurses completed mandatory education prior to the start of their next shift on [DATE], which included notification of required mandatory education via signage at the time clock and via phone/text. - On [DATE], LPN-A, LPN-B, DON, and DSS were interviewed and verified they received education regarding POLST completion, order entry, and policy. - The policy for advanced directives was reviewed and updated to include the POLST will be reviewed upon admit, quarterly, and with change in condition by the IDT (interdisciplinary team) and matched against the medical record for accuracy.

Based on observation, interview, an document review, the facility failed to comprehensively assess/reassess a newly identified wound and implement antibiotic therapy as ordered by the physician for 1 of 1 resident (R28) reviewed for hospitalization s. This resulted in actual harm for R28 who was hospitalized for worsening [CONDITION(S)] and required intravenous (IV) antibiotics. Findings include: R28's Admission Record printed 2/10/22, indicated R28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's significant change Minimum Data Set (MDS) dated [DATE], indicated R28 was moderately cognitively impaired, independent with transfers, and required extensive assistance of one staff with dressing and personal hygiene. The MDS indicated R28 did not have a history of refusing cares. R28's care plan dated 2/4/22, indicated he had the potential for impaired skin integrity. A Weekly Skin Check dated 12/29/21, lacked any indication of open areas on R28's skin. Subsequently, the electronic health record (EHR) lacked documentation of R28's Weekly Skin Check which was scheduled for 1/6/22. Review of R28's Progress Notes included the following: - 1/13/22, at 1:01 a.m. R28, sent himself to the hospital at 8:00 p.m. on 1/12/22 to request pain medication. - 1/13/22, at 2:43 a.m. licensed practical nurse (LPN)-F documented R28 returned from the hospital with an antibiotic order. Corresponding Hospital Discharge Instructions dated 1/12/22, at 11:02 p.m. directed R28 to take [MEDICATION(S)] ([MEDICATION(S)]; an antibiotic) 500 milligrams (mg) tablet, 1 tablet by mouth 2 times daily for 10 days for a toe infection on his right foot. Further, R28 was to seek medical care if his pain or swelling for the infection did not improve within 2 days. R28's Weekly Skin Check dated 1/13/22, identified R28 had intact skin, no open areas, and no new skin concerns despite previously being diagnosed with a toe infection on 1/13/22. R28's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were instructed to clean the wound with wound cleanser, apply an absorbent dressing, and change the dressing twice daily. The orders also indicated R28 was prescribed [MEDICATION(S)] 500 mg by mouth twice daily for 10 days starting on 1/18/22, at 8:00 p.m. for the toe infection. Review of R28's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent review of R28's Progress Notes revealed: - 1/18/22, 8:10 p.m. the pharmacy could not deliver today ([MEDICATION(S)]) for billing reasons. Medication was coming tomorrow and the doses would be rescheduled. - 1/19/22, at 8:32 a.m. and 7:50 p.m. indicated [MEDICATION(S)] was not available. - 1/20/22, at 11:18 a.m. R28 was transferred to the hospital. - 1/20/22, at 1:34 p.m. the facility received a call from the hospital and was informed R28 was admitted for [CONDITION(S)] of the right leg. - 1/21/22, at 9:40 a.m. R28 remained in the hospital and received IV antibiotics. - 1/22/22, at 9:37 p.m. R28 was readmitted to the facility. R28's medical record lacked indication R28's physician was notified [MEDICATION(S)] was not administered as ordered. A Hospital Interagency Transfer Form dated 1/22/22, indicated R28 was prescribed [MEDICATION(S)] for outpatient antibiotic therapy to treat an ulcer on his right second toe during a previous visit on 1/12/22, and had recently failed outpatient antibiotic therapy. During admission on 1/20/22, R28 was found to have an ulcer over his right second toe with discharging puss, swelling, and redness which extended up his right ankle. R28's electronic health record (EHR) lacked documentation of R28's wound from 1/13/21 (when R28 initially returned from the hospital) until 1/30/22 when a Weekly Skin Check identified R28 had an open area to his right second toe. The Weekly Skin Check lacked measurements and wound characteristics. Subsequently, a Weekly Skin Check dated 2/5/22, identified R28's right toe continued to be slightly red and swollen with an open area which measured 0.5 centimeters (cm) by 0.7 cm, however, additional wound characteristics were not documented. During interview on 2/7/22, at 1:04 p.m. R28 stated he was in the hospital two to three weeks ago for a sore on his foot due to an ill-fitting shoe. He stated he had a little nick on his right second toe which kept getting bigger. The swelling increased to four inches above his ankle. R28 stated he was placed on IV antibiotics at the hospital and was observed to be wearing a walking boot on his right foot. During an observation on 2/10/22, at 10:40 a.m. R28's right second toe was red, swollen, had had multiple shallow scabs with flaky skin over the top surface. During interview on 2/10/22, at 10:45 a.m. registered nurse (RN)-A stated skin checks were completed weekly with showers and all skin issues were documented. He stated staff may not have documented R28's wound because he had orders for it to be cleaned and only new skin concerns were documented during weekly skin checks. If a new wound was found, staff completed a risk management form, assessed the wound, and reported it to the nurse practitioner (NP). The NP then assessed the wound or referred the resident to the wound nurse. Whenever staff completed a dressing change drainage and wound characteristics should be documented. He stated it was important to document skin assessments to show the progress of each wound and whether interventions were successful or if additional interventions were required. During interview on 2/10/22, at 12:43 p.m. the director of nursing (DON) stated R28 went to the hospital on 1/12/22, for a toe issue and returned very early in the morning on 1/13/22. He stated there was a breakdown upon R28's return (1/13/22) and the nurse should had faxed R28's antibiotic order to the pharmacy and the medication would had arrived to the facility within the day. Due to the lapse R28 did not receive his medication. The DON confirmed the facility did not administer any antibiotics from 1/13/22, through R28's hospital admission on 1/20/22. The DON stated the antibiotic would had been helpful to stop the progression of the infectious process. Further, nurses should had evaluated the wound when doing dressing changes and he expected to see wound assessment documentation to follow the wound progression. The DON verified R28's medical record lacked wound documentation. During an interview on 2/10/22, at 3:23 p.m. nurse practitioner (NP)-C reviewed R28's EHR and stated the facility called the nurse line on 1/18/22, to request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The on-call provider instructed the facility to check on R28's antibiotic order from the emergency department on 1/12/22. The facility stated they were unable to locate R28's antibiotic order. The on-call provider then gave the facility another order for [MEDICATION(S)] and wound treatment. She stated the expectation was for the facility to assess a wound and update the provider and it was unacceptable not to do so. NP-C also stated she was not informed R28's antibiotic was not started on 1/18/22 (second order provided) and the hospitalization could had been avoided had R28 not gone eight days without being administered the antibiotic. During an interview on 2/10/22, at 4:21 p.m. the administrator agree had R28 received the prescribed antibiotic, as ordered, on 1/12/22, he likely would had avoided hospitalization . On 2/10/22, at 9.32 a.m. and 12:29 p.m. a telephone interview with LPN-F, who documented receiving the antibiotic order on 1/13/22, was attempted and message left. No return call was received. Facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/18, indicated the nurse shall described and document/report a full assessment of pressure sores including location, stage, length, width, and depth, presence of exudates (drainage), or necrotic tissue.

Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) guidelines were followed to prevent or minimize the transmission of COVID-19 for 1 of 5 residents (R4) who were placed on quarantine, though not enforced, following exposure to a COVID-19 positive roommate. This had the potential to affect 54 of 59 residents who had the potential to be exposed to R4 while accessing the communal areas of the facilities. The IJ began on [DATE], at 5:42 a.m. licensed practical nurse (LPN)-A wrote a progress note that she observed R4 in the hallway of the facility. LPN-A explained to R4 that she was on quarantine and should be in her room due to exposure to COVID-19 from a positive roommate. The progress note read; R4 told the nurse she was not going to stay in her room. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:57 p.m. The IJ was removed on [DATE], at 10:23 a.m. but remained at a lower scope and severity of F, no actual harm with potential for more than minimal harm that is not immediate jeopardy, widespread. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], noted R4 had intact cognition and was independent with most activities of daily living (ADL's). R4's face sheet accessed on [DATE], noted R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility provided a listing of COVID-19 positive residents during routine testing on [DATE]. During review of the infection control binder provided by the infection control preventionist, it was revealed the facility had been in outbreak status since [DATE], with a total of four positive staff members and 15 positive residents and one COVID-19 related death on [DATE], due to exposure to a positive roommate. The facility documented that R4 refused the COVID-19 vaccination when offered under the immunization tab of R4's electronic health record (EHR). During continuous observation on [DATE], beginning at 9:13 a.m. R4 approached this surveyor in the south hall without a mask on. R4 was concerned about housekeeping cleaning her room. At 9:22 a.m. R4 was seen outside smoking with several other unmasked residents, the smoking aide assisted R4 to the smoking area. At 9:31 a.m. R4 was in the dining room near the smoking area exit, unmasked and was within 6 feet of other unmasked residents. At 9:36 a.m. R4 was again observed outside smoking with other unmasked residents. At 10:03 a.m. R4 was near the nursing station and continued to self-propel her wheelchair to the north hall and approached a staff member. At 10:08 a.m. R4 was unmasked and in the dining room pouring coffee near other unmasked residents. At 10:21 a.m. R4 was still unmasked and in the dining room near the exit to the smoking area among other unmasked residents. At 10:24 a.m. the smoking aide placed a smoking apron on R4 and she went back outside to smoke. At 10:34 a.m. R4 re-entered the dining room, unmasked and within six feet of other unmasked residents. When interviewed on [DATE], at 9:23 a.m. trained medication aide (TMA)-A stated she was unsure if quarantine residents had to remain in their room or if they are limited to certain areas of the facility. When interviewed on [DATE] at 9:41 a.m. licensed practical nurse (LPN)-A stated a resident on quarantine should be observed for symptoms, they should limit their interaction with other residents however, they cannot stop the resident from going out to smoke when they want to. When interviewed on [DATE], at 10:45 a.m. nursing assistant (NA)-A stated if a resident is on quarantine they should remain in their room. NA-A further stated she was not aware of any residents on quarantine. When interviewed on [DATE], at 11:17 a.m. the infection preventionist (IP) stated R4 was put on quarantine status the evening of [DATE], after her roommate tested positive for COVID-19. Further, the IP stated residents that are on quarantine are required to stay in their rooms and if they are non-compliant with staying in their rooms, the interdisciplinary team will meet to come up with a solution. The IP stated R4 was not compliant with quarantining in her room, but there had not been an interdisciplinary meeting and one had not been scheduled at that time. When interviewed on [DATE], at 11:17 a.m. the infection preventionist (IP) stated she was made aware of R4's roommate testing positive on the evening of [DATE]. The IP stated she then called the facility and notified staff that R4's roommate tested positive for COVID-19 and was moved to the COVID-19 isolation wing in the facility and that R4 should be placed on quarantine. When interviewed on [DATE], at 11:31 a.m. the acting administrator (AA) stated there were designated smoking times for residents that are on quarantine. The AA further stated they currently don't have any quarantined residents that go out to smoke. On [DATE], at 12:18 p.m. social services (SS)-A and the IP stated they conducted a meeting and have developed interventions for keeping R4 in her room during her quarantine. When interviewed on [DATE], at 2:01 p.m. an activities assistant (AA)-A stated R4 disliked wearing masks and would tell staff she would put mask on when she was damn good and ready. Resident refused interview on [DATE], at 2:06 p.m. When interviewed on [DATE], at 2:18 p.m. the director of nursing (DON) stated quarantine residents must be in their rooms. The DON further stated she was unaware R4 was out of her room, self-propelling her wheelchair throughout the facility unmasked. The DON stated that should not have happened. When interviewed on [DATE], at 3:58 p.m. the IC nurse stated R4 refused to be tested during the facility wide outbreak testing on [DATE]. Further, the IC was not sure the last time R4 agreed to testing and referred to a three-ring binder for the information. On [DATE], at 1:30 p.m. during the first attempted removal visit R4 was observed wearing a mask and was being wheeled down the hallway by the activities assistant (AA), they went past the nursing station and as they went past the employee break room, R4 asked AA to stop outside the employee breakroom. R4 then removed her mask and was observed talking to the staff who sat in the room. AA then redirected R4 to leave the mask on. R4 re-applied the mask and AA then wheeled R4 through the dining room to the entrance of the smoking area where R4 joined other residents in the smoking area. -At 1:35 p.m. to 1:37 p.m. R4 was observed being assisted from the smoking area by staff and back into the dining room. At 1:38 p.m. R4 was observed return into the building from the smoking area and as she went past the door threshold AA cued her to wear her mask. At 1:40 p.m. R4 asked AA for a cup of coffee to drink in the dining room. -At 1:41 p.m. AA approached R4 with a cup with coffee and was overheard telling R4 she was supposed to always have the mask on when out of the room except when eating, drinking or smoking. At 1:43 p.m. to 1:49 p.m. R4 was observed drinking coffee in the dining room. At 1:50 p.m. R4 was observed go over to the door again asked to go outside to smoke. As she approached the table with smoking supplies R4 was assisted by the staff to the smoking area however she did not have a mask on as she went past two residents who sat and stood by the door. At 1:57 p.m. R4 returned to the dining room and sat at the table by the wall as she continued to drink the coffee and not wearing a mask. At this same time AA and kitchen staff was observed setting up the dining room for the resident Christmas party and residents were independently coming into the dining room and being seated. At 2:06 p.m. to 2:29 p.m. R4 remained at the table seated not drinking or eating and was not wearing a mask. At 2:11 p.m. the DON came into the dining room and stood by R4 but never redirected R4 to go back to her room or wear a mask. -At 2:13 p.m. the DON re-directed R4 to wear the mask and R4 asked how about the test results. R4 then asked the DON to stop standing by her and still did not put the mask on. The DON continued to stand by R4 and at this time the dining room had 15 residents seated waiting to be served food. At 2:29 p.m. as AA brought R4 food to eat in the dining room, the surveyor intervened, and the DON stated R4 was not supposed to be in the dining room because she was supposed to be quarantined in her room due to the exposure. The DON stated R4 was supposed to have been brought back to the room after smoking but AA was assisting with the Christmas party. -At 2:31 p.m. DON wheeled R4 out of the dining room down the hallway to her room. During interview on [DATE], at 2:39 p.m. the activities assistant stated she did not know that R4 was not supposed to participate in communal activities. The activities assistant stated she thought if R4 had her mask on and maintained 6 feet this was appropriate. AA stated she had told R4 if she was not eating and drinking, she was supposed to have her mask on and she did not know why other staff did not re-direct R4 to put the mask on as she was busy assisting with the activity. During interview on [DATE], at 3:04 p.m. the DON stated the facility was going to revised the training for the staff to include -unvaccinated residents can only go to smoke then back into their rooms and she of the infection control nurse would communicate to the staff the vaccination status of a residents when this situations came up and this would be implemented immediately in IJ the removal staff training. An undated facility policy titled, COVID-19 Outbreak and Routine Testing Procedure was provided. The policy noted residents that refuse testing during an outbreak should be placed on transmission-based precautions (TBP) until the criteria for discontinuing the TBP have been met. Further, for these residents additional monitoring is necessary to ensure the resident maintains appropriate distancing, wears a face covering and practices hand hygiene. Additionally, the policy noted unvaccinated residents should generally be restricted to their rooms and not participate in group activities. The CDC guidance for unvaccinated residents reads; unvaccinated residents that have close contact with someone with the [CONDITION(S)] CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. The IJ was removed on [DATE], at 10:23 a.m. when it could be verified by observation, interview, and record review that the facility took steps to educate staff on the process for vaccinated and unvaccinated residents on quarantine and additional procedures were implemented to direct quarantined residents to remain in their room or to other isolated areas of the facility.

Based on observation, interview, and document review, the facility failed to comprehensively reassess and implement interventions as ordered by the physician to promote healing and reduce the risk of complications of an existing pressure ulcer for 1 of 3 residents (R28) reviewed for pressure ulcers. The resulted in actual harm for R28 who had a worsening stage IV pressure ulcer. Findings include: Pressure Ulcer Definition: Stage IV Tissue loss with exposed bone, tendon, or muscle. Slough or eschar (Dead tissue that is hard or soft in texture, usually black, brown, or tan in color, and may appear scab-like. Eschar tissue is usually firmly adherent to the base of and wound and often the sides/edges of the wound), may be present. It often includes undermining (outwardly visible wound margins) and tunneling (passageways underneath the surface of the skin). R28's Admission Record dated 12/2/21, indicated R28's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact and had no documented rejection of care. R28 was totally dependent of two staff with bed mobility, transfers, and toilet use. R28 had an impairment to both upper and lower extremities and was always incontinent of bowel. R28 had three documented stage IV pressure ulcers which were present upon admission. Several treatments were noted which included pressure reducing device for chair and bed. R28s Care Area Assessment (CAA) dated 5/7/21, indicated R28 was totally dependent of staff for bed mobility, dressing, toilet use, and personal hygiene. The CAA further indicated R28 required a total assist of two staff, with the use of hoyer lift to transfer Further, R28 required extensive assistance of two staff to turn and reposition in bed every two hours and as necessary. R28's care plan dated 9/19/21 indicated R28 had stage IV pressure ulcers on her sacrum right ischium (lower back part of the hip bone), and left ischium. The care plan further identified R28 had the potential to develop additional pressure ulcers related to incontinence, immobility, and weakness. R28's care plan included several interventions including to conduct weekly skin assessments and provide wound care per orders. R28's care plan was revised on 12/2/21, to include assisting R28 to sit up in tilt-in-space wheelchair with a pressure reducing cushion for mealtimes. R28 was not to exceed two hours of sitting to offload pressure. R28's Order Summary Report dated 12/2/21, indicated staff were to offload R28, per facility protocol, and maybe up in chair two hours per day and an additional one hour after a two-hour break in the morning and afternoon. Further, R28 was to be repositioned every two hours and have weekly skin checks completed every Tuesday morning. R28's wound care orders included: - Right/left ischium and sacrum wound care: Make sure all pieces of silver alginate (product used to promote wound healing) were removed from the wound bed. Saturate 4 x 4 gauze with Vashe (wound cleanser). The saturated gauze was then to be placed in R28's wound beds and undermining areas and allow to sit for five minutes. Remove (gauze) and place silver alginate. Place a foam boarder dressing in the morning. An Interdisciplinary team (IDT) progress note dated 12/1/21, at 7:17 p.m. indicated R28 was hospitalized from 10/1/21, to 10/20/21 due to severe [CONDITION(S)] secondary to a decubitus sacral wound abscess (collection of puss related to infection) and [CONDITION(S)]. Additionally, R28 was under observation in the hospital on 11/24/21, related to chest pain. R28's Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] - R28's stage IV sacral pressure wound measured 3.5 centimeters (cm.) x 3.0 cm. x 2.0 cm. with undermining of 5.0 cm. at the three o'clock position. The wound had 80 percent granulation (new tissue), 20 percent muscle and fascia (thin casing of connective tissue which holds muscle in-place), and moderate serous exudate (clear, thin, and watery fluid). R28's stage IV pressure wound to her left ischium measured 1.0 cm. x 1.0 cm. x 1.5 cm with abnormal granulation present within the wound margins. R28's stage IV pressure wound to her right ischium measured 0.8 cm. x 0.8 cm. x 1.0 cm with 100 percent granulation present. Recommendations included offloading the wound and repositioning per facility protocol. R28 may be up for two hours in their chair and one hour after a two-hour break. Review of R28's November 2021 Task Record, revealed no transferring/bed mobility was not documented for 46 of 87 opportunities. There were no documented refusals. Review of R28's December 2021 Task Record, revealed no transferring/bed mobility was not documented for 2 of 3 opportunities. There were no documented refusals. Review of R28's Weekly Skin Check Progress notes revealed: - 11/19/21, at 3:50 p.m. indicated R28 was on a turning and repositioning program and had a coccyx wound. The progress note lacked assessment of R28's wound. - No additional documentation was provided, when requested, for skin assessments on 11/1/21, 11/8/21, and 11/22/21. During a continuous observation conducted on 11/29/21, from 8:30 a.m. to 11:43 a.m. R28 was noted to be laying flat on her back, in bed, with a pillow to the right of her bed. R28's eyes were closed, and she was noted to be moaning and called out to staff for help. At 10:30 a.m., R28 was moaning, ouch. At 11:43 a.m., R28 called out for help and stated she had pain. At 11:44 a.m., licensed practical nurse (LPN)-C was approached and advised R28 had not been repositioned since the continuous observation began at 8:30 a.m. LPN-C stated she would notify a nursing assistant. Throughout the observation, no staff entered R28's room, nor responded to R28 who was calling out periodically. Three hours and 13 minutes had passed. During an observation on 11/29/21, at 10:25 a.m. LPN-B provided wound care to R28. R28 reported she had pain and noted facial grimacing when repositioned to her left side and throughout wound care. R28's dressing was noted to be completely saturated with bloody red drainage which also soaked through to R28's incontinence product and the sheet below her. Further, R28 was also observed to have four [NAME] electrocardiogram (EKG) electrodes on her back which were removed by LPN-B. LPN-B stated the [NAME] electrodes must had been on R28's back since her emergency department visit on 11/24/21. LPN-B removed the old dressing from the sacral, right, and left ischium pressure wounds. LPN-B then poured a small amount of Vashe solution on gauze and placed the gauze on R28's sacral and right and left ischium pressure wounds. The gauze was not completely saturated with Vashe solution. After roughly five minutes, the gauze was removed and LPN-B applied silver alginate to R28's sacral, right, and left ischium pressure wounds. The piece silver alginate was cut round and roughly 1.5 inches in diameter and did not cover the entire wound bed of the sacral wound. LPN-B then covered R28's wounds with a foam dressings. Immediately following the dressing change LPN-B stated she was not aware the gauze needed to be saturated with Vashe solution or the silver alginate dressing needed to cover the entire wound bed. During an interview on 11/30/21, at 12:45 p.m. the assistant director of nursing (ADON) stated she started a performance improvement plan for wound care and assessments as she discovered concerns regarding how wounds were being assessed, staff roles and responsibilities, and providing wound care as directed by the medical provider. The ADON stated R28 had not been assessed by a wound provider for a few weeks as she fell off the list to be evaluated after being transferred to the emergency department on 11/24/21. During an observation on 12/1/21, at 10:00 a.m. the director of nursing (DON) and assistant director of nursing provided wound care to R28's sacral and right and left ischium pressure wounds. The ADON assisted R28 to reposition to her left side and removed an incontinence product. The DON removed the dressings which had a large copious amount of yellow/brown non-odorous drainage with blood which soaked through the dressing. The DON cleansed the outside of the sacral pressure wound and applied Vashe soaked gauze to R28's wound beds for five minutes. The DON then removed the gauze and inserted silver alginate into R28's wounds. The silver alginate did not cover the entire wound bed where undermining was located. The DON then applied a foam dressing. During an interview on 12/1/21, at 1:45 p.m. the director of nursing (DON) stated when she observed R28's dressing change on 11/30/21, it appeared wound care was not completed as ordered. She confirmed the silver alginate dressing did not cover R28's entire wound bed, as directed, and fluid had saturated through R28's dressing and onto R28's incontinence product. The DON described the drainage as bloody discharge and stated R28's wound bed lacked granulation upon her wound assessment today which was noted on previous assessments. The DON confirmed R28's wound had worsened and included several reasons which included weekly skin checks not being completed, lack of timely repositioning, and no consistent wound care. The DON also stated R28 had stool on her incontinent product and sheet when wound care was completed on 11/30/21, and staff needed to ensure R28 was kept clean. Further, the DON stated staff were not reporting to the nurse when bandages became soiled and needed to be changed. During an observation on 12/2/21, at 12:00 p.m. MD-C, the ADON, and LPN-D provided wound care to R28. LPN-D assisted R28 reposition to her left side. R28 expressed pain to MD-C and had facial grimacing. The ADON removed R28's incontinence product and subsequently removed R28's old dressing located on the sacrum and right and left ischium pressure wounds. R28 had small amount of light brown colored stool noted on her incontinence product. Stool was also noted on R28's skin roughly three inches from the sacral wound. The ADON proceeded to cleanse the skin with wound cleanser. MD-C assessed R28's wounds and additional pieces of silver alginate were noted in the sacral wound. MD-C told the ADON and LPN-D to use a cotton tipped applicator to assess the wound and ensure all pieces of silver alginate were removed. MD-C inserted Vashe soaked gauze into R28's wound beds for five minutes. MD-C [NAME] removed the gauze and completely covered R28's pressure wounds with silver alginate. The wounds were then covered with a foam dressing. MD-C then stated to the ADON and LPN-D to ensure a full piece of alginate was used so it completed covered the entire wound bed to promote proper healing. MD-C also instructed staff to offload R28 completely. Immediately following the observation, MD-C was interviewed and stated R28's sacral wound had deteriorated from when she had assessed R28's wounds two weeks ago. R28's sacral pressure ulcer and measurements increased in length and the amount of tunneling. MD-C attributed worsening tunneling to not being fully repositioned or not being repositioned every two hours. MD-C stated the reasons for wound deterioration included: need to offload the wound, continuity of wound care, and incontinence care. MD-C stated during her visit today, R28 had stool in her incontinence product and staff left the stool on R28's skin when wound care was provided. MD-C stated she expected the facility to reposition R28 every two hours, provide R28 a wheelchair cushion, provide good incontinence care, and change dressings immediately if soiled. A subsequent Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] - R28's stage IV sacral pressure wound measured 3.5 cm. x 4.0 cm. x 1.5 cm. Moderate serous excaudate was noted with 10 percent slough (dead tissue) and 90 percent granulation. Further, the wound had undermining which measured 5.5 cm at the three o'clock position, 4.5 cm. at the nine o'clock position, and 7.5 cm. at the 12 o'clock position. R28's sacral wound had deteriorated since her last visit on 11/18/21. R28's wound was debrided of 1.4 cm. of devitalized tissue (non-viable) at a depth of 1.6 cm. Facility policy titled Pressure Injury Treatment (undated) directed to provide care of existing pressure injuries and the prevention of additional injuries. Staff were to review the residents care plan and assess for any special needs of the resident, pressure injury care, current support surfaces, and status of the injury.

Based on observation, interview, and document review, the facility failed to administer pain medication as ordered by the physician for 1 of 1 resident (R28) reviewed for pain. This resulted in actual harm for R28 who had verbal and physical signs of pain when extended-release narcotic pain medication was crushed and staff did not acknowledge or anticipate the need for pain intervention. Findings include: R28's Admission Record dated 12/2/21, indicated R28's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact and had scheduled pain medications, as needed pain medications, and non-medication interventions. The MDS further indicated pain limited R28's daily activities and she rated her pain at 8 out of 10 (0 to ten scale). R28's Care Area Assessment (CAA) dated 5/13/21, indicated R28 had pain related to [CONDITION(S)], cervical stenosis (narrowing of the spinal column) with chronic pain, [CONDITION(S)] (decreased blood flow to limbs), and [CONDITION(S)] (damage to the nerves which causes pain). The CAA further indicated R28 took opioids (narcotic pain medication) and staff were directed to administer medications as ordered. Pain impacted R28's ability to sleep at night and she experienced pain frequently. Staff were to administer pain medication 30 minutes prior to treatment and anticipate R28's need for pain relief. Additionally, staff were to respond immediately to complaints of pain and monitor for non-verbal signs of pain. R28 reported her pain was frequently 6 out of 10. R28's care plan dated 5/2/21, indicated R28 received pain medication related to her disease process. The care plan included several interventions and directed staff to administer analgesic medications, as ordered. Additionally, R28's care plan indicated R28 had chronic pain related to [CONDITION(S)], diabetic [CONDITION(S)] and directed staff to administer analgesia 30 minutes prior to treatments or cares and offer nonmedicinal forms of pain relief such as distraction, warm packs, cold packs, and gentle massage. A Physician's Progress Note dated 11/8/21, indicated R28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note also identified R28's chronic pain was related to cervical [CONDITION(S)] (compression of spinal cord), [CONDITION(S)], sacral pressure ulcer, upper extremity contracture and immobility. R28's Order Summary Report printed 12/2/21, at 8:57 a.m. indicated R28 had a tube feeding, was ordered a dysphasia (difficulty swallowing) mechanical soft diet with nectar thick liquids. Staff may have medications crushed with applesauce for easy swallowing. Review of R28's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Liquid 250 milligrams (mg) /5 milliliter (mL). Give 300 mg (6 mL) by mouth three times a day for neuropathic pain. The order was started on 11/15/21. - [MEDICATION(S)] Extended-Release (narcotic pain medication). Give 15 mg by mouth three times a day for chronic pain. - Acetaminophen (Tylenol) Solution 160mg/5mL. Give 650 mg via g-tube (tube feeding) every six hours as needed for pain. - [MEDICATION(S)] (steroid; reduces inflammation) 5 mg. Give one table via g-tube one time daily for pain. Further, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pain Management Progress Note dated 11/29/21, indicated R28 was frustrated with her pain and had pain all day. R28's reported pain in her buttock, leg, and had increased arm pain, which was described as sharp, achy, and sore. R28 received [MEDICATION(S)] and [MEDICATION(S)] for pain. Further, R28 should continue to work with physical and occupational therapy. R28's [MEDICATION(S)] extended release was increased to 15 mg three times a day. Staff was also to continue administering acetaminophen every six hours, as needed. Further, staff were to administer 6 mL of [MEDICATION(S)] 250 mg/5mL three times daily. During a continuous observation conducted on 11/29/21, from 8:30 a.m. to 11:43 a.m. R28 was noted to be lying flat on her back, in bed, with a pillow to the right of her bed. R28's eyes were closed, and she was noted to be moaning and called out to staff to help. At 10:30 a.m., R28 was moaning, ouch. At 11:43 a.m., R28 called out for help and stated she had pain. At 11:44 a.m., licensed practical nurse (LPN)-C was notified. Throughout the observation, no staff entered R28's room, nor responded to R28 who was calling out periodically. Three hours and 14 minutes had passed. LPN-C stated they would find a nursing assistant to assist R28. During an interview on 11/29/21, at 9:02 a.m. R28 stated she had a lot of pain and it seemed to never be under control. R28 verbalized she was so uncomfortable when staff moved her or provided cares. R28 reported her pain was 8 out of 10 and felt she would be able to manage if her pain was 3 out of 10. R28 stated she did not have a good quality of life because her pain was so bad. During an observation on 11/30/21, at 9:13 a.m. LPN-C crushed [MEDICATION(S)] extended release 15 mg tablet with a pill crusher and placed in a plastic medication cup. After crushing the medications, LPN-C entered R28's room and asked R28 if she had pain and R28 responded, Yes, I hurt all over. LPN-C proceeded to flush R28's G-tube and connected the syringe to the G-Tube to administer the medications. R28 stated to LPN-C, I hurt really bad. R28 had facial grimacing and was grunting. LPN-C proceeded to pour multiple medications together in a medication cup, added water in the medication cup, and dumped into the syringe. LPN-C finished medication administration and left the room. During observation LPN-C did not ask R28 to rate her pain or offer non-pharmacological methods of pain relief. During an interview on 11/30/21, at 9:20 a.m. LPN-C stated all of R28's medications could be crushed because there was an order. LPN-C stated all of R28's medications worked the same way whether crushed, given by mouth, or via tube feeding. LPN-C explained on days she passed medications to R28; she crushed all pills as there was an order from the physician. LPN-C stated she was not aware [MEDICATION(S)] extended release was not supposed to be crushed or impacted pain relief. LPN-C also confirmed she did not offer as needed acetaminophen to R28 or other methods of pain relief to keep R28 comfortable. Subsequent review of R28's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . For each of these administrations, R28's pain was rated from 3 to 5 out of 10 (using a 0 to 10 scale). During an observation on 11/30/21, at 9:41 a.m. R28 was observed lying in bed and was provided a bed bath by nursing assistant (NA)-A. R28 complained of pain when repositioned and when her right arm was moved. R28 also had noted facial grimacing when she received cares. During an interview on 11/30/21, at 9:50 a.m. NA-A stated R28 had a lot of pain and R28's pain was worse when staff attempted to perform cares such as incontinence cares or bathing. NA-A confirmed R28 yelled out in pain throughout the day and when her right arm was touched. During an interview on 11/30/21, at 1:55 p.m. medical doctor (MD)-A stated he was not aware R28's extended-release [MEDICATION(S)] was being crushed or given via a tube feeding. MD-A stated nursing staff should not crush extended-release [MEDICATION(S)] as all the medication would release all at once and not provide coverage for pain as it should. MD-A stated R28 could also receive too much [MEDICATION(S)] at once instead of receiving the medication slowly over time. This could cause serious breathing problems or relate to R28's concerns regarding poor pain control. MD-A stated they did not feel the facility provided appropriate pain control and management for R28. During an interview on 11/30/21, at 4:25 p.m., the consultant pharmacist (CP) stated crushing extended-release [MEDICATION(S)] possibly could not cover the length of time needed and caused R28 to not have complete coverage for her chronic pain. The CP stated the peak (highest level of a medication in the blood) for immediate release [MEDICATION(S)] was one hour and extended release was three hours. If extended-release [MEDICATION(S)] was crushed it would peak between one and three hours and not last the full 12 hours as intended and cause inadequate pain management. During an observation on 12/1/21, at 12:00 p.m. R28 was provided wound care to her stage IV pressure ulcers and moaned and complained of pain when repositioned. R28 was tearful and was noted to flinch and had facial grimacing when touched. R28 verbalized she had pain in her chest and arms. R28 was not observed to be offered pain medication prior to wound care. Subsequent review of R28's November 2021 and December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication Acetaminophen was consistently used prior to dressing changes or other times when R28 identified she was having pain. During an interview on 12/1/21, at 1:42 p.m. the director of nursing (DON) stated she was not aware R28's extended-release [MEDICATION(S)] was crushed. If crushed, may not provide pain relief as indicated or a resident could receive too much medication at once. The DON stated she expected staff to administer medication as ordered and follow-up with the physician if pain impacted a resident's quality of life. During an interview on 12/1/21, at 12:25 p.m. MD-C stated R28 had a lot of pain during wound care visits. MD-C stated she had given direction to staff to manage R28's pain so she could be repositioned every two hours, sit up in her wheelchair, and have less pain during wound care. MD-C stated during her visit today with R28, she had complained of pain. Facility policy titled Activities of Daily Living (ADLs) undated, directed to offer alternative interventions to minimize functional decline and include appropriate pain management.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R2) who was not allowed to have smoking materials did not have access to them. In addition, the facility failed to ensure 1 of 1 resident (R1) who was identified as independent to smoke was smoking in an appropriate area and these smoking practices constituted an Immediate Jeopardy (IJ) for R2 and R1. The IJ began on 5/27/2021, at 8:40 a.m. when R2 and R1 were noted to be smoking in their rooms and the interim director of nursing (DON) and administrator were notified of the IJ on 5/27/21, at 3:30 p.m. The immediate jeopardy was removed on 6/1/21, at 11:50 a.m. after the facility had implemented an acceptable removal plan. However, noncompliance remained at the lower scope and severity level of D, isolated with no actual harm with potential for more than minimal harm. Findings include: R2 R2's diagnoses included dementia with behavioral disturbances, [CONDITION(S)] and [CONDITION(S)] obtained from the MDS dated [DATE]. In addition, the MDS identified R2 had moderately impaired cognition. R2's care plan dated 3/12/21, indicated R2 was a modified smoker and directed the staff to ensure smoking supplies were stored with the smoking monitor/activities monitor/activities department. The care plan identified staff were to instruct R2 about smoking risks and hazards, staff were to instruct R2 about the facility policy on smoking: locations, times, safety concerns and the staff were to notify the charge nurse immediately if it was suspected R2 had violated facility smoking policy. R2's Smoking Safety Assessment - HDGR dated 4/18/21, identified R2 was cognitively intact but the facility was to store tobacco products and fire materials. The assessment however, did not give any explanation for why R2 had modified smoking interventions despite being cognitively intact. The assessment further indicated R2 understood and signed the smoking policy. On 5/27/21, at 9:32 a.m. R2's room was noted to have a profound fresh odor of cigarette smoke. During the observation, the window was observed approximately one inch wide open. R1 was observed at the time seated on the wheelchair which was parked in between the two beds in the room. R1's bathroom door located to the right when entering the room was observed to be shut. During the observation, the two beds in R1's room were observed with mattresses and linen on them, also the privacy curtains, books and magazine were observed in the room which were inflammable. On 5/27/21, at 9:33 a.m. as AD was entering R2's room, she stated R2 was one of the residents who was not supposed to have any smoking materials on him as he was supervised during smoking. AD then went into R2's room and right away stated It smells like cigarettes in here. AD then opened the bathroom door and went into the bathroom and stated you do have ashes in the garbage and loose tobacco. AD then approached R2 and handed him the facility smoking policy and stated You can't borrow and smoke in your room. AD then asked R2 if he had any cigarettes and a lighter and R2 stated no. AD then asked for permission to search the drawers, asked if they was anything in the wallet and she got a lighter out of the wallet. In the bathroom wall above the garbage can was a mounted plastic napkin dispenser with paper napkins, two boxes of gloves above the sink and shaving cream on the sink to the left of the faucet. During a follow up interview on 5/27/21, at 11:32 a.m. AD stated she did not know how R2 had gotten the cigarette to smoke in his room as R2 was a modified smoker and thus was not supposed to have a lighter or cigarettes on him. AD stated for R1, he was independent with smoking and did leave the facility to the community to obtain his smoking materials. AD stated nursing completed the smoking assessments and a modified smoker was someone who was considered not safe holding onto cigarettes or lighter, may drop the cigarette or was not able to light up or hold the cigarette. AD stated the smoking assessments were completed upon admission, quarterly and as needed by nursing. AD indicated then she would be update the resident category and the resident smoking list accordingly for her staff who monitored smoking. AD stated she did not know how the categories were determined and how or if the residents were observed during the assessment. AD further stated in the past when there was a questionable incident of a resident being identified as smoking in the rooms which had not occurred in a while, she and the social worker or the staff who noticed the smell would go to the room to do a room search and would remove the smoking materials to make sure the resident was safe. R1 R1's diagnoses included tobacco use, alcohol use, opioid abuse, and [CONDITION(S)] obtained from the quarterly Minimum Data Set (MDS) dated [DATE]. In addition, the MDS identified R1 had intact cognition. R1's care plan dated 3/21/21, identified R1 was an independent smoker. The care plan directed staff to instruct R1 about smoking risks and hazards, to instruct resident on the facility policy on smoking: locations, times, safety concerns and to notify the charge nurse immediately if it was suspected resident had violated facility smoking policy. R1's Smoking Safety Assessment - HDGR dated 1/18/21, indicated R1 was cognitively intact and independent with smoking. The assessment further indicated R1 understood and signed the smoking policy. On 5/27/21, at 8:40 a.m. R1 was found to have a strong fresh odor of cigarette smoke in his room. During the observation, the window in R1's room was observed to be slightly open approximately one inch wide and below the window on the heat register was a small black fan that was running. -At 8:43 a.m. surveyor reported to registered nurse (RN)-A the cigarette smell in R1's room and RN-A stated he was going to go to the room to check. -At 8:44 a.m. RN-A was observed to exit R1's room and stated he was going to check with the facility assigned smoking monitor to find out if R1 was supposed to have cigarettes and a lighter on him as most residents at the facility were not allowed to keep them in their rooms. RN-A stated R1's room had cigarette smoke smell but he had not searched the room because R1 had denied smoking in the room and he had not removed the smoking materials from the room. RN-A stated residents were not allowed to smoke in the rooms due to safety issues as there were residents who used oxygen in the same hallway and in the facility. RN-A further stated when residents were found smoking in their rooms, the smoking materials were supposed to be removed from the room and handed to the smoking monitor, and then the staff were supposed to get another nurse or social worker to search the room. RN-A was never observed to find another nurse or social worker to search the room but continued to pass the morning medications. On 5/27/21, at 8:52 a.m. surveyor went and got the activities director (AD) who upon going into the bathroom verified the fresh cigarette smoke smell. AD then approached R1 who was seated on the wheelchair in the room watching television and asked R1 if he had been smoking in the bathroom and R1 stated am going to be honest with you I smoked one. AD then went over the facility smoking policy and rules with R1 and informed R1 it was not safe to smoke in the room for safety as there were other residents at the facility who used oxygen and nursing home fires happened very easily. AD then searched R1's room after receiving permission from him and she obtained two packs of [NAME] brand cigarettes with one and two cigarettes remaining in each of the packs and two lighters. AD then informed R1 she was going to have the social worker follow up with him afterwards. On 5/27/21, at 8:54 a.m. AD stated yes you were right he is one of the independent smokers and now we will re-assess him. We will take the smoking materials when they are caught smoking in their rooms and the residents will be provided the smoking materials at the smoking assigned times. On 5/27/21, at 3:06 p.m. licensed practical nurse (LPN)-A stated the items in the bathrooms and residents rooms which included mattresses and linens, privacy curtains, books and magazine were inflammable. During a review of the List of Current Smokers updated 5/25/21, it was revealed R1 was identified as Independent able to smoke independently and R2 was Modified and smoking materials were handed out to the resident. The list identified some residents as S and they were to be supervised by staff. In addition, the list indicated all residents smokers were determined by smoking assessments completed on admission, quarterly or as needed by the nurses. The list did not indicate how a resident category was determined and if the nurses had observed residents to complete the assessment. During interview on 5/28/21, at 7:59 a.m. with the the interim director of nursing (IDON) and the facility administrator, the IDON stated both of them had just assumed the roles in the last two days and directed the surveyor to the activities assistant (AA) on the expectation with residents managing smoking materials. During interview on 5/28/21, at 8:03 a.m. AA stated a modified smoker was a resident who the facility held their smoking materials, provided it to them at the smoking times, would light it up for them and watch them. AA then stated for Independent smoker the resident was able to keep their smoking materials on them and would smoke during the designated smoking times. AA also stated R2 was not supposed to have a lighter or cigarette on him. AA further stated the smoking policy had been reviewed with all the residents who smoked in the building and residents knew they were not allowed to smoke in their rooms. AA further stated residents who smoked in their rooms was a big safety issue. The facility Smoking policy updated 1/4/21, indicated the facility policy was to provide a safe environment for the residents and the goal was to keep residents safe. The policy also indicated the following: D. The facility will hold all smoking materials and hand out at designated smoking times at designated smoking area for the resident safety. E. Residents may not share, sell, give, borrow, or loan cigarettes to other residents or staff. Only a designated staff person will and/or can purchase cigarettes for residents. Residents are not allowed to accept or to give money, bank cards, or credit cards to other non-designated staff persons for any purpose . The policy did not address that residents were not allowed to smoke in the building, and there was no violation provision for residents who violated the facility smoking policy. In addition, the policy did not indicate there were independent smokers and that they were allowed cigarettes and a lighter(s) in their possession in the room. IJ removal: The IJ began on 5/27/21, and was removed on 6/1/21, after it was verified the facility had removed R1's and R2's cigarettes and lighters from the rooms; all residents who smoked were re-educated on the facility smoking policy; smoking assessments were completed for R1, R2 and care plans were updated. Also R1 and R2 cigarettes and light were held by the smoking monitor moving forward and all the residents who smoked were re-assessed and their care plans were updated accordingly. The facility policy was revised to include violation provisions for residents who violated the smoking policy. In addition, the facility implemented education for smoking aides and nursing staff immediately on the revised smoking policy and all the residents who had been identified to smoke were educated on the revised smoking policy and were to sign an acknowledgement of understanding the smoking policy.

Based on observation, interview and document review, the facility failed to ensure attendance of critical follow-up appointments for 1 of 1 residents (R3) who experienced frequent pain after a spinal surgery, and after a hospitalization for a urinary tract infection ([CONDITION(S)]). This resulted in actual harm to R3 who endured ongoing pain and discomfort due to missed neurology and urology appointments. Findings include: R3's facesheet, printed 1/28/21, indicted R3 was admitted to the rehabilitation unit on 12/30/20, following a surgical procedure. R3 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's admission Minimum Data Set (MDS), dated [DATE], indicted R3 had an indwelling catheter and had a recent spinal surgery involving iamina (part of the vertebral arch forming the roof of the spinal canal), discs (act as shock absorbers in the spine), or facets (small joints on the back part of the spine). R3 required extensive or total assistance for most activities of daily living (ADLs). R3's MDS Pain Interview dated 1/5/21, indicated that R3 had experienced pain almost constantly within last five days, which made it hard for R3 to sleep at night, and limited R3's day to day activities. R3 rated her pain at 6/10 moderate during this assessment. R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (hcl) (narcotic) tablet 5 milligrams (mg) 5 mg by mouth every eight hours as needed for pain from 12/30/20, - 1/4/21. -[MEDICATION(S)] hcl tablet 5 mg 1 tablet by mouth two times a day for pain from 1/4/21, - 1/22/21. -[MEDICATION(S)] hcl tablet 5 mg 1 tablet by mouth every 24 hours as needed for pain from 1/4/21, - 1/22/21. -[MEDICATION(S)] hcl tablet 5 mg give 1 tablet by mouth every 12 hours as needed for pain -starting 1/22/21. -[MEDICATION(S)] capsule 150 mg by mouth two times a day for pain. Ongoing. -[MEDICATION(S)] 5 % apply to affected area topically two times a day for pain. Ongoing. -[MEDICATION(S)] tablet 4 mg ([MEDICATION(S)] hcl) give 1 tablet by mouth two times a day for pain from 1/4/21, - 1/22/21. -[MEDICATION(S)] tablet 20 mg by mouth three times a day for spasm. Ongoing. -[MEDICATION(S)] tablet 10 mg give 1 tablet by mouth every 12 hours as needed for pain bid. Ongoing. -[MEDICATION(S)] tablet 600 mg by mouth three times a day for nerve pain from 12/30/20, - 1/4/21. -monitor pain every shift. -acetaminophen tablet 325 mg - give 650 mg by mouth every four hours as needed for mild pain. Ongoing. -[MEDICATION(S)] hcl solution 5 mg/5 ml give 65 mg by mouth one time a day for pta. Ongoing. R3's care plan, dated 12/30/20, indicated R3 had a physical impairment and was unable to care for herself. R3's care plan further indicated R3 was on pain medication therapy [MEDICATION(S)], tylenol, [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] related to (r/t) spinal cord injury and had a foley catheter related to surgery and spinal abscess and directed staff to monitor/document for pain/discomfort due to catheter. R3's after visit summary from Hennepin County Medical Center (HCMC), printed 12/30/20, indicated R3 was in the hospital from 12/5/20, - 12/30/20, for an infection in the spine. A nurse practitioner (NP) progress note, dated 1/18/21, further indicated R3 underwent an emergent T4-T5 laminectomy and abscess decompression on 12/5/20. During an interview on 1/28/21, the director of nursing (DON) indicated administrative staff (AS)-A was responsible for scheduling resident's appointments and transportation. (AS)-A's 1/14/21, calendar page contained handwritten appointment notes for R3 and indicated [R3] Neurosurgery 715 S. 8th St. AS-A's 1/21/21, calendar page contained handwritten appointment notes for R3 and indicated [R3] urology clinic 715 S. 8th St. A patient letter from Hennepin Healthcare to R3 dated 1/14/21, indicated: --Our records indicate that you recently missed your appointment scheduled on January 14 with Neurosurgery clinic. Encounter notes from Hennepin Healthcare indicated R3 was a no show for Radiology and Neurosurgery appointments on 1/14/21. --Encounter notes further indicate R3 had a canceled urology appointment on 1/21/21. When interviewed on 1/28/21, at 12:15 p.m. R3 stated, They do not even tell me that I have an appointment, they don't tell me the times, these are very important appointments for my spine. R3 further stated, If they just tell me when I have them and what time I have them I could just schedule the ride myself. When interviewed on 1/28/21, at 1:32 p.m. AS-A stated she did not know if R3 had missed any appointments. When interviewed on 1/28/21, at 1:42 p.m. R3's Primary Care Clinic Nurse Clinical Coordinator (CC) stated R3 missed a urology appointment on 1/21/21, and that clinic notes indicated the appointment had been canceled by the patient, however, in parentheses it was noted the facility had canceled. CC verified R3 had missed radiology and Neurosurgery appointments on 1/14/21, and that clinic notes indicate the appointment was a no show. CC indicated the neurosurgery appointment had been rescheduled for 2/15/21, but felt this was not acceptable as R3 had a spinal abscess that needed emergent surgical intervention and needed this two week post-surgical care appointment, this has significant gravity to it. When interviewed on 1/28/21, at 1:58 p.m. R3 stated she was not aware of a neurosurgery appointment on 1/14/21, and did not call the clinic to cancel. R3 verified she didn't know about the 1/21/21, appointment with urology, and stated, they told me I had a urology appointment, they didn't tell me what date though. When interviewed on 1/29/21, at 10:30 a.m. the DON verified there were no notes about R3 going to a neurosurgery appointment on 1/14/21. DON stated the expectation would have been to reschedule the appointment if there was a reason it was missed and stated, I think that [AS-A] needs some education on making sure the residents don't miss these appointments. DON stated he would expect AS-A to inform the RN supervisor and reschedule the appointment immediately and stated, Obviously there is a lack of communication. (DON) verified there were no notes about R3 going to urology appointment on 1/21/21, and stated, I am starting to become concerned as it seems there is a pattern here. DON could not explain why R3 has missed these appointments. R3's progress note, dated 1/1/21, indicated R3 was in bed all shift and complained of pain. She was given 5 mg of [MEDICATION(S)] once for pain and it was effective. R3's progress note, dated 1/13/21, at 3:46 p.m. indicated R3 complained of muscle spasms from her legs and said the pain was making it hard for her to breathe. R3 had been given scheduled [MEDICATION(S)] at 8:00 a.m. and 1:00 p.m. that day. Staff placed a call to extended care for further directions concerning R3's pain. R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress notes, dated 1/18/21, indicated R3 had been sent to the hospital that day and had returned with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner (NP) progress note, dated 1/18/21, indicated R3 had severe lower abdominal pain that had been present since at least 1/15/21. R3 reported it felt like razor blades in her bladder. NP directed continued use of the Foley catheter. NP directed R1 would follow up with urology on 1/21/21. NP note further indicated R3 reported spasms in her upper abdomen, in her mid-back and low back, in her sides near her ribs, and in her legs that were fairly frequent and had been present the past few weeks. R3 did not feel the [MEDICATION(S)] and [MEDICATION(S)] had been helpful for this. R3 had been using [MEDICATION(S)] which she felt did relieve her back pain, but not the spasms. NP indicated transitional care unit (TCU) staff would schedule a neurosurgery follow-up. R3's progress note, dated 1/23/21, indicated, R3 complained of pain from her indwelling catheter and wanted it to be flushed. R3's catheter was flowing well and was not cloudy. R3 stated she felt pain in her legs, she was repositioned and kept comfortable, she was given an as needed pain medication and fell asleep. R3's progress note, dated 1/25/21, indicated R3 had muscle pain 7/10 on pain scale and had taken 5 mg [MEDICATION(S)] for the pain. No results of medication efficacy for main management documented. R3's progress note, dated 1/25/21, indicated R3 complained of pain during repositioning, and the NP would be notified in morning of R3's pain and muscle spasms. R3 currently received [MEDICATION(S)] 20 mg three times daily. When observed on 1/28/21, at 11:29 a.m. R3 yelled for assistance from her room and stated she wanted to get out of her wheelchair. At 11:35 a.m. DON and administrator entered R3's room and asked what was wrong. R3 expressed she had pain in her legs. The DON began to move and stretch R3's leg and the administrator went to check on a pain medication for R3. R3 continued to express she had spasms and pain in her legs and wanted to get out of the wheelchair. At 11:40 a.m. DON and registered nurse (RN)-A brought a hoyer lift into R3's room to transfer R3 from the wheelchair into bed. R3 was not observed to receive pain medication. When observed on 1/28/21, at 11:45 a.m. R3 was transferred into bed from her wheelchair. The DON repositioned R3 in bed, moved R3's catheter bag to the side of her bed. R3 stated she was uncomfortable and had been sitting on her catheter and it had been twisted below her body. DON stated R3 needed another leg strap and he would continue to reposition R3 after the female aides came to clean her up. R3's Nurse Pain Tool Observation, dated 1/29/21, indicated R3 had pain and spasm in bilateral legs and R3 rated her current pain level as 9/10 (excruciating). The pain tool did not indicate if anything was given for R1's pain, nor did it indicate the effectivness of R1's current pain interventions. R3's MAR, printed 1/28/21, at 2:18 p.m. indicated R3 was not given as needed [MEDICATION(S)] on 1/27/21, or 1/28/21. R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When interviewed on 1/29/21, at 10:30 a.m. the DON stated R3 had been producing adequate urine output from her catheter, and DON felt the catheter seems to be running fine. DON verified R3 went to the hospital for a catheter replacement, and was also found to have a [CONDITION(S)] at that time. DON stated R3 was also found to have bladder stones that required flushing the catheter if urine flow stopped or slowed. According to the DON staff were aware of the blockage and were watching for urine output. When interviewed on 1/28/21, at 11:50 a.m. the DON stated he had looked at R3's pain medications the other day and verified R3 had [MEDICATION(S)] and other PRN meds and staff were making sure they are using them appropriately now. Facility policy titled catheter care, urinary, undated, indicated check resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. A facility policy on appointments was requested but not provided.

Based on interview and document review, the facility failed to ensure the safety interventions for smoking were implemented for 1 of 6 residents (R1) reviewed for smoking. This failure resulted in an immediate jeopardy (IJ) when R1's cigarette and lighter were not collected from him after smoking, R1 lit a cigarette in his room while on oxygen and sustained facial burns. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. The IJ began on 1/18/21, at 8:28 a.m. when R1's smoking material was not removed and he sustained [MEDICAL CONDITION] with other items in his room were burned. R1 was hospitalized for [REDACTED]. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], included cognitively intact with a [DIAGNOSES REDACTED]. R1's smoking assessment with an effective date of 1/13/21, identified, Cannot use fire safely, uses oxygen, and had a history of [REDACTED]. Interventions included, facility storage of tobacco products and fire materials, and a smoking apron. R1's care plan dated 11/12/20, identified, Resident is a monitored smoker, staff to keep smoking materials and hand out 1 at a time. Due to not following smoking policy. R1's goal was, Resident will smoke in appropriate area and will have no accidents/incidents by next eval. Interventions included, Resident is a monitored smoker per smoking assessment. Smoking apron required as of 1/13/21. Staff to remind to take off oxygen prior to smoking and leave on table indoors. Added on 1/18/21 was, Staff/smoking monitor to keep all smoking material including cigs, lighter and smoking apron. Hand resident one cig at a time. Make sure resident turns in lighter after use. Make sure resident removes oxygen prior to smoking. R1's incident report dated 1/18/21, at 8:28 a.m. included, Writer was sitting at desk with the door open, saw resident roll up in his wheelchair and heard resident stating, 'I need someone to call the ambulance, my face hurts because my oxygen blew up in my face.' Resident was noted to have black soot on nose, lower face and lips. No apparent burning on face and no open areas noted. Hair on left side was slightly singed. Resident alert and oriented x 3 (person, place and time). Oxygen was not in place. Vitals taken immediately. Noted resident was having difficulty breathing. 3L (liters) of O2 (oxygen) put on resident and O2 sat (oxygen saturation level) 86%. Resident was asked if he was smoking in his room, resident stated, No, but I have a lighter in my pocket. Resident wears oxygen continuously via nasal cannula. Resident is a monitored smoker and resident is not allowed to have his own cigarettes. Cigarette butt was found in residents garbage can by staff nurse and resident stated he had a lighter in his pocket. R1's progress note dated 1/18/21, at 9:00 a.m. included, 911 was called and R1 was sent to Hennepin County Medical Center (HCMC) to be evaluated due to black soot on nose, lower face, and lips, and low oxygen level. R1's Medicine History and Physical from HCMC dated 1/19/21, included, Pt (patient) was smoking a cigarette while on oxygen at nursing home and had flash burn to the face. Had nasopharyngoscopy in the ED (emergency department) showing mucous with soot which was likely from nasal drainage- no sign of [DIAGNOSES REDACTED] (redness) or [MEDICAL CONDITION]. Burn consulted and saw pt (patient) in the ed (emergency department) with the following recommendations, 24 hour monitoring for any evolving respiratory compromise. Wound care, pain control IV fluids. (R1) is a 72 y.o. male admitted [MEDICAL CONDITION] his face. He was reportedly smoking a cigarette while on his oxygen at his nursing home and severe caught fire and caused a flash burn to his face. He was seen by burn surgery and reported to have 0.25% total body surface area partial-thickness, second-[MEDICAL CONDITION] his face and lips from flame inhalation. When interviewed on 1/20/21, at 9:17 a.m. licensed practical nurse (LPN)-G stated, there was smoke in R1's room at the time of the incident, his pillow had a deep hole in it, his sheets weren't burnt, I believe he was sitting in his wheel chair with the pillow on his lap and I believe he caught the pillow on fire, his oxygen tubing was on the floor and it was partially burnt. When interviewed on 1/20/21, at 9:38 a.m. registered nurse (RN)-B stated, I noticed a staff member was bringing (R1) up the hallway and his face was burnt. RN-B stated, he must have either been playing with a lighter or smoking while wearing oxygen and he lit on fire. When interviewed on 1/20/21, at 10:53 a.m. R1 stated, when finishing smoking outside he placed a cigarette and lighter in his pocket and then went to the room and lit the cigarette and was burned. Staff did not attempt to collect his lighter or cigarette when he had come into the building. When interviewed on 1/20/21, at 2:46 p.m. the director of nursing (DON) stated R1 had been observed, ashing on himself while smoking on several occasions which prompted the new smoking assessment on 1/13/21, and they added the smoking apron. When interviewed on 1/21/21, at 9:37 a.m. the activity director (AD) stated she did not recall R1 smoking the morning of 1/18/21, the day he lit himself on fire. AD had been responsible for the monitoring the smoking area that morning. The facility Smoking policy dated 7/22/20, and updated on 1/18/21, included, Residents who smoke will be assessed on whether they are able to hold on to their own smoking materials or they will be stored at the nursing station, activity department, or front desk. The past noncompliance immediate jeopardy began on 1/18/21. The immediate jeopardy was removed, and the deficient practice corrected by 1/18/21, after the facility implemented a systemic plan that included the following actions: On 1/20/21, at 9:54 a.m. the administrator provided a binder with the facility's immediate plan of correction dated 1/18/21. The binder included, the smoking policy, education provided to staff with sign in sheets, education provided to residents who smoke with sign in sheets and signed acknowledgment of the smoking policy by the residents. In addition, copies of each residents' smoking assessments and updated are plans. All of these items were reviewed by the surveyors and all smoking resident's assessments, care plans, smoking policy acknowledgment and education had been provided on 1/18/21. R1, R22, and R23 were interviewed on 1/20/21, and verified receiving education on the smoking policy, including the dangers of smoking with oxygen on, smoking indoors, and the need to turn in their lighter and cigarettes after smoking. During observation of the smoking area on 1/20/21 on multiple occasions, the residents were monitored by staff and each resident was asked to turn in their lighters when returning indoors from smoking. LPN-D, RN-D, NA-A, AD, and NA-C were interviewed on 1/20/21, and stated they had received education on the smoking policy, monitoring the smoking area and need to collect lighters/cigarettes when residents came in from smoking. In addition, smoking binders were available to determine which residents needed supervision/smoking materials collected/smoking apron, et, in which they could reference. The activities department staff reviewed the smoking binders/books for accuracy and identified hazardous smoking residents and placed each resident in groups: independent, modified, or supervised smokers on 1/18/21. The facility ensured each smoking binder/book was placed at the receptionist desk, the nurses' station, and the smoker aide table for reference on 1/18/21. A smoking binder dated 1/18/21, was located in each of these areas on 1/21/21. The social services director (SSD) and the activity director (AD) completed room searches for smoking materials for those residents identified as hazardous smokers on 1/18/21. This was verified through interview of the SSD on 1/21/21, and documentation from the SSD on 1/18/21. The administrator held a meeting on 1/18/21 and educated the residents on the updated smoking policy and each resident who smokes signed an acknowledgement of smoking policy form on 1/18/21. This was verified on 1/21/21, by record review and the signed smoking policies. The nursing staff were educated prior to working their next shift on the updated smoking policy and the smoking monitoring system which was initiated on 1/18/21 by the RN nursing supervisor. This was verified by sign in sheets on 1/21/21, and interview of staff on 1/20/21.

Based observation, interview and document review, the facility failed to comprehensively assess and notify the physician regarding the development of a newly formed pressure ulcer, obtain treatment of [REDACTED]. This resulted in actual harm when R4 developed an unstageable pressure ulcer to his right heel which required surgical excisional debridement. Findings include: R4's Admission Record dated 6/19/20, indicated R4 had [DIAGNOSES REDACTED]. breathing) and muscle weakness. R4's significant change Minimum Data Set ((MDS) dated [DATE], indicated R4 was in a persistent vegetative state with no discernible consciousness and was totally dependent on staff for all activities of daily living (ADL). The MDS indicated R4 was at risk for developing pressure ulcers and had one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.) The MDS also indicated R4 required a pressure reducing device for chair and bed, a turning and repositioning program, pressure ulcer care and application of ointments/medications and nonsurgical dressings other than to feet. The MDS further indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. R4's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 5/4/20, indicated the significant change assessment was done as R4 had a new stage 2 ulcer, most likely a Kennedy terminal ulcer (dark sore that develops rapidly during the final stages of a person's life) related to his situation. R4's Care Plan dated 3/18/20, indicated R4 was at high risk for impaired skin integrity and identified R4 had a wound to the left elbow and a stage 2 pressure ulcer to the left buttock related to immobility, incontinence, malnutrition/failure to thrive, reliance on staff for performance of ADL's and type 2 diabetes. The care plan directed R4 required PRAFO (pressure relief ankle foot orthosis) boots on at all times, turn and reposition every two hours while in bed, pressure reducing air mattress in bed and cushion in wheelchair when out of bed, check for bowel and bladder incontinence and provide care every two hours and as needed. The care plan also directed staff to assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the physician, monitor/document/report to physician as needed changes in skin status: appearance, color, signs and symptoms of infection, as well as any new wound size and stage. R4's Braden Scale (a tool which predicts the risk for developing a facility acquired pressure ulcer/injury) dated 3/18/20, identified R4 was very high risk. R4's Braden Scale dated 5/21/20, also identified R4 was very high risk. R4's Weekly Skin Check dated 5/21/20, completed by licensed practical nurse (LPN)-C identified R4 had stage 2 pressure ulcers to the left elbow and left buttock and required daily dressing changes, heel protective boot, and repositioning every two hours. The skin check did not identify any open areas to R4's right heel. On 6/17/20, at 10:17 AM registered nurse (RN)-A was observed to perform dressing changes to R4's wounds. RN-A began with changing the dressing to R4's bottom. RN-A stated R4 had two open areas: the first open area was noted at the top of the buttocks crease and was approximately 0.5 centimeters (cm) x 1.0 cm. The second open area was noted to be approximately 6.0 cm directly below the first and was approximately the size of a pencil eraser. RN-A indicated the wounds were measured on Mondays when seen by the wound nurse. RN-A proceeded to perform a dressing change to R4's left elbow. The old dressing was noted to have a small amount of serosanguinous drainage (mixture of blood and serum). The left elbow wound was noted to be approximately 3.0 x 4.0 cm with slough (a layer of dead tissue separated from surround living tissue) on a majority of the wound bed. RN-A proceeded to remove an old dressing from R4's right foot/heel. The dressing was noted to have a moderate amount of serous drainage. A large wound which consisted of approximately 10.0 cm of eschar (dry, black, hard dead tissue) was observed to cover R4's entire right heel with 1.0-2.0 cm of bloody tissue along the plantar side of the wound. A demarcation of new skin extended approximately 3.0-4.0 cm along the plantar surface of R4's right foot. After completing the dressing change, RN-A applied a pressure relieving boot to R4's right foot. R4's Treatment Administration Record (TAR) dated 6/1/20 - 6/30/20, revealed the following physician medication and treatment orders and nursing orders: -Clean Left buttock with wound cleanser, apply [MEDICATION NAME] (sic) and cover with (border gauze) daily per order. one time a day for wound care -Clean left elbow with wound cleanser apply santyl (a topical product used to help the healing [MEDICAL CONDITION] skin ulcers), [MEDICATION NAME] (sic) and cover with (border gauze) every two days per wound doctor. -Stage II or III wound with drainage: cleanse with water, apply foam composite dressing (facility stock). Change every 3 days and as needed. The order start date was 4/23/20. However, R4's TAR and clinical record lacked identification of and specific orders related to the care and treatment of [REDACTED]. On 6/18/20, at 10:25 a.m. RN-B verified she made weekly rounds with the wound doctor and indicated they had seen R4 on 6/15/20 and discovered he had a right heel wound. RN-B indicated they had been unaware of R4's heel wound prior to that date. RN-B stated when R4 was on the COVID unit, it had been reported to her that R4 had a dry skin area on the right heel and the heel was soft. At that time, she had directed LPN-C to implement foam boots. RN-B stated during wound rounds on 6/15, she was embarrassed when they spotted gauze on the R4's right foot, as the right heel wound had not been reported to her or the wound doctor nor had it been reported or discussed in the facility morning meeting. RN-B stated all she had been aware of was that R4's foot/heel was soft. RN-B verified R4's clinical record lacked documentation regarding the necrotic heel wound and stated she waited for the physician to complete documentation and then she (RN-B) had a week to complete her documentation. RN-B stated the wound doctor debrided R4's wound on 6/15/20, which would explain the wound bleeding. RN-B confirmed R4's right heel wound was an unstageable ulcer and indicated if it had been reported earlier, it may not have gotten so bad. R4's Specialty Physician Wound Evaluation & Management Summary dated 6/15/20, indicated R4 had a new DTI (deep tissue injury) of the right heel and underwent a surgical excisional debridement procedure to remove thick adherent eschar and devitalized tissue. The summary identified an unstageable wound (due to necrosis) of the right heel with a duration of greater than one day and included the following treatment plan. However, R4's clinical record lacked entry of these orders: -Primary dressing: Xeroform sterile gauze apply once daily for 30 days. -Secondary dressing: gauze roll non sterile (kerlix) apply once daily for 30 days; ABD pad sterile apply once for 30 days -Peri wound treatment: skin prep apply once daily for 30 days -Recommendations: float heels in bed; offload wound; reposition per facility protocol; Sponge boot: prevalon boots and wedges Review of R4's Weekly Wound Assessments dated 6/18/20, revealed the assessments were performed on 6/15/20, and not documented in R4's clinical record until 3 days post assessment. The assessments included the following: -stage 2 left buttock cluster wound first identified 3/17/20. The left buttock cluster wound measured 7.0 cm x 1.0 cm x 0.1 cm with 30% granulation and 70% dermis with scant drainage. -left elbow stage 2 pressure ulcer first identified 3/17/20. The left elbow measured 3.0 cm x 2.5 cm x 0.2 cm with 10% necrotic, 10% slough, 40% granulation, 40% dermis with moderate serous drainage. -right heel pressure ulcer, unstageable due to necrosis, which was acquired 6/15/20. During assessment, the right heel ulcer measured 11.0 cm x 11.0 cm with 40% granulation, 10% slough and 50% necrotic with moderate serous drainage. Ulcer was debrided by wound doctor. On 6/18/20, at 5:49 p.m. LPN-C stated about two weeks ago, when R4 was on the COVID unit, he remembered talking to RN-B about R4 having dry skin on his right heel. LPN-C denied R4's heel ulcer being open at that time and stated the skin was more soft from laying in bed. LPN-C verified RN-B had recommended R4 wear a boot to that foot. LPN-C stated R4 had been discharged from the COVID unit on 6/1/20, and estimated the boot was implemented shortly before then. LPN-C denied any staff reporting a concern to him regarding R4's worsening heel ulcer and stated they should have done so. LPN-C indicated the nursing assistants (NA) should be checking residents' skin condition daily with cares and verified the ulcer should have been identified earlier, during the weekly skin check. On 6/18/20, at 5:56 p.m. NA-G verified R4 wore boots on his feet and had a sore on his right heel. NA-G stated R4's right foot was bandaged and she could not say how long R4 had had the bandage on the foot. On 6/18/20, at 6:00 p.m. LPN-E indicated she primarily worked the evening shift and would only deal with resident dressing changes if they were not completed on the day shift. LPN-E stated she did not recall R4 having a wound on his heel. On 6/18/20, at 6:02 p.m. NA-H verified R4 had a bandage on his right foot but could not identify how long it had been there. NA-H indicated she had never assisted with a dressing change for R4 and had never seen his wound. NA-H stated if they noticed any problems with resident skin they were to report to the nurse and document in the computer. On 6/18/20, at 6:17 p.m. the skin observation documentation on the Documentation Survey Reports was reviewed with RN-B. RN-B stated if an NA identified a new open or reddened skin area, she would have expected it be reported to the nurse who should then document a progress note regarding the area. RN-B confirmed R4's clinical record lacked documentation regarding the aforementioned new opened or reddened areas identified. RN-B also verified the NA's were to document their skin observation task in the computer every shift and confirmed the documentation had not been completed daily on each shift, as required. On 6/18/20, at 6:33 p.m. the director of nursing (DON) verified NA staff were to document skin observations every shift, daily and newly identified issues with resident skin were to be reported to the nurse who should then document a progress note and request a wound consultation. DON confirmed R4's necrotic heel wound should have been reported, a wound consult should have been requested when the wound was first identified, and an assessment of the wound should have been completed. During review of R4's skin observation documentation on the Documentation Survey Reports, the DON stated he recognized they had a system issue with reporting of resident skin concerns. The undated Prevention of Pressure Ulcers policy indicated the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. The policy directed to routinely asses and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown. The policy also directed to report any signs of a developing pressure ulcer to the physician.

Based on interview and document review, the facility failed to comprehensively assess skin integrity and failed to ensure care plan interventions were implemented to prevent development of pressure ulcers for 1 of 3 residents (R2) reviewed who were at risk for pressure ulcers. This resulted in actual harm when a resident developed two stage two pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) definition of Stage 2 pressure ulcer includes: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. R2's undated face sheet identified R2 had [DIAGNOSES REDACTED].) R2 had been admitted to the facility on [DATE], and discharged on [DATE]. R2's admission Minimum Data Set ((MDS) dated [DATE], identified R2 had severely impaired cognition. R2 had not rejected cares. Further, R2 was totally dependent on staff assist for bed mobility and toileting. R2 was at risk for pressure ulcers and the MDS identified R2 had no current pressure ulcers. R2's MDS lacked documentation for skin care interventions such as turn and reposition program and lacked documentation for pressure relieving device on bed or wheelchair. R2's admission care plan dated 4/23/20, indicated R2 had intact skin and R2 was incontinent of bowel and bladder. R2 was confused and non-verbal. The care plan lacked documentation of skin care interventions. R2's physician orders [REDACTED]. R2's admission skin assessment dated [DATE], indicated R2 had no pressure areas. R2 had a scar noted to the top of scalp and [DEVICE] (gastric feeding tube tube inserted through a small incision in the abdomen into the stomach and is used for long-term enteral nutrition) noted on the abdomen. The skin assessment lacked a facility risk assessment tool or Braden Scale (used to identify residents at risk for pressure ulcer). R2's admission tissue tolerance assessment (assessment to determine an appropriate repositioning schedule) indicated no change in color skin alteration after one hour interval. The tissue tolerance assessment lacked documentation for a two hour interval. R2's progress notes indicated on 4/24/20, at 12:35 a.m. R2 was alert and oriented x 1 and unable to make needs known. R2 was on a [DEVICE] running at 55 mL(milliliter)/hour Vital AF (formula). Incontinent of bowel and bladder. Resident restless and not aware of safety. Would require a lower bed to prevent future falls. R2 was one assist with all ADLs and two with transfer. Skin intact no concerns noted. R2's physician progress notes [REDACTED]. R2 was described as thin, alert, calm and cooperative. No acute distress. Skin had no visible rash or [MEDICAL CONDITION]. The progress notes lacked documentation of R2's change in condition and being sent to emergency roiagnom on [DATE], and lacked any documentation of altercation in skin integrity or pressure ulcers. R2's emergency department (ED) admission paperwork dated 4/29/20, indicated R2 had a pressure injury stage 2 on left posterior elbow. Additionally, R2 had a stage 2 pressure injury to middle groin area. ED documentation indicated both pressure injuries had occurred prior to arrival at ED. Lastly, R2 had been admitted to the hospital from the ED [MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to an infection) [MEDICATION NAME] bacteremia. During phone interview on 5/19/20, at 10:41 a.m. family member (FM)-A stated R2 had only been at Victory five days when R2 had to be rushed to the hospital. FM-A stated R2 was sent to the North Memorial ED due to a change in level of responsiveness. FM-A stated the ED doctor told FM-A that R2 had sores on (R2's) bottom and had two infections. FM-A stated R2 did not have a history of sores until R2's admission to Victory Health and Rehab. FM-A stated R2 was admitted to the hospital from the ED. FM-A stated R2 had since then been admitted to a new nursing home. During interview 5/19/20, at 12:20 p.m. licensed practical nurse (LPN)-A stated they had worked with R2 once. LPN-A stated R2 had not refused cares. R2 was described as bedbound, ill, weak, restless. LPN-A stated R2 had no open areas to the skin. LPN-A did not remember what skin care interventions R2 had in place but typically it would be in the orders. During interview on 5/19/20 at 12:37 p.m. registered nurse (RN)-A stated they had worked with R2 once and on that day sent R2 to the ED due to change in condition. RN-A was unable to comment on what cares were in place for R2 or if R2 was at risk for pressure ulcers. During interview via phone 5/20/20, at 12:07 p.m. Hospitalist physician (MD)-A confirmed R2 had documented pressures ulcers upon arrival to the ED. MD-A stated [MEDICAL CONDITION] was from bacteria of unknown source. MD-A stated it was uncertain if [MEDICAL CONDITION] was connected to the pressure ulcers because the wounds were not cultured. During interview via phone on 5/20/20, at 12:53 p.m. facility medical director (MD)-B stated R2 was clearly at risk for pressure ulcers due to being so debilitated. MD-B stated it would not take a lot for R2 to get to a stage 2 pressure ulcer and that pressure ulcer could occur in less than a two hour window. MD-B confirmed R2 had no documented pressures sores upon admission to the facility. MD-B stated for residents that were at risk for pressure ulcers it would be the expectation for the facility nurses to implement interventions right away such as a pressure relief mattress and orders to be moved frequently. During interview via phone on 5/20/20, at 1:39 p.m. nurse practitioner (NP)-A stated R2 was seen via telemedicine on 4/27/20. NP-A stated R2 was frail, complicated and definitely at risk for pressure ulcers. (R2) cannot position independently. NP-A stated pressure ulcers are usually preventable. NP-A stated the expectation would be for the nursing staff to place the at risk residents on at least an every two hours repositioning schedule. During interview via phone on 5/20/20, at 2:13 p.m. assistant director of nursing (ADON) stated, Most people who are in bed and cannot move around are at risk for pressure ulcers. The ADON stated the expectation would be for the nurse that identified the risk to consult with the ADON, put in orders for supplies and update the care plan for repositioning for residents at risk. The ADON stated, Not quite sure what (R2) had in place for pressure ulcer prevention. During interview via phone on 5/20/20, at 3:23 p.m. nursing assistant (NA)-B stated they had worked with R2. NA-B could not recall what interventions were placed for R2 for repositioning or cares and stated would talk to the nurse if NA-B had questions on care. During interview via phone on 5/20/20, at 4:10 p.m. the director of nursing stated, Absolutely, (R2) should have had a preventative plan in place for pressure ulcers and did not. DON further stated they were unaware if any preventative skin care interventions had been placed or implemented during R2's stay. Facility policy titled Pressure Ulcer Risk Assessment, undated, indicated residents were to have a pressure ulcer risk assessment completed upon admission, weekly for three weeks, with each additional assessment, quarterly, annually and with significant changes. Additionally, at-risk residents need to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Risk factors include: immobility, altered mental status, incontinence, poor nutrition. Staff were to proceed to care planning and interventions individualized for the resident and their particular risk factors. Facility policy titled Repositioning, undated, indicated residents who are in bed should be on at least an every two hour repositioning schedule. Residents who are in a chair should be on an every one hour repositioning schedule.

Based on observation, interview and document review, the facility failed to ensure incomplete medication orders, were clarified with the provider, and correctly transcribed and administered in accordance with established physician orders [REDACTED]. This resulted in an immediate jeopardy (IJ) situation and substandard quality of care for R269 who received medication outside the recommended use causing a significant medication error which was not adequately investigated or addressed by the facility. The IJ began on 11/15/19, when physician orders [REDACTED]. R269 returned from the hospital on [DATE], and still had the orginal order for the [MEDICATION NAME] medication. The facility had not clarified with the physican if R269 should be receiving this medication, or what parameters and frequency to use the [MEDICATION NAME]. The administrator and director of nursing (DON) were notified of the IJ for R269 on 11/26/19, at 2:55 p.m. The IJ was removed on 11/27/19, however, non-compliance remained at isolated, actual harm which is not immediate jeopardy (Level G). Findings include: R269's Admission Record printed 11/27/19, indicated R269 was admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. On 11/25/19, at 1:34 p.m. R269 explained she was upset because she had been given [MEDICATION NAME] on 11/22/19 with her morning medications. R269 stated she routinely received a nasal spray ([MEDICATION NAME] Propionate Suspension; a nasal spray used to treat used to relieve symptoms of inflammation and swelling of the mucous membrane of the nose, characterized by a runny nose and stuffiness and usually caused by the common cold or a seasonal allergy); however, she was aware this was not the usual morning nasal spray as soon as it was given it tasted bitter when it ran down her throat. Following the administration of the [MEDICATION NAME], the staff proceeded to give her [MEDICATION NAME] (a synthetic opioid prescribed for moderate to severe pain which may also be used to treat opiate addictions) and [MEDICATION NAME] (a medication used for anxiety and [MEDICAL CONDITION]). R269 stated she immediately began to seize after taking all the medications. R269 described it as generalized [MEDICAL CONDITION] activity and stated I peed myself with every [MEDICAL CONDITION]. R269 stated this occurred at the nurses station and she felt people were watching her. R269 demonstrated facial movements with eyes wide open, looking to the extreme right, accompanied by grimacing, grinding of teeth, and abnormal mouth movements, and added she was making grunting sounds. R269 also demonstrated a flailing movement, with arms and legs extended rigidly with each [MEDICAL CONDITION]. R269 stated she was taken by the ambulance for evaluation, and even vomited once while in the ambulance. The emergency medical service crew (EMS) attempted to start an intravenous (IV) line for medication administration; however, stated they were unsuccessful because of her poor veins which caused pain. R269 stated she continued to experience [MEDICAL CONDITION] activity for several hours after being given these medications, and returned to the facility from the hospital later the same day. R269 stated she suffered for the remainder of the day with vomiting, loose stools, nasal drainage and stomach cramps. R269 described this event as horrible when she recalled the reaction and added she felt her brain had been kind of weird since this episode as it had done something to me, I don't know how to explain. I am crying all the time. R269 stated the incident made her feel violated and added, I don't feel safe here. R269 stated she spent the first night following the event with her husband as she needed someone close by to provide care if needed and she did not feel safe. On 11/25/19, at 2:26 p.m. trained medication aide (TMA)-A stated she administered [MEDICATION NAME] to R269 on 11/22/19 as outlined on the medication sheet. A review of the Medication Administration Record (MAR) for (MONTH) 2019, identified an order for [REDACTED]. TMA-A stated she had given the [MEDICATION NAME] on 11/18/19, 11/19/19, and 11/21/19 as documented; however, a review of the label on the empty [MEDICATION NAME] box, observed to be in the drawer in the medication cart, identifed on 11/15/19, two individual doses were dispensed by pharmacy. During interview, a second unopened box of [MEDICATION NAME] (two doses) was observed at this time in the cart and was labeled as having been dispensed by the pharmacist on 11/23/19, and was available to R269 for use. TMA-A stated that [MEDICATION NAME] was used if R269 was short of breath, adding she gives the medication when R269 asks for the spray. TMA-A went on to explain [MEDICATION NAME] was only given in an emergency, or again, if resident was short of breath. TMA-A adamantly stated she had given the [MEDICATION NAME] doses as documented on the MAR, even though the supply of pharmacy dispensed quantities did not validate the administration on 11/18, 11/19 and 11/21/19. TMA-A stated the facility had provided education mostly on anything we are giving; however, TMA-A stated there had been no recent education regarding administration of [MEDICATION NAME] provided on or following the incident on 11/22/19. R269's (MONTH) 2019 MAR also identified another staff member, TMA-C, had documented they had administered [MEDICATION NAME] on 11/16/19, 11/17/19, 11/20/19, and 11/22/19. TMA-C was unavailable for interview. A supply of two doses of [MEDICATION NAME] was dispensed by the pharmacy on 11/15/19, with a refill of two additional doses was dispensed by the pharmacy on 11/23/19 and remained in the cart. R269's care plan initiated 11/16/19, indicated R269 had chronic pain due to [MEDICAL CONDITION] disc disease (disease of the discs of your spine which causes pain). The care plan directed staff to anticipate R269's need for pain relief, evaluate for the the effectiveness of pain intervention, and to monitor for and document for any side effects of medication. The side effects were described in the care plan as constipation, new/increased agitation, restlessness, confusion, hallucinations, dysphagia (difficulty swallowing), nausea, vomiting, dizziness and falls. However, the care plan lacked any identified problem statements or subsequent interventions to address R269's history of substance abuse and opioid and cocaine dependence despite being identified on her Admission Record and having physician orders [REDACTED]. On 11/25/19, at 3:07 p.m. TMA-D stated R269's current order for [MEDICATION NAME] indicated it was be used only as needed (PRN). TMA-D stated [MEDICATION NAME] was a drug used in the event of an overdose; however, stated she would not have administered this without consulting a nurse. TMA-D stated she had learned about the drug [MEDICATION NAME] in her training as a TMA; however, had not received any training about this medication from the facility. On 11/25/19, at 3:21 p.m. TMA-B stated she was aware of R269 receiving [MEDICATION NAME] and being transported to the hospital; however, added she had limited knowledge of use of this medication and had not received any additional training following 11/22/19 incident, to ensure it was being given safely or under proper rationale. On 11/25/19, at 3:29 p.m. licensed practical nurse (LPN)-D stated the TMA-C informed her R269 was acting weird and identified R269 shaking, yawning and her nose was running. LPN-D stated TMA-C informed her R269 had received her dose of [MEDICATION NAME] as scheduled on the MAR along with the ordered [MEDICATION NAME] and [MEDICATION NAME]. LPN-D stated R269 was sent to the ER via the ambulance for evaluation. LPN-D stated she then reviewed the order on the MAR and discovered the MAR listed R269's [MEDICATION NAME] as a scheduled dose; however, the original orders did not reflect a scheduled frequency. LPN-D stated she notified the director of nursing (DON) and a call was placed to the provider for clarification. LPN-D stated she discussed this order with the triage nurse for the physician office who identified [MEDICATION NAME] was usually given on an as-needed basis; however, LPN-B stated she had not received an order from a physician to clarify the intended frequency. LPN-D stated the DON did provide education to all staff working on 11/22/19, regarding the use of [MEDICATION NAME] by providing a drug pamphlet which described the indication for use and proper administration of the medication, including need for ongong monitoring. Even though the DON identiifed she educated staff on the use of [MEDICATION NAME], there was no indication the original physician order [REDACTED]. On 11/25/19, at 3:34 p.m. LPN-C stated he was informed of an error which had occurred with the use of R269's [MEDICATION NAME] and had been provided with education regarding this medication upon his arrival for the afternoon shift on 11/22/19. LPN-C stated he was aware [MEDICATION NAME] was to be used PRN for opioid overdose. On 11/25/19, at 3:39 p.m. LPN-E stated [MEDICATION NAME] was used for reversing the effect of opioid's and once given, the staff were to monitor for the response to the medication and update the doctor in follow-up. LPN-E stated she had been provided with education regarding the use of [MEDICATION NAME] following the identification of the [MEDICATION NAME] medication administration and R269's transfer to the emergency room . On 11/25/19, at 3:43 p.m. the assistant director of nursing (ADON) stated on 11/22/19, upon the ambulance's arrival to the facility, the paramedics determined what had happened. ADON stated she had observed R269 exhibiting [MEDICAL CONDITION] movements, with arms flexing and extending. ADON also demonstrated facial movements of contortion, opening and closing of mouth, and stated resident was making groaning/grunting noises. The ADON stated after R269 was transported to ER for evaluation, she had followed up with TMA-C, whom informed her R269 had received both doses of [MEDICATION NAME] in the box, as the order on the MAR indicated to repeat dose if no reaction. ADON stated the empty box of [MEDICATION NAME] was removed from the cart on 11/22/19, however, ASON was unaware a subsequent dosing had been received on 11/23/19 and was availble for use as observed by surveyor on 11/25/19 at 2:26 p.m. Subsuquent follow up was completed by the DON; however ADON stated she was unaware of any training having been provided to staff administering medication since 11/22/19, pertaining to the administration of [MEDICATION NAME]. ADON stated R269 returned to the facility on [DATE], a few hours after being sent via ambulance and she (ADON) had spoken with her upon her return. ADON stated R269 was unaware of specific details of the event at that time, but was aware she had received [MEDICATION NAME], experienced subsequent withdrawal and needed IV medication. ADON stated she was unaware of any paperwork received following the visit to ER, or any orders for a change in treatment adding she assumed the evening nurse had reviewed any new orders received upon return. On 11/25/19, at 3:55 p.m. the DON stated she was at the nurses station and observed R269 become rigid and start grinding her teeth which caused R269 to be sent off for evaluation. DON stated the [MEDICATION NAME] was removed from the cart; however, stated there was dosing available in the locked emergency kit. DON stated an incident report was completed and she proceeded to provide education to staff members regarding the use of [MEDICATION NAME] by using a [MEDICATION NAME] information supplied from a website called, Drugs.com. DON stated TMA-C was sent home and was not currently on the schedule as a result of the [MEDICATION NAME] administration. A listing was provided of staff members who had been provided with training on [MEDICATION NAME] which included 13 staff members, including the DON. A provided staff listing identified 35 staff were responsible for medication administration including TMA's, LPN's, and RN's. The DON stated she was going to follow up with staff education on 11/25/19; however, the DON added she was unaware the [MEDICATION NAME] had been reordered on [DATE] and placed back in the cart until it was removed on 11/25/19 by ADON, after it was shown to her by the surveyor on 11/25/19, at 2:26 p.m. R269's untitled facility incident report dated 11/22/19, identified R269 experienced . shaking and grinding her teeth 13 times (sic). The report identified R269 was sent to ER for evaluation and the DON removed the medication from the cart. The report indicated staff training was to be completed. DON stated she obtained a copy of the [MEDICATION NAME] product information and reviewed this information with staff present on duty on 11/22/19. An employee listing to identify training was provided and indicated training was provided on 11/22/19 and 11/25/19. R269's Inter Agency Transfer Form edited 11/15/19, identified R269 was to receive [MEDICATION NAME] 4 mg/0.1 ml nasal spray. The order listed instructions for use which directed after removing nasal spray from box, gently insert the tip of the nozzle into either nostril. Press the plunger firmly to give dose; remove device form nose. If no reaction in 2-3 minutes, give a second dose. R269's physician order [REDACTED]. The order was entered by LPN-B on 11/15/19. R269's entire medical record was reviewed and lacked any evidence the original order had been clarified to ensure proper frequency of administration. There was no evidence or original order which identified to give the [MEDICATION NAME] on a daily basis. Further, the entry did not reflect a review of the orders by a second staff member. On 11/26/19, at 10:05 a.m. R269's primary medical doctor (MD)-A was at the facility and was scheduled to see R269 for her initial visit. R269 had been seen by nurse practitioner (NP)-A on 11/18/19 for the initial visit following admission. MD-A stated if the order for [MEDICATION NAME] was unclear, the order should have been clarified by the provider. Additionally, MD-A stated with R269 being on chronic [MEDICATION NAME], she did not think an order of [MEDICATION NAME] was appropriate. MD-A stated she was unaware of R269's [MEDICAL CONDITION] activity, but stated [MEDICATION NAME] can cause withdrawals from pain medication and stated R269 being provided [MEDICATION NAME] in combination with her [MEDICATION NAME] and [MEDICATION NAME] was not a good thing. MD-A stated this would be undoing the purpose for her [MEDICATION NAME], which was to prevent her from withdrawal and to prevent her from using other drugs, adding the patient would feel horrible. MD-A stated she typically would not manage these medications as R269 was followed at the [MEDICATION NAME] clinic, and these medications should be managed by an addiction specialist. MD-A stated upon resident return to the facility, MD-A stated she would anticipate an update on the resident status with any changes of medications or orders identified. Further, MD-A stated if someone returned from the ER without papers, it would be expected that they communicate with the hospital immediately to verify what was done, what was ordered, and if any follow up was indicated. MD-A reviewed her electronic communication system to verify she had not received notification of the visit to ER. R269's progress note(s) dated 11/22/19 to 11/27/19 were reviewed and identified the following: On 11/25/19, a late entry for 11/22/19 day shift was completed. Which identified R269 was transferred via EMS to the ER for evaluation of adverse reactions identified as runny nose, yawning, weakness, trembling, and what appeared as convulsions. A subsequent note of 11/22/19, at 2:44 p.m. indicated R269 was being sent back from the ER. The note did not identify or dictate any need for follow up or any change in R269's physician orders. On 11/22/19, at 5:21 p.m. R269 returned from the ER and the note recorded her vital signs were within normal ranges and resident did not appear in distress. The note indicated R269 was alert and oriented and able to express needs. However, R269's medical record lacked any evidence the staff clarified or obtained further direction on the ongoing use of R269's [MEDICATION NAME] and subsequent management of her developed withdrawal symptoms; nor any evidence of the staff attempting to contact the hospital or other providers to obtain any clarification on the orders. R269's ED Records dated 11/22/19, identified R269 was provided with an intramuscular (IM) injection of [MEDICATION NAME] (A medication which blocks the actions of chemicals in the body that can trigger nausea and vomiting) on the way to the ER. Upon arrival to the ER, R269 was identified as having experienced nausea, vomiting, diarrhea, shaking, and anxiety. The note identified R269 had vomited on her shirt upon arrival to the ER. R269's heart rate was 105 beats per minute (identified as being outside of normal limits), and her blood pressure was 152/48 mm/Hg (millimeters of mercury). R269 was described as appearing uncomfortable and diffusely tremulous (widespread trembling or tremors). The section Medical Decision Making and Plan, indicate R269 presented to the ER in florid opiate withdrawal (manifesting a complete and typical clinical syndrome of opiate withdrawal) and was described as having an elevated heart rate and anxious appearance. The note indicated R269 had received an IM injection of [MEDICATION NAME] (an antipsychotic medication) while in the ER. On 11/26/19, at 10:53 a.m. LPN-B explained the process for entering physician orders [REDACTED]. The first person completing the orders reviews and transcribes the orders, then flags the chart for review. LPN-B stated a second person was then responsible to review the orders for accuracy. LPN-B reviewed R269's medical record and verified the [MEDICATION NAME] was initially transcribed as daily despite not having any frequency or indication for use that was listed from the hospital on administration. LPN-B stated the entry was completed by accident as he had pushed the wrong button and it got saved as daily. LPN-B stated he was unaware of who had checked the order. LPN-B stated there were so many things going on at one time, it was just something that was skipped. On 11/26/19, at 11:27 a.m. RN-B was interviewed and stated she worked the evening R269 returned from the hospital after receiving the [MEDICATION NAME]. RN-B stated R269 did not return with any new orders or paperwork from the hospital. RN-B stated if she had received orders, she would have placed a call to the primary provider; however, as she did not receive any orders she did not do so. RN-B stated if paperwork was not received with ER visit, this was generally documented and acknowledged she did not call the ER to follow-up despite R269 not having any paperwork. On 11/26/19, at 12:58 p.m. the Consultant Pharmacist (CP) stated upon admission to the facility, the physician orders [REDACTED]. Upon review of his notes, CP stated he had reviewed R269's orders on 11/18/19, and noted recommendations were made, however, they were none related to the order for [MEDICATION NAME]. CP reviewed R269's order for [MEDICATION NAME] when asked by the surveyor and stated it must had been missed as a transcription error. CP stated although R269 did not routinely use her as-needed [MEDICATION NAME], the use of [MEDICATION NAME] while taking [MEDICATION NAME] would likely decrease the benefits of the [MEDICATION NAME] and potentially cause symptoms of withdrawal (i.e. runny nose, yawning, [MEDICAL CONDITION] activity). CP stated the order for [MEDICATION NAME] was not clearly written or transcribed and he would have expected the facility to have clarified the order with the provider to ensure resident safety. On 11/26/19, at 1:16 p.m. LPN-D stated when R269 left for the hospital, she had reviewed and revised R269's MAR as she noticed it was incorrect. However, LPN-D stated she just changed it without obtaining any clarification on the order from the provider and reiterated there had been no additional contact with the physician to clarify the [MEDICATION NAME] order. On 11/26/19, at 1:28 p.m. a meeting was held with the administrator, DON, and ADON. The administrator stated he had self reported the information regarding the med error to the state agency (SA). The DON stated she was present at the nurse's station when this occurred and called 9-1-1. R269 was transported to the ER for evaluation. DON stated although she had recently started at the facility less than a month ago, she inquired of the process for implementing orders and performing the second check for accuracy. DON stated she had been informed by LPN-B this had not worked because orders generally required immediate activation, and a second check did not allow for timely processing. ADON stated she had found out approximately a week ago, when entering an order as pending, the orders deleted from the system after one day. ADON stated she was unaware of a formalized system for processing orders, but stated the chart tabbing system would work. ADON stated all orders should be signed off as transcribed, and then signed off with a secondary check. These signatures should appear on the document, not just with electronic entry. ADON stated there needed to be two people signing off when orders were checked. The ADON, DON and administrator reviewed R269's original order for [MEDICATION NAME] and verified the order lacked indication and frequency for usage. The DON stated the order had not been clarified with the physician prior to transcription, and the frequency outlined on the MAR was not reflected in the initial order. In addition, the DON stated she was unable to find any orders or paperwork sent in follow-up after R269 returned from theER on [DATE], adding they assumed the correct orders were in place; however, stated the papers/orders were not in the medical record. A policy, titled Transcription of Prescriptions dated (MONTH) 2019, identified transcription as being when one nurse takes medication orders and details from the physician's orders [REDACTED]. A section labeled, Procedure, directed the transcription of a prescription should involve two nurses, the ADON or designee, and the night nurse will counter-sign MD orders verifying a review and no transcription errors. Further, the policy directed, Any nurse administering medication who is unclear about a transcribed prescription should not proceed until they verify or confirm the prescription with the medical practitioner or pharmacist. The IJ which began on 11/15/19, was removed on 11/27/19, when the facility successfully implemented a removal plan which included obtaining a clarified order for R269's [MEDICATION NAME] including when and how often to administer the medication, educating nursing staff on the process for safe medication order transcription and ensuring only licensed nursing personnel administer [MEDICATION NAME] going forward. On 11/27/19, from 12:40 p.m. to 12:52 p.m. direct nursing staff were interviewed and verified the education for the removal plan had been completed and systems were now in place to ensure accurate, safe order transcription. R24's admission Minimum Data Set ((MDS) dated [DATE], identified R24 had intact cognition, had [MEDICAL CONDITION] or [MEDICAL CONDITIONS] and received [MEDICAL TREATMENT]. Further, R24's Twin Cities Physicians order, dated 10/7/19, identified a prescription for calcium acetate (sometimes referred to as Phoslo; a supplement used to control the level of [MEDICATION NAME] in the blood for patients on [MEDICAL TREATMENT] due to severe kidney disease) 667 milligrams (mg) capsules. The directions written by the physician directed, Take 3 capsules (2001 mg) by mouth three times a day with meals. In addition, R24's most recent Adequacy of [MEDICAL TREATMENT] laboratory report, dated 11/4/19, identified several laboratory results for R24 including a [MEDICATION NAME] level recorded as 8.7 mg/dl (milligrams per deciliter) with a reference range (desired range) of 2.4 to 5.1 mg/dl. On 11/19/19, at 1:19 p.m. R24 was seated in his room on the bedside visiting with the surveyor and explained he had just finished his lunch meal approximately 30 minutes prior. At this time, trained medication aide (TMA)-A entered the room with a cup full of medications and provided it to R24. When questioned on the medications inside, R24 stated it was his Phoslo pills which he takes several times a day since he was on [MEDICAL TREATMENT]. R24 stated the staff usually bring him the Phoslo outside of meal times, but he thought taking it within an hour or two of eating was OK. Later on 11/19/19, at 6:31 p.m. TMA-B was passing medications on R24's hallway. TMA-B was interviewed and explained she did not provide R24 any medications during the supper meal (5:30 p.m.) as he didn't have any scheduled until bedtime. TMA-B reviewed R24's Medication Administration Record (MAR) and stated R24 had four medications, including the ordered calcium acetate, ordered in the MAR for 8:00 p.m. TMA-B provided R24's packaged calcium acetate to the surveyor. The label affixed to the outside of the punch-style package directed to take the medication three times daily with meals. When questioned about the label directing the medication be taken with meals, TMA-B stated the medication should be given at meals. R24's MAR dated 11/2019, identified an order for [REDACTED]. The order lacked any indication to provide the medication with food or meals, and listed three times for administration which included 8:00 a.m., 2:00 p.m. and 8:00 p.m. with all of the spaces to record administration of the medication filled in verifying the medication had been provided at those listed times. Further, the order start date on the MAR was recorded as 10/8/19, which identified the medication had been provided at these times since that date. When interviewed on 11/19/19, at 6:54 p.m. the director of nursing (DON) stated R24's calcium acetate should be given with meals, and giving it outside of the ordered meal times could contribute to R24's higher [MEDICATION NAME] level. R24's calcium acetate used to be given to him at meals, however, it had somehow gotten switched to different times back in (MONTH) 2019. Further, the DON stated giving R24 the calcium acetate outside of meal times would be considered a medication error. During interview on 11/20/19, at 8:46 a.m. the consulting pharmacist (CP) stated he reviewed R24's record and the ordered calcium acetate was being given not as it was ordered with meals. This could play some role in R24's current elevated phosphorus level. On 11/20/19, at 3:06 p.m. the [MEDICAL TREATMENT] registered dietician (RD)-C was interviewed and stated she was unaware the nursing home staff were giving R24 his calcium acetate outside of meals. RD-C explained giving R24 the medication outside of meal times could cause elevated blood phosphorus levels and added, That would explain why his (R24) phosphorus is high. RD-C expressed R24's ideal blood phosphorus level would be somewhere between 3.0 and 5.5 (mg/dl) and stated the staff should be giving the medication correctly to help reduce R24's blood phosphorus levels to help prevent weakened bones, [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (a serious disease in which calcium accumulates in small blood vessels of the fat and skin tissues). An undated Food and Drug Administration (FDA) Supplement Approval posting identified calcium acetate is used to control high blood phosphorus levels in patients with [MEDICAL CONDITION]. The directions listed identified the medication should be taken . with each meal. An undated Medication Orders policy was provided. The policy directed each resident must be under the care of a licensed physician and a current list of orders must be maintained in the medical record. A section labeled, Recording Orders, was listed which directed staff to record orders for the medication including specifying the type, route, dosage, frequency and strength of each medication ordered; however, the policy lacked any information on how to ensure orders were correct and being administered correctly with special instructions (i.e. giving with meals). No further policies on medication error(s) or subsequent procedures were provided.

Based on observation, interview and document review, the facility failed to ensure mechanical lift sling(s) were accurately assessed, sized and used to prevent injury according to manufacturer's instructions and guidelines for 1 of 1 residents (R67) who sustained a fall from sling, while being transferred, resulting in an injury. These findings resulted in an immediate jeopardy (IJ) for R67 who was continued to be transferred by all direct care staff who provided care after R67's fall without being re-educated to the manufacturer's guidelines for operation, use of disposable slings after being laundered against manufacture's instructions and continued use of slings not assessed to be appropriate for each resident, which could have resulted in additional falls and subsequent harm and/or significant injuries. The facility failed to have a system to ensure that correct size slings were used for each resident, correct slings were used with each mechanical lift and re-education was provided for safe operation of the mechanical lifts which had the potential to affect 13 additional residents (R34, R5, R4, R2, R23, R38, R20, R39, R41, R22, R30, R118, and R61) who used a sling and mechanical lift for transfers. The IJ began on 11/1/19, when R67 was transferred in a mechanical lift which was operated against manufacturer's guidelines, using a sling which was not recommended by the manufacturer for ongoing use after being machine laundered. These factors contributed to R67 falling from the sling during a transfer and resulted in him striking his head and having blurred vision and dizziness which needed to be evaluated at the hospital. Upon R67's return, the facility failed to ensure R67's mechanical lift transfers were assessed for the correct sling size, continued use of disposable slings after being machine laundered, and failed to ensure staff were appropriately re-trained in their use resulting in the potential for continued falls and subsequent high potential for serious harm and/or injury. The administrator, director of nursing (DON), and facility owner (FO) were notified of the IJ for R67 on 11/22/19, at 2:51 p.m. The IJ was removed on 11/24/19, at 2:49 p.m., but noncompliance remained at the lower scope and severity of isolated actual harm which is not immediate jeopardy (Level G). In addition, the facility failed to prevent the elopement and provide safety for 1 of 1 residents (R68) who was identified as an elopement risk and whom had repeated elopements. This resulted in an immediate jeopardy (IJ) situation for R68 when the facility failed to ensure appropriate, systemic actions were taken to prevent similar occurrences, after R68 was identified as missing. The IJ began on 11/05/19, when R68 was sent to a medical appointment off-campus at an acute care hospital unsupervised with a transportation company despite having a [MEDICAL CONDITION] (TBI). R68 did not return following the medical appointment with the transportation company, and was returned to the facility by his family who found him wandering around by his family's house, over two miles away from the nursing home. Two days later, on 11/7/19, R68 returned from a medical appointment with staff, upon their return R68 was not adequately supervised and eloped from the facility. He was found several hours later by a family member (FM)-C at their home. R68 was cold, wet, incontinent of urine, and with bloody feet. R68 was then brought to the Emergency Department (ED) for treatment, and admitted to the psychiatric unit for his continued safety. The administrator, DON, and FO were notified of the IJ for R68 on 11/21/19, at 3:15 p.m. The IJ was removed on 11/24/19, at 2:49 p.m., but non-compliance remained at the lower scope and severity of isolated potential for more than minimal harm which is not immediate jeopardy (Level D). Findings include: MECHANICAL LIFTS: A Minnesota Department of Health (MDH) intake form 11/01/19, identified a received complaint which described on 11/01/19, R67 informed reporter that he was recently dropped from a Hoyer (mechanical lift) sling, and was seen in the emergency room and returned to the facility the same day. However, the reporter further indicated R67 was admitted to the hospital on [DATE], through 11/03/19, due to ongoing headaches, dizziness, and complaint of only seeing light and dark from his right eye. A second report was submitted to the Minnesota Department of Health (MDH) intake form 11/12/19, identified a complaint which described on 11/01/19, R67 informed reporter that he was recently dropped from a Hoyer sling, and shortly after was nearly dropped a second time. The reporter stated the facility was contacted, and spoke with the director of nursing, who stated she was not sure if the fall R67 mention had been reported. R67's 5-day PPS (Prospective Payment System) Minimum Data Set ((MDS) dated [DATE], identified R67 was cognitively intact and required extensive assistance with bed mobility, was totally dependent on staff for transfers, and was administered an anticoagulant medication (used to thin the blood) on a daily basis. R67's Care Plan concern (initiation date 09/19/17), indicated: Resident requires total assist with transfers related to ([DIAGNOSES REDACTED]. The only intervention listed was : Total assist of 2 with hoyer lift for transfers. R67's Care Plan did not identify the appropriate sling size that should be used with R67. On 11/18/19, at 10:57 a.m. R67 was interviewed and explained about 2-3 weeks ago he was wanting to get out of his bed and get transferred into his wheelchair however, due to the room size, the staff transferred him from his bed to the hall where his wheelchair was located with a sling and mechanical lift. R67 explained during the transfer from his bed, the sling wasn't hooked up right which caused him to slide out of the sling and fall onto the floor, where he struck his head on his roommate's bed footboard. R67 stated the fall resulted in him having dizziness, a headache and vision changes, which R67 described as he could only see light and dark shapes from his right eye for 2-3 days. R67 described the sling the staff had used when he was transferred as yellow trimmed with rainbow straps adding, during a different transfer which did not result in a fall, he thought he heard ripping sounds while being transferred using the same sling, though unable to recall a date for that transfer. The provided facility nursing assistant care sheets dated 4/19/19, indicated R67 was to be transferred via a sliding board and 1 assist. On 11/20/19, at 10:07 a.m., interview with North Memorial Hospital registered nurse (HRN) stated she was concerned when she found out R67 was in the emergency department (ED) the day before (on 11/01/19), and then admitted the following day with complaints of vision changes and an elevated INR (lab test used to determine blood coagulation (blood clotting) ability) of 7.9 (normal range 2.0 to 3.0). HRN stated R67 had reported to her he did not have vision issues prior to the fall, and woke up this morning with a severe headache that was still present. HRN stated CT scans of R67's head did not reveal any acute cranial concerns. R67's provided Fall Investigation dated 11/01/19, and revised 11/04/19, identified the following, . staff said that this resident was in hoyer sling when he fell out of the sling on to the floor states that he did not hurt himself but hit the back of his head. No sight of injury but (complained of) slight dizziness and head spinning now, no (complaint of) pain . continue to be alert coherent and oriented times 3. The incident report lacked any evidence of an investigation as to the cause of the fall, including wether the fall resulted from staff error or potential mechanical lift and/or sling failure. On 11/20/19, at 10:50 a.m., interview with North Memorial Hospital social worker (HSW) stated R67 had been admitted to the hospital for pneumonia (on 11/12/19) and during that stay informed her of the fall on 11/01/19, where he was dropped from a Hoyer sling to the floor. HSW stated she became more concerned when R67 stated the nursing home staff had dropped him again after the 11/01/19 fall, so HSW called the facility and spoke with DON about R67's voiced concerns. On 11/20/19, at 2:47 p.m. physical therapy assistant (PTA)-A and certified occupational therapy assistant (COTA)-A were interviewed. They had been working on strengthening and transfers with R67 however, currently only the therapy staff were performing manual transfers, and the nursing staff were still to be using the mechanical lift to transfer R67. Therapy had just started using a sliding board with R67 (from bed to wheelchair), but R67 was not ready for nursing to transfer this way. Both COTA-A and PTA-A stated that nursing should be assessing and determining the correct sized slings to be used when transferring residents in the mechanical lifts, adding therapy would only assess someone if they had been asked. Neither the PTA-A nor COTA-A were aware R67 fell from the Hoyer lift. On 11/21/19, at 10:16 a.m. R67 stated the staff did not always use the same lift sling, and pointed to a blue sling sitting on his room chair which was tabled extra large in size. R67 explained when staff transferred him that morning (on 11/21/19), they used a different sling which had rainbow colored trim present. Nursing assistant (NA)-A and licensed practice nurse (LPN)-A entered the room and NA-A grabbed the extra large, blue sling to use. LPN-A stopped NA-A and stated she wanted to check the sling size as it looked too big for R67. LPN-A then left the room. NA-A was interviewed at this time, and stated she determined which sling size to use on each resident by how they looked while on each resident. NA-A then left the room. At 10:37 a.m. NA-A and NA-B returned with an E-Z Way Smart Lift with a yellow trimmed sling (labeled Medium Size), which NA-A stated would work better for R67 as it(s) not too big. The sling was placed around R67 however, NA-A noticed the right sided leg strap loop (used to attach to the machine) was missing. NA-A then left the room to obtain a different sling. At 10:40 a.m. NA-B, who remained in the room, talked with R67 and stated they needed to get a sling in his room that fit him correctly. R67 stated aloud the blue trimmed sling (identified as Extra Large), which had been in his chair prior, would have fit Dumbo (an elephant). At 10:42 a.m. NA-A returned with a different yellow trimmed sling with rainbow strap loops. NA-B and NA-A then transferred R67 from his wheelchair to his bed using the yellow trimmed sling, and then placed the sling on R67's wheelchair. When questioned immediately following, both NA-D and NA-A stated they determined which size of sling to use by looking at the person it would be used on. Further, NA-A and NA-B stated the blue sling which had been placed in R67's room prior was too large for him, and the yellow sling they used instead, fit him perfectly. After R67 was settled in bed, and staff left, the sling utilized to transfer resident was inspected. On the back panel, was noted the manufacturer's logo for Practical Products For Living, Inc and product information which included the following, Patient Specific Sling. Can be Used For Bathing & Showers, Pools ONLY ONCE. Two further labels were noted, with the 1st indicating, Patient Specific with the word Disposable following by the manufacturer posting, Wash Indicator Patient Specific Sling (Disposable) Sling. DO NOT USE THIS SLING THIS SLING HAS BEEN WASHED. A review of the manufacturer's information for Patient Specific Slings (undated) from Practical Products For Living, Inc. identified, All disposable slings come with 'WASH INDICATORS' to alert staff that the sling has been washed. Further, Disposable slings can be 'Spot Cleaned' and have a 'Cloth Type' feel that is more comfortable for most patients. In a telephone interview on 11/21/19, at 1:30 p.m. a Practical Products representative (PPR) stated the mechanical lift slings being described were disposable, and the black indicator (which contained the language outlined above) on the back of the sling washes away when the sling is laundered. PPR stated the sling should not be used by facility staff afterwards. The sling was only able to be spot cleaned and not laundered, and used by one resident several times as long as not laundered beyond spot cleaning. PPR explained when a disposable sling was laundered, it will destroy the product and weaken the fibers, straps, and loops which could cause it to break and lead to an accident or fall. Further, PPR stated if the facility had laundered the slings exposing the black indicators, then the slings should be discarded and not used. During telephone interview on 11/21/19 at 2:40 p.m., the Minnesota Based Sales Representative (MBRS) for Inovihealthcare (who sells disposable slings for Practical Products For Living) stated the disposable slings could be thrown out after one use, or spot cleaned if used for a specific resident. MBRS explained each sling had a black laundry indicator square on it's back which washed away if the sling had been laundered revealing a message to not use again. MBRS stated if the slings are washed, then their strength and overall integrity were affected, and using them could cause a fall and serious injury. During an interview on 11/21/19, at 3:29 p.m. LPN-B stated he completed R67's Fall Investigation report at the time of the fall, and educated the two NA who assisted R67 on how R67 should be positioned in the mechanical lift sling. However, LPN-B acknowledged he did not document any of this re-education. Further, LPN-B stated he did not do any further investigation into the fall aside from what had been documented on the completed investigation adding he could not recall what color or sized sling had been used when R67 sustained the fall from the lift. The provided facility nursing assistant care sheets dated 4/19/19, sheets identified 13 additional residents (R34, R5, R4, R2, R23, R38, R20, R39, R41, R22, R30, R118, and R61) used the mechanical lifts for transfers. However, all of the provided care sheets lacked any direction or dictation to identify which size sling should be used to transfer them. On 11/21/19, at 3:43 p.m. NA-C was interviewed and verified she was one of the two NAs present when R67 sustained the fall from the mechanical lift. NA-C stated she could not recall which size lift sling had been used however, recalled it was yellow in color with rainbow colored straps. NA-C explained when she had arrived in R67's room, R67 had already had the sling wrapped around him and he was attached to the mechanical lift. NA-C and NA-D both checked the strap loops to ensure they were behind the black rubber [MEDICATION NAME] (used to prevent the strap loops from coming off the metal loops furring transfer) and raised him up from his bed. As R67 was being pushed in the mechanical lift from his bed to the wheelchair in the hallway, NA-C explained NA-D pushed the lift from behind and she (NA-C) pulled on the sling straps from the front until approximately one-half way across the room, when one of the front loops became detached causing R67 to fall approximately three feet onto the floor, where he struck his head on the bed footboard. NA-C stated the floor staff do not have a document or process to demonstrate which size sling should be used for each resident, and because R67's room is small, one staff person was behind him with the controls and the other was in front pulling on the sling. NA-C stated the floor staff determine which sling to use for each resident based on their size. Further, NA-C stated they had not been asked about how the fall occurred, except by LPN-B adding no other nurses, the DON or anyone from administration had questioned her about how the fall had happened. R67's medical record was reviewed with a incident report, dated 11/01/19, which indicated R67 had a fall from a Hoyer sling lift. The report indicated R67 was oriented times 3, vital signs were taken, and R67 reported hitting the back of his head and complained of dizziness and head spinning. Although the facility filed an incident report within R67's medical record, the medical record lacked evidence that a comprehensive fall assessment had been completed to determine any causative factors pertaining to R67's fall. Furthermore, the facility lacked any indication the facility had reviewed R67's fall as being an inappropriate transfer (someone pushing and the other pulling on the sling), the sling size which had been used, or if the disposable sling contributed to R67's fall. On 11/21/19, 11/22/19, and 11/25/19, attempts were made to contact the NA-D to interview regarding R67's fall however, NA-D did not return any calls. The facility provided skills performance reviews for NA-C and NA-D dated 11/1/19, for the use of the mechanical lift. However, the registered nurse (RN) who performed the skills assessment no longer worked at the facility and was unable to be contacted. On 11/21/19, at 5:25 pm. a tour of the facility's laundry room was completed with LPN-[NAME] LPN-G was shown three (3) disposable lift slings which had just been laundered and were ready to be sent back out to the floor for use. LPN-G verified the black indicators on the rear of the slings had been washed off which revealed the manufacturer's message the sling should not be used. LPN-G took the slings and stated, We would throw them away and replace them. During a phone interview on 11/22/19, at 8:59 a.m. E-Z Lift Company representative (EZR) stated EZ Way lifts should only be operated with EZ brand slings as other company slings have not been tested with their lifts which caused a potential safety hazards and potential falls. EZR stated slings straps should only be pulled on when a resident is on a transfer surface, and staff are adjusting the fit and attaching to the lift clips. EZR stated pulling on straps while a resident is suspended, can cause the straps to be pulled off the clips causing falls, and can change the center of gravity of the lift, causing the lift to tip. A telephone interview on 11/22/19, at 12:55 p.m. a representative for Barrier Lifts (a manufacturer of disposable slings) (BLR) stated when the facility started purchasing the disposable slings she provided on-site training to facility staff on how to use and care for the slings. BLR stated the inservice included education that the slings were for single patient use and were not to be washed because the integrity of the fiber becomes compromised. BLR stated each box comes with care instructions as well, and if a sling becomes soiled to the point of needing to be cleaned it should be thrown, and a new sling in a bag should be taken from the box. BLR further stated the slings were not to be shared between residents for infection control purposes. During transfer observation on 11/21/19, at 10:40 a.m., it was noted the facility utilized E-Z Way mechanical lifts. A review of the E-Z Way lift Operator's Instruction (undated), indicated: EZ Way slings are made specifically for EZ Way Smart Lift®s. For the safety of the patient and caregiver, only EZ Way slings should be used with EZ Way lifts. During an interview on 11/21/19, at 3:46 p.m. LPN-G and the DON were shown the disposable slings being used. Neither one realized they were manufactured to be disposable and were not to be laundered. When showed the missing laundry indicator, both LPN-G and DON stated the slings should not be used. LPN-G stated the facility had been using the slings for several months. The DON, who was new, was unaware of the slings were disposable, and was unaware the slings were being shared between residents. Both were also unaware the E-Z Lift manufacturer recommendations indicated only E-Z Lift slings should be used with their lifts. On 11/22/19, at 10:18 a.m. the FO, administrator, DON and assistant director or nursing (ADON) were interviewed. All present voiced they were unaware these disposable slings were used throughout the facility and not meant to be used after being laundered. When questioned regarding the interchangeable use of EZ Way lifts with other manufacturer brand sling(s), the FO stated he felt EZ-Way just wanted their slings purchased. The administrator confirmed there had been no additional investigation in R67's fall outside of the completed investigation report, and all present confirmed there had been no facility-wide education completed with the staff pertaining to the correct sizing of slings, or safe operation of the mechanical lifts which contributed to R67's fall on 11/1/19. A facility policy on mechanical lift operation and sling sizing was requested however, none was provided. The IJ which began on 11/1/19, was removed on 11/24/19 at 2:49 p.m., when the facility successfully implemented a removal plan which consisted of ensuring all disposable slings were removed and no longer in use after being laundered. New mechanical lifts and slings were purchased as identified by the manufacture. Education was also conducted to licensed and non-licensed nursing staff on ensuring safe transfers with the correct sized sling for each resident. On 11/24/19, from approximately 1:30 p.m. to 2:30 p.m. direct care staff were interviewed and verified education had been completed, and systems were in place to ensure residents were transferred using appropriate methods, and correctly sized slings to prevent further falls and potential injury. ELOPEMENT: A received Common Entry Point Intake Form dated 11/10/19, identified a complaint had been filed with the State Agency (SA) about R68 having repeated elopements. The form identified R68 had a [MEDICAL CONDITION] (TBI), and had been sent unsupervised from the nursing home to a medical appointment on 11/5/19, where he was supposed to meet family. However, R68's family member (FM) then discovered R68 at a relative's house over two miles away from where his appointment had been. The report alleged R68 had been missing for several hours as a result of being sent unsupervised. The nursing home was contacted regarding the incident via family members. The nursing home then identified someone from the nursing home would accompany R68 to future appointments to avoid the same incident(s) in the future. On 11/7/19, R68 was again sent to an 11:00 a.m. medical appointment however, at approximately 5:30 p.m. R68 was spotted by family neighbors walking down an alley towards his relative's home. The report identified R68 as, . appeared very cold, and had wet himself. Further, the report identified R68 had blood on his foot, and was taken to a local hospital where he was subsequently hospitalized . R68's Continuity of Care Document dated 10/31/19, identified the course of R68's hospitalization prior to his admission to the nursing home. R68's admission [DIAGNOSES REDACTED]. Further, the note identified R68 required a helmet when out of bed, and supervision with all mobility without an assistive device . (due to) impaired cognition and safety awareness. R68's nursing home Admission Record printed 11/27/19, identified R68 had a history of [REDACTED]. Further, R68's admission MDS dated [DATE], was not completed, and the section to record R68's cognition was left blank. R68's nursing home progress note(s) dated 11/1/19, to 11/12/19, were reviewed, and identified the following entries: On 11/1/19, R68 was recorded as alert and orientated with confusion. The note described, Helmet is on head in bed resting, no distress noted. There were no recorded progress notes from 11/4/19, to 11/6/19. On 11/7/19, at 5:59 p.m. the nursing home contacted R68's relative . to find out when she will be bringing the patient back to the facility. Family member (FM)-C admitted that (R68) was at her place. A subsequent note dated 11/7/19, at 8:10 p.m. indicated, Hospital called that (FM-C) took (R68) to the hospital and current (sic) at the hospital. On 11/8/19, at 7:32 a.m. R68 was recorded as being hospitalized . Further, a subsequent note dated 11/8/19, at 4:13 p.m. identified the facility social worker (SW) had approached R68 with the facility's alcohol and substance abuse policy. The note recorded, Resident signed and dated policy and was given a copy. This note was recorded despite R68 being hospitalized and off-campus. No further progress notes were recorded which demonstrated R68 wandered, eloped and/or had been sent to a medical appointment without supervision. Further, there was no evidence in the medical record R68 had been assessed for elopement risk upon his initial admission to the nursing home. On 11/20/19, at 10:55 a.m. the health unit coordinator (HUC)-A and activity assistant (AA)-A were interviewed. HUC-A stated he had made a medical appointment for R68 on 11/5/19, at 9:00 a.m. and he did not have staff accompany him to the appointment adding R68 had been sent to the appointment using Travel-On transport. At 10:45 a.m. HUC-A received a phone call from the hospital (where R68's appointment had been) and was told R68 never arrived for the appointment as scheduled. HUC-A explained he proceeded to contact the transportation company who voiced they had dropped him off and left. After this incident occurred on 11/5/19, HUC-A stated the facility had ordered some wanderguard signal devices since they had run out and had none left to use. R68 had another appointment scheduled for 11/7/19, and AA-A attended the appointment with him then they both returned to the nursing home. AA-A stated she had not been informed R68 could not be left alone due to his risk of elopement and wandering, and just went with him to the appointment as R68 wore a helmet and she thought he appeared vulnerable and needed someone to go with him. HUC-A stated she was unaware R68 had then eloped from the nursing home after returning from his appointment, nor was she aware R68 had apparently walked from the nursing home to his relative's house which was several miles away. Further, HUC-A stated R68 never had a wanderguard placed on him as they had not arrived before his hospitalization and subsequent discharge from the nursing home on 11/8/19, and provided the WanderGuard signal device(s) receipt to review. The corresponding Stanley Security Solutions, Inc Order Form dated 11/7/19, identified the facility had ordered the signaling device for their WanderGuard system on 11/7/19, not on 11/6/19, as the facility completed report identified. Further, the receipt identified the receipt was printed for shipping on 11/7/19, at 1:02 p.m. A subsequently completed Wandering Risk Assessment signed 11/6/19, by licensed practical nurse (LPN)-I, identified R68 was assessed as being forgetful with a short attention span and not understanding his surroundings. R68 was a new admission within the past month, independent with his mobility, and consumed anti-anxiety and/or hypnotic medications along with narcotics. Further, the assessment identified R68 as, Moderate Risk for Wandering. The assessment lacked any identified interventions or subsequent actions which could or would be taken to reduce R68's risk for elopement. During interview on 11/21/19, at 10:02 a.m. licensed practical nurse (LPN)-I stated she was unsure if she had completed and locked R68's Wandering Risk Assessment on 11/6/19, and was aware he had a history of [REDACTED]. Further, LPN-I stated herself and the DON, whom she reported R68 needing a wanderguard to, both no longer worked for the facility. R68's undated care plan identified R68 had a history of [REDACTED]. However, the care plan lacked any recorded problem statements, goals or interventions pertaining to R68 being at risk for wandering and/or subsequent elopement despite R68 being assessed on 11/6/19, as at risk for wandering and potential, subsequent elopement. On 11/20/19, at approximately 11:15 a.m. the activity director (AD) provided two lists which had been used to alert staff to the identified residents as risk for wandering and subsequent elopement. However, AD was interviewed about the provided list(s) and verified R68's name had never been added to the lists. A Wander Guard List dated 11/1/19 was provided and identified a total of five residents were listed as using wanderguard devices to help prevent elopement. A subsequent list dated 11/12/19, identified four residents now used the wanderguard system. However, R68's name was absent from both of these lists. Further, the lists identified it was facility' policy that no resident with a wanderguard was allowed to leave the facility without an escort which included to medical appointments. No other lists or documentation was provided to demonstrate R68 had been added to the wanderguard list so staff would have immediate knowledge to be vigilant for his whereabouts to help prevent elopement. During interview on 11/20/19, at 1:59 p.m. the front desk receptionist (FDR)-A stated a wander guard book was kept at the front desk which contained the residents name and photo who were determined to be at risk for elopement. However, FDR-A stated R68 had never been listed as an elopement risk in the wanderguard book to her knowledge. During interview on 11/20/19, at 3:29 p.m. family member (FM)-D stated on 11/05/19, R68 was supposed to be at his medical appointment, however, he was instead found at FM-C's house rummaging through her kitchen. FM-D explained on 11/07/19, R68 was found in an alley way next to FM-C's house with his helmet on. FM-D was upset and stated they told the director R68 would not be returning to the nursing home as he was found incontinent of urine and had bloody feet. R68 was then taken from FM-C's house to the Emergency Department (ED) where they kept him for safety as it was apparently not safe for him to be at Victory since this was his second elopement while under their care. When interviewed on 11/20/19, at 4:14 p.m. FM-E stated R68 had missed his appointment on 11/05/19, so she had called the facility and nobody had any idea what had happened. FM-E stated she had spoken to the administrator and HUC-A about her concerns with R68 missing the appointment. FM-E explained on 11/7/19, R68 had been sent to another appointment; however, after returning to the nursing home he had somehow eloped and went missing until around 5:30 p.m. when FM-C's neighbor had found him. FM-E stated R68 was an elopement risk and the facility should have known that due to his prior history of eloping from the hospital which occurred prior to his admission to the nursing home. The National Weather Service (NWS) Climatology Report dated 11/7/19, identified the maximum temperature of the day was 28 degrees (F) and low temperature was 15 F. During interview on 11/20/19, at 11:54 a.m. the facility administrator stated he had filed a vulnerable adult report with the SA regarding R68's elopement and proceeded to hand the surveyor a manilla colored file. The administrator stated, Everything should be in the file and there is a lot going on here and things are a little fuzzy here. The file was reviewed and identified the following: A facility Investigative Report dated 11/14/19, identified R68 had discharged from the nursing home on 11/8/19, and family member (FM)-C was looking for another care facility to send him to from the hospital. The report identified R68 had been assessed to require a wanderguard (a system which alarms if a patient attempts to leave an area) or a one to one (1:1) which the administrator told the director o

Based on observation, interview, and document review, the facility failed to comprehensively assess, adequately monitor, and develop interventions to ensure safety and reduce the risk of injury or harm to 6 of 6 residents (R3, R12, R13, R16, R15, and R14) identified to be consuming alcohol on or off campus. These findings constituted an immediate jeopardy (IJ) situation and substandard quality of care for R3, R12, R13 and R16, who had sustained episodes of resident to resident altercation(s), fall(s) with injuries and/or required emergency medical care due to unsafe alcohol consumption. The IJ began on 10/2/19, when it was identified R3, R12, R13, and R16 had been consuming alcohol in potentially unsafe manners. Although R3, R12, R13, and R16's medical record(s) had documented evidence of unsafe alcohol consumption, and direct care staff had knowledge these residents continued to be consuming alcohol on a recurrent basis, it was not comprehensively assessed nor were interventions developed or in place to ensure adequate monitoring and safety for these residents placing them at risk of substantial harm and/or injury. The administrator, director of nursing (DON) and corporate director of operations were notified of the IJ for R3, R12, R13, and R16 on 10/3/19, at 5:20 p.m. The IJ was removed on 10/5/19, at 12:04 p.m. when the facility implemented a removal plan which included development and implementation of new standardized assessments for use when residents were suspected to be intoxicated, and educating staff on procedures when [MEDICAL CONDITION] was suspected to ensure medications are withheld; however, non-compliance remained at a pattern level with potential for more than minimal harm which was not immediate jeopardy (Level E). In addition, the facility failed to ensure the resident environment was kept in a safe manner to avoid accidents for 1 of 1 residents (R1) who sustained a fall with significant injury while being loaded into an ambulance due to pavement and concrete which was in a state of disrepair. This resulted in actual harm to R1 when the ambulance gurney tipped over due to this concrete and pavement in disrepair causing R1 to fracture her elbow. Findings include: ALCOHOL USE: An undated, facility provided Alcohol and Illegal Substance Policy identified alcohol beverages would only be dispensed upon the written order of a physician with a purpose, To ensure the health and safety of residents. A procedure was listed which identified all alcohol use in the facility would be directed by a physician's orders [REDACTED]. The policy continued, Due to the possible side effects from mixing prescribed medications with alcohol and/or illegal substances, a resident who the facility suspects of being under the influence or believe has been using alcohol or illegal substances will experience the following, and listed several steps to implement including having a nursing assessment and vital signs completed, contacting emergency medical services (EMS) if needed, and having their room searched and the alcohol confiscated and destroyed. Further, the policy directed to contact the physician and request orders for a alcohol level or drug screening if indicated, evaluation in the emergency room (ER) or detox if needed, and, Hold current medications if MD ordered. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition and demonstrated no hallucinations or delusions. On 10/2/19, at 11:25 p.m. R1 was interviewed about their care in the nursing home. R1 stated there were several residents, including R12 and R3, who consume alcohol in the building which scares me. R1 explained some of the ambulatory residents even take orders for others (for alcohol) and then go out to obtain it for them coming back with big ass bottles of vodka. R1 explained a situation had occurred in the past two weeks when a resident was sitting outside and wouldn't wake up as he was too intoxicated (R13). R1 stated she had observed, on several occasions, R3 to walk down to the liquor store or have it delivered to him adding this had happened last probably last week. R1 stated all these concerns had been reported to the facility management; however, they don't do nothing about it. R3's quarterly Minimum Data Set ((MDS) dated [DATE], identified R3 demonstrated no physical or verbal behaviors towards others and was independent with locomotion on and off the unit. However, the MDS' section(s) to complete to identify R3's cognition and mood symptoms were left blank and not completed. In addition, R3's current Order Recap Report printed 10/4/19, identified R3 had [MEDICAL CONDITION] disorder and diabetes mellitus, type II. R3 had current physician orders [REDACTED]. R3's physician orders [REDACTED]. R3's care plan dated revised 8/14/19, identified R3 had an alteration in behavior due to drinking alcohol in his room and refusing care. The care plan listed a goal which read, Will follow VHR (Victory Health & Rehab) policy on drinking through the next review date. Further, the plan included the following interventions to help R3 meet the identified goal which included: Document findings in the progress notes, establish R3 had been drinking or was intoxicated and complete room searches per protocol, offering list(s) of AA (alcoholics anonymous) meetings in the community, update physician, take vital signs per policy and hold medications per policy. On 10/1/19, at 11:48 a.m. R3 was seated in the main dining room at a table. He had a large clear mug in his hand which contained a light tan colored fluid inside. R3 was hesitant to speak with the surveyor and just stated, Everything's going great, as he walked away. Later, on 10/1/19, at 2:38 p.m. R3 was in his room with the doorway closed. The surveyor attempted to interview R3; however, he refused to speak with the surveyor. R3's medical record was reviewed, and the following entries and notes were identified: A progress note entered on 4/5/19, identified R3 had ordered vodka. The nurse completing the note, the DON and the administrator went to R3's room and completed a search. Three empty bottles of vodka and a distilled water container (approximately 1000 milliliters (ml)) which was approximately 1/2 full of Vodka was found. The note identified, Facility Drug (and) alcohol policy initiated. Provided (sic) notified . ordered to hold the following medications for 12 hours: [MEDICATION NAME],, [MEDICATION NAME], and [MEDICATION NAME] (an antidepressant) . also ordered to hold the similar for 12 hours if resident continue (sic) to drink alcohol. R3 was recorded as apologizing for violating the facility' drug and alcohol policy and was educated on not mixing his medications with alcohol consumption. Further, the note directed R3 verbalized understanding and agreed to not violate the policy again. R3's corresponding Physician's Telephone Orders slip dated 4/5/19, identified several orders obtained for R3 when he was suspected to be intoxicated. These included holding his ordered [MEDICATION NAME] and [MEDICATION NAME] for 12 hours. Further, the order included, If (R3) continues to drink alcohol, hold the same medications above for 12 hour span. The order was signed by nurse practitioner (NP)-[NAME] A progress note entered on 4/10/19, identified the social services department visited with R3 about the event recorded on 4/5/19, concerning the alcohol being ordered and/or found in his room. The note directed, (social worker) talked resident after this situation resident said to social worker he is so sorry for this situation (social worker) will be follow up. A progress note entered on 4/12/19, identified R3 had been seen by the in-house psychologist on 4/5/19. The house psychologist would continue to follow up as needed. R3's subsequent Associated Clinic of Psychology (ACP) Contact/Communication note dated 4/5/19, identified the staff had confiscated several bottles of alcohol from R3's room. The note identified education was provided regarding having his room searched which could feel potentially intrusive; however, for R3's safety it could be expected. R3 denied any concerns with wanting or needing assistance to stop drinking; however, the note added, . (R3) had alerted staff he sometimes worries about his alcohol use. A subsequent ACP Progress Note dated 4/19/19, identified R3 had been seen and R3 notes he is not drinking, though has started smoking again instead. R3 had connected with an AA (alcoholics anonymous) mentor who came to the facility, and was attempting to start a AA group there. R3 was encouraged to continue attending these meetings as part of a relapse prevention technique; however, R3 declined to call the mentor at the time and noted he would do it later. The note read, I again encouraged to not put it off. He declined to do it now. Further, a section of the note labeled, Recommendations, directed, AA follow up can continue to be encouraged for sobriety management and mood benefit. However, R3's medical record lacked any evidence the facility had continued to pursue or offer assistance to R3 to create an AA group at the facility, nor attend any meetings offsite to help ensure his continued sobriety despite this recommendation from ACP. A progress note entered on 7/22/19, identified R3 refused to allow the nursing staff to check his blood sugar level or enter his room. The note identified, (R3) was seen with a bag and suspected to have alcohol (liquid) in it, that he had returned from out while he was on LOA (leave of absence). MD (medical doctor) notified about patient behavior. A corresponding On Call Provider Note dated 7/21/19, identified the nursing staff had contacted the physician regarding R3 who had went to the liquor store and . has barricaded himself in his room and does not wish to be seen. Nursing staff are asking what to do with his evening medications - [MEDICATION NAME] ([MEDICATION NAME]; an anticonvulsant) and [MEDICATION NAME] (an anti-diabetic). The note continued, PLAN - Hold evening medications if there is concern the patient is drinking alcohol (and) notify primary Provider on the next working day of this situation and patients current status. However, R3's medical record lacked any evidence of an assessment being conducted to determine if (or how much) alcohol R3 had consumed or his current status with respect to respiratory status, neurological condition or mobility to ensure R3 was safe despite being suspected of drinking alcohol. In addition, R3's Medication Administration Record [REDACTED]. Further, the medical record lacked any evidence of a room search being conducted to verify and/or remove alcohol in accordance with R3's established care plan. A subsequent ACP Progress Note dated 8/23/19, identified R3 had several diagnostic impressions which included, Alcohol use disorder, severe. The session documented, (R3) notes he has abstained from alcohol. The note lacked any evidence ACP had been informed or assessed R3 for alcohol consumption despite being suspected of drinking alcohol on 7/22/19, as recorded in the facility progress notes. Further, the note dictated to continue with previous recommendations as relevant. A progress note entered on 9/2/19, identified R3 went to another resident, R4, room which caused R4 to respond to R3 to shut his door before . he kicks his ass. R3 proceeded to contact 911 as he felt threatened by R4. The note identified, (R3) is under the influences of alcohol and keeps antagonizing (R4). A corresponding Telephone Encounter dated 9/2/19, was completed by the on-call provider which identified, . on call was contacted by answering service. Attempts made to connect to nursing facility without success. R4's significant change MDS dated [DATE], identified R4 had intact cognition. On 10/1/19, at 2:11 p.m. R4 was interviewed about his altercation with R3. R4 explained R3 was one of the residents in the nursing home who consumed alcohol. This caused R3 to become a Dr. Jekyll and Mr. Hyde type person and resulted in a situation on 9/2/19. R4 stated a mutual conversation between himself and R3 had occurred, which R4 told R3 he [MEDICAL CONDITION](human immunodeficiency virus), then a little while later R3 took a red marker and wrote on R4's door to his room, AIDS: Beware. R3 then continued to follow R4 around the building and R4 stated he just went off and struck R3 with a cane. R4 stated R3's action of writing on his doorway was offensive to him. A corresponding incident report dated 9/3/19, was completed which identified staff found R3 . in his room with a bottle of alcoholic drink, mixing it with pop. Writer told (R3) 'you cannot drink here, we have a policy. R3 responded, This is my house and my life, I do what I want. The report identified the writer returned to R3's room a few minutes later to search for the bottle of alcohol; however, the bottle could not be found. Further, a section on the report labeled, Action identified sections to select what actions had been completed in response to the incident including options to select of a care conference was needed, or if the care plan had been reviewed. However, this entire section was left blank and not completed. However, again, R3's medical record lacked any evidence of an assessment being conducted to determine how much alcohol R3 had consumed or his current status with respect to respiratory status, neurological condition or mobility to ensure R3 was safe despite being recorded as consuming alcohol and antagonizing other residents in the facility. R3's MAR indicated [REDACTED]. R3 was provided numerous medications including [MEDICATION NAME] and [MEDICATION NAME]. Further, again, he medical record lacked any evidence of a room search being conducted to verify and/or remove alcohol in accordance with R3's established care plan, nor was there evidence R3 had been comprehensively assessed to determine a plan or subsequent interventions to ensure R3 was safe if he continued to consume alcohol despite having repeated episodes of consuming recorded in the medical record. R3's Progress Notes dated 4/8/19 to 8/12/19, identified R3 had been seen a total of seven times by the physician and/or NP. On 4/8/19, a note identified R3 had a history of [REDACTED]. R3 was re-educated on the facility alcohol policy as a result. On 6/24/19, R3 was recorded as having alcohol dependence; however, this physician identified, . This is currently in remission. The patient had one relapse since his admission to the nursing home, but has been sober now for a couple months. On 7/22/19, R3 was again identified as having alcohol dependence with dictation reading, Patient has had at least 1 relapse since his admission to the nursing home. The note lacked any dictation or evidence the provider seeing R3 at the time had knowledge he had been suspected of consuming alcohol on 7/21/19, despite a physician order [REDACTED]. There were no further physician progress notes [REDACTED]. When interviewed on 10/2/19, at 10:22 a.m. trained medication aide (TMA)-A stated she heard R3 had a resident to resident altercation with R4. R3 had written something inappropriate on R4's doorway which caused R4 to react. TMA-A explained she had never seen R3 consume alcohol at the nursing home; however, had episodes when she can smell (it) on his breath, with the last time being approximately a month prior. TMA-A stated the staff had found bottles of vodka in his room in the past which had been reported to the nurses and added she had heard rumors going around of residents consuming alcohol as they pour it into other containers and then consume it so they aren't caught with it. Further, TMA-A expressed she is not sure what happens when someone is found to have alcohol after it's reported adding, I don't know what to do besides reporting it and she had not been provided any education or guidance on when to potentially hold medications for anyone if suspected to be consuming alcohol. On 10/3/19, at 9:46 a.m. the current temporary social worker (LSW)-A was interviewed and stated he (hadn't) been directly involved in any intervention development or treatment options for R3. The nursing department was assisting to oversee him with his alcohol use, and LSW-A stated from a social services perspective it's a blank page of things they had done. LSW-A stated he had never observed R3 to be consuming alcohol personally, however, was aware there had been situations where he had been intoxicated or suspected to be intoxicated. LSW-A expressed if someone was consuming alcohol they would typically refer them to ACP (psychology services) as one of the starting places for treatment and intervention development; however, LSW-A acknowledged the social services department had not helped R3 facilitate any onsite AA meetings or arrange for him to attend outside meetings per the ACP recommendations as he felt the facility had more pressing concerns to be addressed. During interview on 10/3/19, at 10:00 a.m. licensed practical nurse manager (LPN)-C stated she worked full-time and was the unit manager for the facility. LPN-C stated she was aware there had been concerns with several residents, including R3, going off campus and bringing back alcohol adding it happened mostly on the evening shift. LPN-C stated R3 had been known to drink alcohol in his room, however, R3 did not allow staff into his room. LPN-C stated R3 was always getting alcohol and bringing it back or having it delivered to the nursing home. LPN-C stated she felt residents had the right to do this, so no bag checks or other processes to ensure alcohol wasn't brought inside the facility had been implemented. Further, LPN-C stated nurses should be doing vital signs and notifying the physician if a resident was consuming alcohol to ensure medications were withheld as the side effects could be harmful to them if medication were provided while intoxicated. On 10/3/19, at 2:10 p.m. nurse practitioner (NP)-A was interviewed. NP-A explained she was aware of for sure one episode which R3 had been using alcohol which was some time ago. NP-A stated she was not sure if she had ever been directly notified of the repeated episodes of R3 consuming alcohol and added the order she provided on 4/5/19, to hold certain medications for R3 if found to be consuming alcohol, should have been a blanket order and continued. NP-A explained the staff should contact the physicians each time R3 is found to be consuming alcohol so his medications could be reviewed as R3 was prescribed several medications which could interact with alcohol and cause respiratory depression and potential cause harm to him. NP-A stated a good nursing assessment for someone found to be intoxicated would include reviewing their respiratory status, vital signs, mentation and just their general behavior. Further, NP-A stated she felt R3 was aware of the risks of drinking; however, R3 struggles with his alcohol use and sometimes makes the bad decisions. On 10/3/19, at 11:03 a.m. the director of nursing (DON) was interviewed. The DON stated she started working at the facility in mid-July 2019, and explained residents needed a physician order [REDACTED]. If someone is suspected as being intoxicated, the staff should be monitoring and assessing them for their gait, word slurring and any behavior which is not the norm. If alcohol is found, the resident' room should be searched, the physician should be notified and all the actions taken and assessed should be recorded in the progress notes. The DON reviewed R3's medical record. On 7/22/19, the DON stated the record lacked evidence R3 had been assessed for safety and well-being when found to have alcohol and the MAR indicated [REDACTED]. The DON expressed the progress notes were lacking information and stated R3's medications should have been withheld. On 9/2/19, the DON stated R3's record lacked evidence any vital signs or assessment had been completed despite R3 being recorded as intoxicated to ensure he was safe and not suffering any effects of [MEDICAL CONDITION]. The MAR indicated [REDACTED]. The DON stated the nurse should have done her assessment of R3 and ensure medications were withheld; however, she didn't do all that. Further, the DON stated she was unaware R3 had been potentially bringing alcohol back to the facility, nor was she aware the alcohol use policy was not being implemented during these recorded incidents. On 10/4/19, at 8:43 a.m. a telephone interview was conducted with the evening shift registered nurse supervisor (RN)-[NAME] He stated he was aware of a couple incidents when residents, including R3, would leave the nursing home and return intoxicated or with alcohol. RN-A explained the TMA staff were assigned to pass medications on the shift(s) and he had not provided them any instruction or direction to hold medications when someone was suspected as being intoxicated, nor had he been told to monitor any specific residents for potential alcohol consumption despite knowledge of some residents going off campus and consuming alcohol. RN-B stated he was unaware R3 did not have his medications withheld when he consumed alcohol on the date(s) outlined in the progress notes R12's quarterly MDS dated [DATE], identified R12 had intact cognition and displayed no verbal, physical or other behavioral symptoms towards himself or others. Further, R12 was independent with bed mobility and transfers. R12's Order Summary Report signed 9/30/19, identified R12 had no current orders for alcohol administration as outlined in the facility' policy. In addition, R12 had current orders for numerous medications including aspirin, [MEDICATION NAME] sodium (treat high cholesterol), [MEDICATION NAME] (diuretic and antihypertensive medication), and [MEDICATION NAME] (an anti-diabetic). R12's care plan revised 731/19, identified R12 was at risk for falls related to a gait and balance problem, and directed to keep R12's environment safe. A section of the care plan identified R12 had a psychosocial problem related to his illnesses and alcohol dependence. However, the care plan lacked any identified goals or interventions for staff to implement or monitor for R12 to ensure he remained safe if/when consuming alcohol. R12's medical record was reviewed, and the following entries and notes were identified: A progress note on 10/3/18, identified R12 admitted to the nursing home. R12 was recorded as, . shakes when walking and uses wheelchair to move around the facility. A progress note on 6/21/19, identified R12 signed himself out of the facility to go to the library. R12 returned four hours later. A progress note on 7/6/19, identified R12 signed out to go to Walmart. R12 was then found walking down Lyndale (Avenue) towards the Camden Bar. The note continued, Writer explained to resident that staff could not let him go to Walmart at this time, due to being unstable while walking. Resident very upset at writer. Writer also notified (administrator). The medical record lacked any assessment or dictation if R12 had been intoxicated at this time. A progress note on 8/13/19, identified R12 had sustained a fall in him room. R12 hit his head on the nightstand and sustained a cut on his right elbow. R12 refused to be seen at the hospital. R12 then sustained a second fall in his bathroom. R12 stated he had 3 drinks outside, vodka. R12 felt he was not drunk, and his vital signs were taken and recorded. A corresponding Incident Report dated 8/13/19, identified R12 had sustained a fall in his room. R12 . fell on the floor really hard on the floor hitting his head against the dresser. The report continued, (R12) was in denial, he kept saying '(I) am OK just let me go back to bed' Meanwhile, resident was very unstable and could not get up on his own. R12 was lethargic and treatment was provided to R12's left elbow where he sustained bruising. R12's vital signs were obtained and neurological checks were started; however, a section in the report labeled, Factors, identified R12 had told staff he . had some alcohol drinks prior to the fall incident. The report identified a physician had been contacted, however, lacked any dictation supporting what, if any, provider orders were obtained or if any medications were ordered to be held for R12. Further, R12's MAR indicated [REDACTED]. R12's corresponding Post Fall Risk Assessment - HDGR assessment dated [DATE], identified R12 had sustained a fall in his room which caused a laceration on his left elbow. The report listed a section labeled, Underlying Disease or Conditions, which identified, Resident intoxicated (at) this time. A Review of the POS [REDACTED]. The assessment identified no referrals were necessary as a result of the fall. A progress note on 8/17/19, identified R12 again signed out of the facility and left . to the store. A progress note on 9/2/19, at 9:49 p.m. identified R12 was . was noted to be sleepy and hard to a louse (sic) this after dinner outside in the smoke area. Took several touching to arouse resident and when he was up he started cursing staff and other resident who wanted him to go back to his room and sleepy. According to other residents, Resident was noted drinking something from a cup few minutes before he fell asleep. R12's vital signs were obtained and the note ended with, . in bed sleeping at this time. There was no corresponding incident report completed in the medical record; nor did the record demonstrate R12 had been assessed to determine if he had been intoxicated or consuming alcohol; nor of his respiratory status or neurological status to ensure he didn't need EMS service and was safe to remain in the facility. In addition, R12's record lacked any evidence the physician had been notified of R12's demonstrated episode of lethargy and potential intoxication, and R12's MAR indicated [REDACTED]. A progress note on 9/13/19, at 7:33 a.m. identified R12 was up and about on the evening shift and ate 100% of his dinner. However, at approximately 5:00 a.m. R12 . appeared intoxicated lying on the floor and when asked if he fell , resident denied falling. stated (sic) to this writer in a very loud tone 'I did not fall I feel like lying on the floor and it is non (sic) of your business' refused to be helped back in bed and refused vital signs . got himself back in bed. Noted with unsteadiness. Nursing will continue to (sic) monitor. There was no corresponding incident report completed in the medical record; nor did the record demonstrate R12 had been assessed to determine if he had been actually intoxicated or consuming alcohol; nor of his respiratory status or neurological status to ensure he didn't need EMS service and was safe to remain in the facility. In addition, R12's record lacked any evidence the physician had been notified of R12's demonstrated episode of potential intoxication, and R12's MAR indicated [REDACTED]. In addition, a completed Twin Cities Physicians DISCHARGE note dated 9/30/19, identified R12 was seen for a discharge summary. The note identified R12 was . stable with respect to Other [MEDICAL CONDITION] of liver. Had an episode of intoxication this weekend and was sent to HCMC Detox. The note continued, He is very on edge today. Seen standing in his room yelling 'I hate this place and they do nothing for me. I want to get out of here! There was no other evidence in R12's medical record demonstrating he had been admitted to the HCMC detox unit within the past 7 day period, and the corresponding detox report was requested, however, none was ever provided by the facility. R12's medical record was reviewed and lacked any evidence R12 ever had the facility' alcohol and illegal substance use policy reviewed with him despite repeated episodes of intoxication or being suspected of being intoxicated. The record lacked any ongoing, comprehensive assessment of R12 to help develop interventions to ensure safety with continued use of alcohol, nor any assessment or plan to ensure medications were being consistently held if R12 was identified as intoxicated. Further, the record lacked evidence R12 had been referred to ACP for counseling and/or treatment despite these repeated episodes of consuming alcohol in an unsafe manner. R12 discharged the nursing home on 10/1/19. When interviewed on 10/2/19, at 2:50 p.m. TMA-A stated she recalled the incident on 9/13/19, when R12 was laying on the floor. TMA-A stated you could tell he was impaired at the time as he was slurring his speech and was not acting like his typical self. TMA-A added, (He) wasn't normal. TMA-A explained she had never personally observed R12 to have bottles of alcohol; however, she had heard other residents had been seen at times leaving the local liquor store and then returning to the nursing home with it. TMA-A stated residents were good at hiding bottles to avoid getting caught using the alcohol adding most of the issues had occurred on the evening shift with residents being intoxicated. Further, TMA-A stated she had never been instructed to complete any ongoing monitoring of R12, despite repeated episodes of consuming alcohol and becoming intoxicated. During interview on 10/2/19, at 4:08 p.m. licensed practical nurse (LPN)-A stated he was unaware of any residents consuming alcohol in the facility. LPN-A explained he had not been instructed to monitor any specific residents for their behaviors or for potentially consuming alcohol, nor had he given any specific instructions to the TMA(s) to do the same and added alcohol is not allowed in this building. Further, LPN-A stated if someone had been suspected of drinking the nurses should be doing their vital signs and notifying the physician. On 10/3/19, at 9:46 a.m. LSW-A was interviewed regarding R12's documented episodes of alcohol use and subsequent falls. LSW-A stated he didn't have a lot of experiences with him while he resided at the nursing home; however, LSW-A was aware of situations when R12 had been suspected of consuming alcohol including when he had lost a direct express card when out with people he didn't know at a local hotel. LSW-A expressed if someone was consuming alcohol they would typically refer them to ACP (psychology services) as one of the starting places for treatment and intervention development; however, LSW-A acknowledge

Based on interview and document review, the facility failed to ensure developed pressure ulcers were comprehensively assessed and monitored to ensure healing and prevent complications for 2 of 3 residents (R13 and R5) reviewed for pressure ulcer care. This failure resulted in actual harm for R13 whose pressure ulcers worsened, became infected and required hospitalization . Findings include: R13's Admission Record printed [DATE], indicated R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). R13's admission Minimum Data Set (MDS) had not been completed, however, the narrative note of [DATE] indicated R13 was, able to speak all needs, and identified he went out on the patio to smoke. R13's care plan initiated [DATE], indicated R13 had an indwelling suprapubic catheter (a tube inserted through the abdominal wall and into the bladder to drain urine), as well as a [MEDICAL CONDITION] (the bowel had been surgically rerouted to the abdominal wall to expel stool). R13 was identified to have pressure ulcers, with the potential for additional pressure ulcer development related to disease process, history of ulcers and immobility related to [MEDICAL CONDITION]. The care plan directed the facility to administer treatments as ordered and monitor for effectiveness. Staff were directed to assess/record/monitor wound healing, measuring length, width, and depth where possible and to report both improvements and decline to the provider. Flow sheets as follows with all wound documentation completed by RN-A: LEFT FOOT AND ANKLE identified as site on the document, however, the diagram identified one area on the left lateral malleolus. The wound was identified as stage 3 pressure ulcer (A full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling). [DATE]: Areas of length and width 0.2 cm; Granulation (red beefy tissue): No notations; Drainage: None/minimum, Drainage color: Sanguineous (bloody); Surrounding skin: intact: undermining/tunneling: None; Current dressing/tx(treatment): [MEDICATION NAME]; Odor: None; Pain: 7; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: No documentation: [DATE]: Areas of length and width 0.2 cm; Granulation: No notations; Drainage: None Drainage color: Drainage marked as sanguineous, although checked as none present; Surrounding skin: intact: undermining/tunneling: None; Current dressing/tx(treatment): None listed although drainage identified; Odor: None; Pain: 8; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: This was checked as yes, however, there was no narrative notes or other communication to physician to reflect this. [DATE]: Areas of length 0.2 cm and width 0.2 cm; Granulation: No notations; Drainage: None, Drainage color: Drainage marked as sanguineous, although checked as none present; Surrounding skin: intact: undermining/tunneling: None; Current dressing/tx(treatment): None listed although drainage identified; Odor: None; Pain: No rating identified; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: No documentation identified this had occurred. SACRUM: Stage 3 pressure ulcer [DATE]: Areas of length 7 cm, width 6 cm, and depth 2 cm; Granulation: 80% slough (The other 20% was not described); Drainage: None/minimum, Drainage color: Serosanguinous (blood and serum); Surrounding skin: macerated: undermining/tunneling: None; Current dressing/tx(treatment): [MEDICATION NAME]; Odor: None; Pain: 7; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record. [DATE]: Areas of length 7 cm, width 5 cm, and depth 2 cm; Granulation: 80% slough (yellow, stringy dying tissue). (The other 20% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None; Current dressing/tx(treatment): Acetic Acid for dressing; Odor: None; Pain: 8; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes and orders were changed for dressing from [MEDICATION NAME] to sacrum to an Acetic Acid moistened dressing to wound. [DATE]: Areas of length 7 cm, width 5 cm, and depth 2 cm; Granulation: 80% slough (The other 20% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: No documentation; Current dressing/tx(treatment): Not identified; Odor: None; Pain: Not rated; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes, however, documentation is not reflective of contact with the physician. LOWER LEFT BUTT[NAME]KS: Pressure ulcer-Stage 3 [DATE]: Areas of length 4 cm, width 2.75 cm, and depth 4 cm; Granulation: 20% slough (The other 80% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None; Current dressing/tx(treatment): Not identified; Odor: None; Pain: Not rated; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes, however, documentation is not reflective of contact with the physician. [DATE]: Areas of length 4 cm, width 2.75 cm, and depth 4 cm; Granulation: 20% slough (The other 80% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None; Current dressing/tx(treatment): Not identified; Odor: None; Pain: Not rated; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record. [DATE]: Areas of length 4 cm, width 2.5 cm, and depth 3.75 cm; Granulation: 25% slough (The other 75% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None; Current dressing/tx(treatment): Not identified; Odor: None; Pain: Not rated; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record. RIGHT GROIN PRESSURE ULCER STAGE IV [DATE]: Areas of length 10 cm, width 4 cm, and depth 4.5 cm (Outer thigh depth 2.75 cm, middle depth 2 cm; Granulation: 80% slough (The other 20% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None, however depth identified as 3; Current dressing/tx(treatment): Acetic Acid Moisture in Kerlix (In next column, it identified Cover with ABD; Odor: None; Pain: 7; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record. [DATE]: Areas of length 10 cm width by 3 cm, and depth 4.5 cm (Outer thigh depth 2.75 cm, middle depth 2 cm; Granulation: 80% slough (The other 20% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None, however depth identified as 3; Current dressing/tx(treatment): Column under [DATE] indicated: Acetic Acid Moisture in Kerlix. Column for [DATE] indicated: Cover with ABD; Odor: None; Pain: 8; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record. [DATE]: Areas of length 9.75 cm, width 3 cm, and depth 4.5 cm (Outer thigh depth 2.70 cm, middle depth 2 cm; Granulation: 85% slough (The other 15% was not described); Drainage: Minimum, Drainage color: Serosanguinous; Surrounding skin: macerated: undermining/tunneling: None, however depth identified as 3; Current dressing/tx(treatment): Column under [DATE] indicated: Acetic Acid Moisture in Kerlix. Column for [DATE] indicated: Cover with ABD No designation for treatment under the column for [DATE]; Odor: None; Pain: 9; Debridement: No; Positioning plan: yes; Nutritional plan: yes; Pressure relieving mattress/device: Yes, Physician Notified: Yes. However, there was no narrative note or other communication with the physician in the record In addition to the weekly measurements, the narrative notes identified the following notations of R13's wound care, however, lacked specific information as to which site they were pertaining to. R13's narrative notes of [DATE], at 10:35 p.m. identified wound treatment was completed with a large amount of pus, dark brown in color, odor noted. The documentation lacked specific designation as to where the dark, brown pus, with odor noted was located, or any other assessments such as vital signs, level of pain, or interventions, such as notification of the physician. On [DATE], at 4:15 p.m. R13's narrative notes indicated wound (Unspecified site) had greenish secretions of a moderate amount. The documentation lacked indicators of location, odor, or assessment of resident including vital signs or pain assessment. The documentation also lacked if notification of the physician occurred, and if so, what recommendation was made. On [DATE], at 2:18 p.m. R13's progress notes identified wounds are greenish thick sloughs drainage copious moderate amount with foul smell. At this time R13's vital signs identified R13 had an elevated temperature at 100.4 degrees Fahrenheit (F.), and a rapid heart rate of 138. R13 requested to be sent to the hospital for evaluation and was subsequently transported to the hospital via ambulance. On [DATE], at 3:27 p.m. licensed practical nurse (LPN)-D stated R13 was hospitalized and was being treated for [REDACTED]. LPN-D stated she checked his vital signs and R13 requested to be seen at the hospital and was subsequently transported. A review was completed of the emergency department (ED) note of [DATE], which indicated R13 presented for evaluation of wounds. While in the ED, lab work was drawn with an elevated sedimentation rate (ESR-levels when elevated indicate inflammation in the body) and C-reactive protein (CRP-levels in the blood which increase when there is a condition causing inflammation). R13's temperature remained elevated at 100.4 degrees F. with a heart rate to the 130's. R13 was admitted for possible osteo[DIAGNOSES REDACTED] (An infection of the bone). The State Agency (SA) Report of [DATE], at 3:50 p.m. identified R13's wounds had markedly declined since last seen by the Wound-Ostomy-Continence (W[NAME]) nurse on [DATE] in comparison to the most recent assessment by the W[NAME] nurse on [DATE]. LEFT TR[NAME]HANTER: (Facility documentation reflected left lower buttocks) On [DATE], the areas of length 4.5 cm, width 6.5 cm, and depth 7 cm; Wound base at this time is Granulation: 40% slough (The other 60 % described as pale, pink unhealthy granulation tissue). Positive for bone presence. It was noted to have undermining circumferentially up to 5 cm, with the deepest at 11 o'clock. With palpation of the wound bed, it was noted the periwound skin (The skin directly surrounding the wound) was intact. The drainage was described as copious, serous, serosanguinous, yellow, and a few blood clots. No odor noted. Pain was absent. RIGHT TR[NAME]HANTER: On [DATE] the measurements were 5.5. cm by 6.5 cm by 1 cm. On [DATE], the measurements were described as significantly increased at 5.5 cm by 8 cm by 5 cm. A MRI scan was ordered to further assess. The wound base was described as 90% pale granulation tissue, 10% slough, with undermining circumferentially up to 5 cm. The drainage was described as copious, with serous drainage flowing out of the wound with any movement. Periwound skin was intact. RIGHT GROIN: On [DATE], the measurements were 2 cm by 8 cm by 4 cm with 15% slough and 85% pale granular tissue. On [DATE], the wound was described as larger, with wound bed deteriorated and moderate odor from the wound. Measurements were 3.2 cm by 10.5 cm by 4 cm. The wound base is noted to be 15% percent pale granulation tissue with 85% slough, some with purple discoloration. The wound is noted to have undermining up to 4 cm at 9 o'clock to 3 o'clock. The wound bed is firm, with the periwound skin noted to have redness which is blanchable. The wound is noted to have a moderate amount of Serosanguinous and yellow drainage with a moderate odor. PERINEUM: On [DATE], this area has started as a skin tear with wound size only 3.8 cm by 1.2 cm by 0.3 cm. On [DATE], wound measurements are 5 cm by 10 cm by 2 cm with a wound base of 15% slough and 85% pale pink granulation. There was undermining identified up to 2.5 cm at the ,[DATE] o'clock position. The wound bed was firm with a moderate amount of Serosanguinous drainage without odor. LEFT LATERAL MALLEOLUS (The bony prominence on each side of the human ankle). On [DATE], the area measured only 0.1 cm by 0.1 cm. On [DATE], the area measures 1 cm by 1 cm by 0.1 cm with the wound base being 100% slough, half of which is discolored purple. The wound has a scant amount of Serosanguinous drainage. A review of the narrative note of [DATE], at 10:44 p.m. indicated R13 was asked three times to do wound treatment but each time he refused. The narrative note identified the provider was notified, however, it lacked information to indicate if the provider was informed of the refusal of treatment or if the contact informed the provider of the change in wound status. A review of the Treatment Administration Record (TAR) of that date indicated wound care had been completed, however, the narrative notes did not reflect resident acceptance after refusal of treatment three times. On [DATE], at 8:55 a.m. RN-A stated R13 received wound care twice daily, however, stated he does refuse quite often. RN-A stated the dressing was changed as ordered and if any changes of the wounds were seen, it was documented in the narrative notes. RN-A indicated the evening dressings were refused, however, did not identify any modifications, or alternatives offered to R13 to improve receptiveness. The dressing changes were scheduled twice daily at 8:00 a.m. and 8:00 p.m. R13's (MONTH) TAR indicated R13 was to receive wound care twice daily with acetic acid, kerlix moistened with acetic acid, followed by covering of the wound with an ABD (A large, absorbent dressing). A review of the TAR identified R13 received wound care on 22 of the 25 occasions while at the facility, with one of the dates lacking documentation being R13's admission [DATE]. The TAR lacked documentation for [DATE] and [DATE] at 8:00 p.m. and for the 8:00 a.m. on [DATE]. A review of the narrative progress notes lacked any indication as to if the treatment was not completed, missed, or other rationale as to why documentation was not completed. On [DATE], at 4:56 p.m. the DON stated prior to admission to the hospital for his wounds on [DATE], she was aware R13 was running a temperature, not feeling well, and his wound had, a really bad smell. R13's narrative notes of [DATE], identified a large amount of pus, dark brown in color, with an odor noted. The DON stated this had not been identified on wound rounds of that date. The DON stated the provider should have been contacted to update on R13's change in status and informed of the drainage appearance, amount and a description of the odor. DON stated upon review of the narrative of the [DATE], at 4:15 p.m. that the color had changed, R13's temperature should have been checked and the provider notified. The DON stated the documentation did not reflect assessment or follow through. On review of the note of [DATE], at 2:18 p.m., the documentation described greenish, thick slough drng. (drainage) Copious amt with foul smell. Elevated temp 100.4 F. The DON stated this may have indicated an, infection was brewing. Upon review of the wound measurements completed on wound rounds, it appeared R13's wound status had improved. Upon review of the ED and admission notes, DON stated R13 was admitted to the hospital related to his wounds, with the [DIAGNOSES REDACTED]. An undated policy, Pressure Ulcer, identified the purpose of the procedure was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The policy identified staff should review the care plan for any special needs of the resident. The general guidelines identified the focus on assessing the resident and current status of the pressure ulcer, as well as education and quality improvement. The policy identified if the resident refused the procedure or intervention, the reason for the refusal and the resident response to explanation of risks of refusing the procedures, the benefits of accepting the care, and available alternatives. The staff are directed to document the family and physician notification of refusal. R5's quarterly MDS dated [DATE], identified R5 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADLs). Further, the MDS identified R5 was at risk for pressure ulcer development; however, had no current pressure ulcers. R5's Admit/Readmit Assessment-HDGR dated [DATE], identified R5 had, No skin issue noted. There was no recorded pressure ulcers and/or excoriated skin upon R5's return from the hospital. R5's skin care plan revised [DATE], identified R5 was at risk for pressure ulcer development related to immobility. The care plan listed two goals for R5 which included having open area(s) heal and remain free of signs of infection, and have intact skin which was free of redness or discoloration. There were several interventions listed to help R5 meet these goals which included administering treatments as ordered then monitoring effectiveness, assessing and monitoring R5's skin daily and as needed, turning and repositioning at least every two hours, and nursing to check R5's skin on a weekly basis or more as needed. R5's progress note(s) identified the following recorded entries: On [DATE], identified R5 had developed three superficial open areas on her coccyx. The wounds' measurements were recorded as 3.9 centimeters (cm) by (X) 1.3 cm; 3.5 cm X 2.6 cm; and 2.9 cm X 1.0 cm in size. None of the wounds had a recorded depth. Further, the note identified R5 had returned recently from the hospital with excoriated skin on her coccyx and the nurse practitioner (NP) initiated a treatment. On [DATE], the NP recommended to continue barrier cream to R5's buttocks with each incontinence episode and turn her every two hours and as needed. The note continued, Careplan and care guild (sic) updated. On [DATE], R5's weight was recorded as being down over 10 pounds (lbs) in the past month. The note read, Her wt. (weight) loss trend continues and is the expected outcome as disease progresses. On [DATE], R5 enrolled in hospice care . due to medical condition. On [DATE], R5 was identified to have poor oral intake and appear weak. The note read, . on hospice and receiving comfort cares at this time. On [DATE], (R5) was turned an d re=positioned (sic), dressing change done to O/A (open area) on buttocks. On [DATE], Wound to buttocks changed and resident turned and re-positioned (every) 2 hours with oral cares. (W)ill continue with comfort cares as needed. On [DATE], R5 expired. R5's medical record was reviewed and lacked any evidence R5's developed pressure areas had been comprehensively assessed after developing to ensure appropriate interventions were identified and implemented to ensure wound healing and prevent worsening and/or additional pressure ulcers from forming. Further, the medical record lacked any evidence R5's developed pressure ulcer(s) had been monitored to ensure healing on a consistently, weekly basis. There were no further recorded measurements, description of the wound and/or wound bed, pain or odor and drainage characteristics demonstrating ongoing monitoring had been completed. During interview on [DATE], at 9:30 a.m. trained medication aide (TMA)-A stated she recalled R5 had a wound on her coccyx when she seemed to stop eating and decline. TMA-A recalled seeing R5's bottom approximately one month prior to her death ([DATE]) and stated she thought the wound appeared like a stage one or something. There was only one big sore now, and not three wounds as had first presented on [DATE]. TMA-A stated the nurse managers who worked there at the time were notified and directed to keep applying barrier cream to the wound. Further, TMA-A stated she was not sure of the process for pressure ulcer assessment and monitoring. When interviewed on [DATE], at 10:18 a.m. licensed practical nurse (LPN)-B verified R5's developed wound was a pressure ulcer and explained the process which should be completed when a resident develops a pressure ulcer. The wound should be measured, the physician notified, and an assessment completed including a review of the residents' skin turgor, repositioning needs and pretty much everything which impacts their skin. The facility used a wound nurse currently, however, one was not in place when R5 had developed her pressure ulcer so someone had been coming into the facility from outside to monitor them. LPN-B stated she had seen R5's pressure ulcer several days before she expired, and at that time, the wound was pretty nice sized and was approximately the size of an orange. LPN-B stated R5's pressure ulcer was at least a stage III ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer). On [DATE], at 4:51 p.m. the director of nursing (DON) was interviewed. A developed pressure ulcer should be reported to the physician and then staff have to investigate the ulcer to determine how it developed and measure it. The resident would then be included on routine wound rounds. The DON reviewed the medical record and stated R4 readmitted from the hospital in early (MONTH) 2019, and verified the assessment completed shortly afterwards identified R5's skin to be clear and free of pressure ulcers or skin abnormality. Further, the DON verified the lack of a comprehensive assessment when R5 developed pressure ulcer(s) on [DATE], nor any subsequent monitoring of the ulcers to ensure healing. The DON stated an assessment should have been completed and the wound should have been monitored despite R5 having a deteriorating medical condition and not eating well. A provided undated Pressure Ulcer policy identified pressure ulcer treatment required a comprehensive approach which included managing infections, managing systemic issues and maximizing the potential for healing. The facility' pressure ulcer treatment program should focus on several strategies which included assessing the resident and current status of the ulcer(s) and providing pressure ulcer care. Further, the policy directed several items which should be recorded in a medical record which included the date and time the wound dressing was changed, the wound appearance including the wound bed and presence of drainage, and all other completed assessment data.

Based on interview and document review, the facility failed to ensure 1 of 4 residents (R6) reviewed was free from significant medication errors when facility staff administered R6 [MEDICATION NAME] (an antihypertensive), [MEDICATION NAME] (an [MEDICATION NAME]), [MEDICATION NAME] (an antihypertensive), carvedilol (an antihypertensive), and [MEDICATION NAME] (a muscle relaxant) in error resulting in R6's hospitalization . Findings include: R6's record was reviewed. R6 was admitted to the facility (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. R6's admission paperwork dated (MONTH) 3, (YEAR), was reviewed. The admission paperwork included three pages labeled Medication Schedule (P1, P2, and P3). The three pages labeled Medication Schedule did not indicate a date and included no patient identifier. R6's admission paperwork included information from a hospital discharge date d (MONTH) 18, (YEAR), and a list of medications labeled Medication List at Discharge that had R6's patient identifier. A comparison of the Medication Schedule indicated that the medications listed on P2 had no medication orders that matched the medication orders from the Medication List at Discharge. The medications listed on that page included the following orders: [MEDICATION NAME] 10 mg tablet daily, [MEDICATION NAME] 4 mg tablet daily, [MEDICATION NAME] 325 mg two tablets three times daily, [MEDICATION NAME] 5 mg tablet three times daily, [MEDICATION NAME] 50 mg daily, carvedilol 25 mg twice daily, [MEDICATION NAME] 600 mg three times daily, [MEDICATION NAME] ER 10 mg tablet daily, [MEDICATION NAME] 25 mg tablet daily, [MEDICATION NAME] 40 mg tablet daily, [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] ER 750 mg tablet daily, [MEDICATION NAME] 90 mg tablet daily, and [MEDICATION NAME] 50 mg tablet daily. All the medications listed above appeared on the same page of the Medication Schedule. A review of P1, P2, and P3 indicated two separate orders for [MEDICATION NAME]. The [MEDICATION NAME] order on P1 matched the Medication List at Discharge which read [MEDICATION NAME] 500 mg two tablets every 12 hours. The [MEDICATION NAME] order on P2 read [MEDICATION NAME] 325 mg three times daily and had no corresponding order on the Medication List at Discharge. R6's Medication Administration Record [REDACTED]. R6's MAR indicated [REDACTED] R6's MAR indicated [REDACTED] R6's MAR indicated [REDACTED] R6's MAR indicated [REDACTED] R6's MAR indicated [REDACTED] R6's progress note dated (MONTH) 4, (YEAR), at 3:35 p.m. indicated that at 12:00 p.m. R6 had wobbled in the hallway with an oxygen saturation level of 63% on room air, blood pressure 64/40, and became sleepy. The facility staff transferred R6 to the hospital. R6's hospital records dated (MONTH) 7, (YEAR) at 1:42 p.m. indicated R6 was hypotensive in the emergency department on (MONTH) 4, (YEAR), with systolic blood pressures in the 70's. It further indicated R6 was admitted to the facility with an incorrect medication list and that R6 received blood pressure medications in error at the facility that likely caused R6's [MEDICAL CONDITION]. During an interview on (MONTH) 23, (YEAR), at 3:10 p.m., DON-H stated the facility learned that R6's medication list was inaccurate from the hospital after R6's admission to the hospital on (MONTH) 4, (YEAR). DON-H stated the facility determined the discharging facility included a page of medications that were not for R6 in the admission paperwork. DON-H stated the medication in the admission paperwork list did not have R6's patient identifier and that as part of the follow-up, the facility staff were educated to ensure that each page of the admission paperwork has a patient identifier on it. The policy entitled physician's orders [REDACTED]. It further states that all care given to the resident must have a direct order from an attending physician and that dosage ambiguities are avoided.

Based on observation, interview and document review, the facility failed to implement psychologist recommendations for in-patient chemical dependency (CD) treatment for 1 of 1 residents (R3) resulting in neglect of care. Although R3 continued to consume alcohol, frequently showing signs of intoxication, R3 was not offered an opportunity for CD treatment. R3 was not offered treatment options, including the potential for court ordered CD treatment, or educated on the risks/benefits of pursuing treatment. R3 sustained a closed head injury and hospitalization following a fall while intoxicated. This neglect of health care resulted in an immediate jeopardy (IJ) situation for R3. The IJ began on 11/24/17, when the facility was aware of R3's frequent consumption of alcohol to the point of intoxication. The facility was aware R3 signed out on 11/21/17, and was returned by the police on 11/24/17. R3 again signed out on 12/2/17, and did not return until 12/4/17. Although R3's whereabouts was unknown, upon return the facility made no attempt to assess where R3 had been, how any injuries occurred, or how that may impact his plan of care. Although facility staff was aware R3 had an extensive history of alcohol use, evidence of ongoing alcohol use, and extensive absences there was no administration and interdisciplinary communication regarding an assessment of R3's condition and significant risk for injury/death related to excessive alcohol use. The facility neglected to initiate the psychologist's ongoing recommendations to address R3's chemical abuse. The administrator, director of nursing, vice president of quality, and corporate nurse consultant were notified of the immediate jeopardy at 12:54 p.m. on 1/11/18. The IJ was removed on 1/16/17, at 1:28 p.m. but noncompliance remained at the lower scope and severity of isolated actual harm which is not immediate jeopardy (Level G). Findings include: The facility Freedom from Abuse, Neglect, and Exploitation policy revised 11/16, defined Neglect: is the failure of the community, it's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. According to the Center for Disease Control and Prevention (CDC), the short term health risks of alcohol use may include: - Injuries, such as car accidents, falls, drowning's, [MEDICAL CONDITION] - Violence, including homicide, suicide, and sexual assault - Alcohol poisoning, a medical emergency that results from high blood alcohol levels. According to the Mayo Clinic, a number of factors can increase your risk of alcohol poisoning, including: your size and weight, overall health, recent food intake, combining alcohol with other drugs, percentage of alcohol in the drinks, rate and amount of alcohol consumption, and tolerance level. Over time, excessive alcohol use can lead to the development of chronic diseases and other serious problems including: - High blood pressure, [MEDICAL CONDITION], stroke, liver disease, and digestive problems - Cancer of the breast, mouth, throat, esophagus, liver, and colon - Learning and memory problems, including dementia - Mental health problems, including depression and anxiety - Social problems - Alcohol dependence, or alcoholism The CDC reported the person most likely to die of [MEDICAL CONDITION] is a white, non-Hispanic (68% of alcohol related deaths) and male aged 35-64 (76% of alcohol related deaths). The National Institute on Health, [MEDICAL CONDITION] and Alcoholism (NIAAA), reports a person's risk for alcohol related dangers is individualized based on risk factors, but as blood alcohol levels increase, so does the risk of impairments. The NIAAA reports a blood alcohol level of 0.31% to 0.45% represents a life threatening impairment. Symptoms include loss of consciousness, danger of alcohol poisoning, and suppression of vital life functions including respirations. R3's discharge (DC) orders from Hennepin County Medical Center (HCMC) dated as dictated 10/2/17, identified him to be [AGE] years old with the [DIAGNOSES REDACTED]. The DC orders also identified the [DIAGNOSES REDACTED]. The nurse practitioner (NP) note dated 10/7/17, indicated, Likely secondary to [MEDICAL CONDITION]. The NP note dated 11/13/17, reported the completion of an abdominal ultrasound which revealed hepatomegaly (an abnormal enlargement of the liver). R3's admission Minimum Data Set ((MDS) dated [DATE], identified R3 had intact cognition, moderately severe depression and was independent with all activities of daily living. R3's undated Admission Record identified R3 had [DIAGNOSES REDACTED]. R3's mood state Care Area Assessment (CAA) dated 10/5/17, indicated R3 had an actual problem with mood due to R3's recent move to the nursing home. His mood state would be care planned with a goal of improvement and maintaining current level of functioning. The CAA identified R3 had moderately severe depression; however, R3 denied having depression. Further, R3 endorsed many symptoms of depression and would be referred to psychology services. R3's undated Vulnerable Adult Prevention Assessment indicated R3 had a mental health [DIAGNOSES REDACTED]. The assessment provided a section labeled, Plan of Action, however, the section was not completed and left blank. R3's care plan dated 10/4/17, identified, The resident has a potential for psychosocial well-being problem r/t (related to) Recent Admission, Depression and ETOH abuse. The resident will verbalize feelings related to emotional state by review date. The resident will demonstrate adjustment to nursing home placement by/through review date. Interventions included: Assist/ encourage/support the resident to set realistic goals. Consult with: Pastoral care, Social Services, Psych services, Other. When conflict arises, remove residents to a calm safe environment and allow to vent/ share feelings. The care plan did not identify any interventions on R3's current level of alcohol consumption, how to manage/intervene if he was identified drinking ETOH, how to identify if R3 was intoxicated, or how the facility was minimizing R3's risks related to ongoing alcohol use/abuse. Additionally, there were no interventions in the plan of care related to reviewing available options for alcohol cessation programs. On 1/8/18, at 11:57 a.m. R3 was observed to be a white male. He was laying in bed in his room. R3 did not have a shirt on and his lower half was covered with a bed sheet. R3 had a visible pink scar across the bridge of his nose. R3 stated his only vice was drinking alcohol. R3 walked down to the local bar, which was a few blocks away, two to three times a week and usually drank a couple of bloody (NAME)'s (cocktail containing vodka and vegetable juice) and a couple beers at the bar. R3 stated nobody from the facility had really discussed his alcohol use with him, but it was none of their business. On 1/8/18, at 2:35 p.m. R3 remained in bed with an unopened black and green can (larger than a 12 oz can) by his legs, half covered by the bed sheet. R3 stated it was a can of some sort of alcohol, but he was not going to drink it and did not elaborate further. R3 pulled the bed sheet over the can so it was no longer visible. R3 was talking rapidly and slurring his speech. He stated when he drank too much he fell , but could not remember the incidents due to being too drunk. On 1/8/17, at 4:17 p.m. nursing assistant (NA)-J knocked on R3's door and entered his room. R3 was audibly loud with NA-J asking why she was checking on him. NA-J explained it was her job to check on residents and see if they needed anything to which R3 responded he was fine. R3 was slurring his words while speaking to NA-J; NA-J left the room and closed the door. NA-J stated R3 was slurring his words, but said he was fine and went across the hallway to help another resident without reporting R3's slurred speech to facility staff. On 1/9/17, at 1:24 p.m. R3 was not in his room and out of the facility at an appointment. NA-A was in R3's room changing the bed sheets with the window open. NA-A stated she had the window open because the room smelled of rotten beer. R3's room was noted to have a lingering odor of stale alcohol. R3's Associated Clinic of Psychology (ACP) progress note dated 11/3/17, identified [DIAGNOSES REDACTED]. He reports having depression at baseline levels but his anxiety level has increased. He continues to remain sober and reports having no urges to drink or smoke cannabis. A recommendation included, NH (nursing home) staff are encouraged to provide positive reinforcement regarding (R3's) efforts to remain sober. R3's ACP progress note dated 11/17/17, identified (R3) reported that he's been walking down to the local bar and drinking with friends. Writer observed that his face was flush and he seemed to be inebriated during this visit. He was reminded that ETOH cannot be brought into the facility and he agreed. We both agreed that his ultimate goal is to find stable housing and learn how to control his drinking. A recommendation included, NH staff are encouraged to provide positive reinforcement regarding (R3)'s efforts to remain sober. R3's medical record did not include an assessment and plan related to current alcohol use. R3's ED (emergency department) Provider Notes dated 11/21/17, identified R3 presented to the emergency department for evaluation of alcohol problem and head injury at 7:41 p.m. The patient had been drinking and hit his head on a barstool. R3's blood alcohol level measured at 0.326 percent (0.08 percent is the legally intoxicated level in MN) and R3 endorsed using marijuana. The physician identified R3 was a difficult historian due to his intoxication along with being quite belligerent, had slurring speech and smelled of alcohol and marijuana. R3 had some abrasions to his face. Lab indicated an ETOH level of 326 milligrams (mg) per deciliter (dl) (50 mg/dl indicates mild intoxication) which was flagged as high. A head computerized tomography (CT) scan (series of x-rays at varying angles) showed no evidence of a brain bleed and the note listed a section for, MDM (medical decision making), which dictated as R3 became sober and well enough to walk around, he could go to detox. A detox bed would be sought, and if not available, he could be placed in observation until he sobers. The note listed R3's [DIAGNOSES REDACTED]. No further notes were included to indicate when R3 was discharged or if he was admitted for detox or observation. R3's progress note dated 11/24/17, at 11:21 p.m. identified R3 was dropped off at the facility by the police department at 2:30 p.m. following his leaving the facility on 11/21/17. Police did not say where R3 came from. R3 appeared very tired and weak but denied being intoxicated. Scratches were noted on the forehead and a superficial cut was on the bridge of his nose. R3 refused vital signs and measurement of the cuts. Nursing would continue to monitor. R3's Investigation Report Summary dated 11/28/17, identified the facility filed a follow up investigation to the the state agency in response to the Incident Report Summary dated 11/22/17. The investigation identified on 11/24/17, at 2:30 p.m. the Minneapolis police officers dropped R3 off at the facility. The police officers did not provide information regarding where they had picked up R3, but R3 was visibly intoxicated though stable. R3 had a superficial cut on the forehead but denied pain or discomfort. R3 had been in the facility since that time. The summary identified the medical record was reviewed and staff would continue to follow the care plan for all residents and no harm was done. Also the facility served a high number of residents with a history of alcohol dependence or abuse as well as homelessness. They tend to leave facility against medical advice and sometimes return or end up in the hospital. There was no evidence in the investigation report or the progress notes that the facility attempted to determine where R3 had been when out of the facility. There was no evidence the facility assessed how this absence may impact R3's ongoing treatment, safety, and plan of care. There was no evidence of communication with facility administration and the interdisciplinary team reviewing the comprehensive assessment of R3's alcohol related issues, and ongoing recommendations from ACP in order to develop and implement appropriate interventions with R3. R3's ACP progress note dated 12/1/17, included, Today (R3) reported to writer that last Tuesday, 4 days after being brought to the NH by Mpls (Minneapolis) police inebriated and with facial lacerations. (R3) went out into the community again, purchased alcohol and proceeded to get drunk and go downtown. He made it back to the NH (nursing home) on his own . Writer explained why his NH team has determined that he requires in- patient CD (chemical dependency) treatment based on his recent behavior, involving putting himself at risk of harm to self or others. Writer also explained to that if he doesn't go into treatment voluntarily he runs the risk of being placed on a 72 hour hold and being possible court ordered to receive in- patient CD treatment. Therefore it's in his best interest to go into CD treatment voluntarily. Recommendations included, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. NH staff are encouraged to provide positive reinforcement regarding (R3)'s efforts to remain sober. R3's medical record did not identify a discussion with ACP staff about accessing a treatment program, monitoring for increased drinking/acting out, or any other recommendations the consultant may have regarding R3's visit on 12/1/17. Additionally, there was no discussion regarding the potential for voluntary or court ordered treatment. R3's progress note(s) identified the following: - 12/3/17, at 5:27 a.m. R3 signed out of the facility for a leave of absence (LOA) on 12/2/17, at 10:20 a.m. and was not in the building by 2:00 a.m. Police were called and a missing person's report was filed. - 12/4/17, at 7:40 p.m. Resident returned to the facility at approximately 5:55 p.m. Providers and police were updated. The progress note did not identify where R3 was or his condition upon return. Although R3's whereabouts was unknown, there was no evidence the facility attempted to determine where R3 had been when out of the facility. There was no evidence the facility assessed how this absence may impact R3's ongoing treatment, safety, and plan of care. There was no evidence of communication with facility administration and the interdisciplinary team reviewing the comprehensive assessment of R3's alcohol related issues, and ongoing recommendations from ACP in order to develop and implement appropriate interventions with R3. R3's ACP progress note dated 12/8/17, identified, NH staff reported (R3) has been isolating in his room for the past week and hasn't been out of the facility. Today he presented as agitated and angry . Writer reminded him that when a person collapses on the sidewalk in front of the bar, passed out and inebriated, he is unable to make decisions on his own and is at risk of self-harm. Therefore, that person is vulnerable to being placed on a 72 hour hold and subject to Commitment Court Intervention. (R3) expressed resistance to this recommendation. Writer regularly reviews chart for medication changes and consults with staff. Past recommendations remain relevant. Recommendations continued to include, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. R3's medical record continued to lack an assessment/plan related to the in-patient CD recommendation. R3's ACP progress note dated 12/15/17, identified, NH staff reported (R3) was involved in another intoxication event this past week. Today, he presented as agitated and angry and acted inebriated. He repeated over and over that he 'wants to get the hell out of here.' Writer recommended after he is discharged from the NH, that he enter CD treatment voluntarily. (R3) expressed resistance to this recommendation. Writer regularly reviews chart for medication changes and consults with staff. Past recommendations remain relevant. Recommendations continued to include, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. R3's progress note(s) identified the following: - 12/16/17, at 8:06 p.m. At approximately 8:00 p.m. staff reported R3 was drinking. Two empty bottles of vodka were found in R3's bed. R3 denied drinking, his speech was slurred. R3's room smelled of alcohol as well as his breath. At 9:30 p.m. R3 complained of lower back pain and 650 milligrams of Tylenol was given. The incoming staff were notified. - 12/18/17, at 2:34 p.m. R3's nurse practitioner was updated on R3 consuming a large amount of alcohol over the weekend. Staff continue to monitor for any signs of distress. - 12/18/17, at 10:53 p.m. R3's room smells like alcohol, with no empty bottles observed. R3 denied drinking when asked. Will continue to monitor and update provider with changes. - 12/21/17, at 8:46 p.m. Alcohol was observed in R3's room. Resident returned from LOA at approximately 7:00 p.m. Incoming staff notified. R3's ACP progress note dated 12/29/17, identified, (R3) presented sober and alert. He notes that 'everything is under control' referring to his refrain from drinking. He notes being totally depressed because 'I'm here'! We discussed the difference between the AA (alcoholics anonymous) approach vs (versus) harm reduction. (R3) reassured writer that his ultimate goal is to resume being sober. He did it for 6 years he knows he can do it again. Writer regularly reviews chart for medication changes and consults with staff. Recommendations included, NH staff are encouraged to support (R3)'s effort to drink less and remain sober in and out of the facility. R3's ACP progress note dated 1/5/18, identified, (R3) was reading in his room when the writer arrived. He presented as sober and alert . (R3) reassured writer that his ultimate goal is to resume being sober. We discussed his 'triggers' about what makes him have the urge to drink. He notes that his depression has decreased since he's refrained from drinking . Writer regularly reviews chart for medication changes and consults with staff. Recommendations continued to include, NH staff are encouraged to support (R3)'s effort to drink less and remain sober in and out of the facility. R3's medical record was reviewed and lacked a comprehensive assessment, and interventions for addressing R3's ongoing alcohol consumption. The medical record did not identify how to ensure R3 was adequately supervised and monitored for alcohol consumption and resulting intoxication to minimize the risk of negative outcomes up to and including alcohol poisoning. There was no plan in place to monitor for alcohol detoxification should R3 stop drinking alcohol. There were no interventions in place to address the repeated ACP recommendations to obtain treatment for [REDACTED]. R3's care plan dated 10/4/17, was not updated to reflect any ACP recommendations, or interventions developed based on a comprehensive assessment of ongoing alcohol consumption. On 1/9/18, at 3:57 p.m. R3 entered the facility carrying a large black bag over his right shoulder. R3 smelled of alcohol and was slurring his speech. R3 stopped and talked with the health unit coordinator (HUC) at the front desk before going to his room. On 1/9/18, at 7:36 p.m. R3 was lying on his bed watching television. His bed side table was on the right hand side of him, there was a 20 ounce (oz) mug on the bed side table. The mug had approximately 16 oz of green beverage with ice cubes. The beverage smelled strongly of alcohol. R3 stated he was drinking apple stuff. When asked if the green beverage was alcohol R3 smiled and covered the top of the mug with a book and stated he was not supposed to drink alcohol in the facility. R3 was very talkative displaying scattered thought patterns. R3's face was flushed and speech was slurred. R3 directed surveyor to stop at the bar after leaving the facility that evening, and have a good time. During interview on 1/9/18, at 7:46 p.m. licensed practical nurse (LPN)-C stated she had not been in R3's room that evening. LPN-C stated there was not a plan in place for monitoring any residents for alcohol consumption or any facility protocol on what to do if a resident was suspected to be drinking. LPN-C stated if she thought a resident was drinking she would hold any narcotics prescribed for the resident and call the doctor. She stated she was not aware of any incidents related to R3 drinking. When interviewed on 1/10/18, at 9:51 a.m. NA-K stated residents in the facility walk to the bar and liquor store then come back to the facility. I thought there was something up with (R3) because of how he acts sometimes. He doesn't want to be bothered or checked on in his room, doesn't allow us to make his bed, we can just drop off his meal tray and leave. NA-K stated she was never told R3 was drinking in and out of the facility. NA-K was unaware empty alcohol bottles have been found in his room. She had never been instructed by nurses or administrative staff on what to do if a resident was drinking or suspected of drinking. She would let a nurse know if she came across situation related to alcohol use. On 1/10/18, at 1:25 p.m. LPN-A stated he worked the a.m. and p.m. shifts. LPN-A stated there used to be a lot of residents that walked down to the bar and came back. He stated more often the current residents are walking to the liquor store and bringing it back and hiding it in their rooms. LPN-A stated, We don't know a resident is drinking unless someone reported finding the alcohol or smelling it. Residents have the right to go out and come back and can't search them. LPN-A stated there was no facility protocol on what to do if a resident was drinking in or out of the facility. There was no protocol to monitor residents who were known to be intoxicated. LPN-A stated, We call the manager and then watch the resident to make sure they don't hurt themselves or others. We also hold their medications if they take narcotics and call the doctor. LPN-A stated he only knew R3 signed out of the building and came back. LPN-A has never been instructed to monitor any resident in the facility for alcohol use. When interviewed on 1/10/18, at 1:29 p.m. LPN-D stated there were known issues with residents going to the bar and drinking at the bar. She had never dealt with it, but had heard about it through shift to shift report. Residents were not allowed to have alcohol in the building. She would call the DON and administrator and hold medications and call the doctor. LPN-D stated she was not aware of R3's drinking, but had not recently worked the wing he resided on. LPN-D stated she had never been instructed to monitor any resident regarding alcohol use. During interview on 1/10/18, at 1:33 p.m. registered nurse manager (RNM)-B stated R3 was an alcoholic and was not drinking when he was admitted to the facility in October 2017. R3 was really good about controlling his drinking until recently. RNM-B stated she heard R3 had been going to the local bar down the road and the last time she knew of was on 1/7/18. RNM-B was unsure if R3 was bringing alcohol into the facility and drinking in the facility. She had never found alcohol in his room or heard anyone else had. RNM-B reviewed R3's progress notes and stated there were incidents of R3 leaving the facility and not returning, with missing person reports filed. Progress notes indicated empty vodka bottles were found in R3's room and R3 smelling of alcohol, and having slurred speech. RNM-B stated she was not aware R3 was seen in the emergency department when he was absent from the facility 11/21/17- 11/22/17. She stated there was no progress note, or reports from staff reflecting he was in the emergency department, therefore, she did not look for documentation in the hard chart. She stated the facility is responsible for residents in and out of the facility, but staff does not know where residents are going when they leave the facility. The facility did not have any policies or protocols on alcohol use or intoxication, RNM-B added, it would be a good idea to have protocols and policies so staff know what to do in those situations. The facility is well aware of residents drinking and there is no monitoring for alcohol use for any residents. On 1/10/18, at 1:45 p.m. RNM-A stated residents are discharged from the hospital with active alcohol problems. They come to the facility for rehab and once they are feeling better they go out and start drinking again. There are no protocols for alcohol use within the facility. During interview on 1/10/18, at 1:56 p.m. with DON and administrator, the administrator stated there had been residents in the past going to the bar and liquor store. The DON added there was currently issues with residents going to the bar and bringing alcohol back to the facility from the liquor store. We do not allow alcohol use in the building and if staff are suspicious of alcohol use in the building, staff should comb the room. The administrator stated the facility has a policy stating alcohol is not allowed in the building and everyone receives the information on admission. She was not aware of any alcohol related incidents with R3. The DON reviewed R3's progress notes and was reading the alcohol related progress notes aloud. The administrator, after hearing some of R3's progress notes, stated R3's drinking incidents nowring a bell. The DON stated R3 had a [DIAGNOSES REDACTED]. Our responsibility is to work on interventions to keep (R3) safe and work on appropriate discharge. There was a daily interdisciplinary team (IDT) meeting every morning to discuss incidents and how the facility was going to handle the incidents; however R3's chart did not include any IDT assessment or interventions. DON could not recall any specific conversations in IDT meetings regarding R3's alcohol use. R3 did not have any internal incident reports regarding alcohol use or incidents involving alcohol. Further, DON stated R3's care plan had not been updated since admission, and did not reflect any interventions related to alcohol use. The progress notes definitely put him on the radar. Staff had not told him R3 was having alcohol related incidents. Although the facility struggled with residents drinking, there were no protocols in place related to alcohol use, including intoxication. The administrator stated there definitely needed to be protocols and procedures for staff to follow if alcohol was found on a resident, or if a resident was returning to the building intoxicated or suspected of alcohol use. There was definitely a need with the population the facility serves, however, the administrator was not sure what the protocols should be. It had been a struggle without a fulltime social worker. They were currently using a temporary agency and had a different social worker every day, that was trying to just address current issues. She stated ultimately it was the facility's responsibility to ensure a residents' safety in and out of the building. During interview on 1/10/18, at 3:13 p.m. licensed social worker (LSW)-A stated R3's social service files had no alcohol assessment, or referrals for alcohol dependency treatment programs. She reviewed another social workers notes in a paper tablet indicating R3 was to be referred for chemical dependency, but stated nothing was in progress. R3 was seeing a psychologist with ACP weekly, the facility should have followed through with those recommendations, completed an assessment and care planned R3's alcohol use. The social worker who was working at the facility in November 2017, definitely should have brought the psychology recommendations for in-patient CD treatment to the IDT team, so a plan could be worked on to address R3's needs. During a follow up interview on 1/11/18, at 9:47 a.m. DON stated R3 had been seeing the psychologist weekly, as R3 was attempting to receive a disability [DIAGNOSES REDACTED]. The facility had no internal incident reports on any alcohol related incident aside from one report and investigation submitted to the state agency. The social worker attended daily IDT meetings; however, the social worker, who left abruptly in December, never brought the psychology recommendations to the IDT meeting for review. DON was not aware of the psychologist's recommendation including; in-patient CD treatment or encouraging R3 to remain sober. The social worker received report from the psychologist, as well as kept all the ACP provider notes in a binder in the social work office. The social worker failed to bring the recommendations to the IDT for review, so a plan could be made for the psychology recommendations for R3 regarding in- patient CD treatment. The IDT should have been made aware of the psychology recommendations, so a plan could be made for in- patient CD treatment. The recommendations were never followed through, R3 should have been assessed and interventions should have been care planned. On 1/16/17, at 3:17 p.m. R3's psychologist was contacted by phone without a return call. The IJ that began on 11/24/17, was removed on 1/16/17, at 1:28 p.m. when the facility: - Offered R3 in and out patient CD treatment as well as a Rule 25 (an assessment conducted in order to receive public funding for chemical dependency treatment) evaluation. R3 was open to a Rule 25 evaluation. - Reviewed the risks and benefits of continued alcohol use with R3. - Developed an alcohol and illegal substance policy which included reviewing the policy with R3 and notifying him of actions the facility would take if alcohol use was suspected. - Held an IDT meeting, including the psychologist, and updated R3's care plan to include alcohol related interventions, - Developed a process to identify other residents at risk. - Educated front line staff on the alcohol and illegal substance policy. Educated nurses on the alcohol and illegal substance policy as well as an intoxication tool including safety interventions to initiate. - Residents receiving psychology services had their notes reviewed and process started to follow up on all recommendation. On 1/16/18, from 11:21 to 11:43 a.m. front line staff and nurses were interviewed and stated they were educated on the new alcohol and illegal substance policy. When they saw R3 leaving the facility to let a nurse know so they could speak to him about drinking prior to leaving the facility. Nurses were aware to educate R3 about drinking prior to leaving the facility. Nurses were aware of the new intoxication tool to complete when suspecting R3 was drinking. The noncompliance remained at the lower scope and severity level of G an isolated scope and harm level severity, as R3 required medical intervention on 11/21/17, following a fall while intoxicated.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions to minimize the risk of harm to 1 of 1 residents (R3) who consumed alcohol on and off facility property, became significantly intoxicated which required medical intervention. This resulted in an immediate jeopardy (IJ) situation for R3 who remained at risk of serious injury related to unsafe alcohol use. In addition, the facility failed to comprehensively assess and implement interventions to minimize risk for injury to residents who had alcohol related incidents, which resulted in the potential for harm that is not immediate jeopardy for 4 out of 4 residents (R43, R51, R54, R5) identified by the facility to have a history of alcohol related incidents. The facility failed to comprehensively assess and develop interventions to provide adequate supervision and safety with unsupervised smoking for 1 of 1 residents (R44) identified to have [MEDICAL CONDITION] their clothing and wheelchair (w/c) cushion. This resulted in an immediate jeopardy (IJ) situation for R44 who remained at risk [MEDICAL CONDITION] serious injury with unsupervised smoking. In addition, the facility failed to ensure a smoking assessment was completed for 1 of 1 newly admitted residents (R269) who smoked. The facility failed to comprehensively assess falls and develop appropriate interventions to minimize the risk of further falls for 1 of 1 resident (R9) with serious falls. This resulted in actual harm for R9 when she fell and sustained a right frontal interdependency hemorrhage, (IPH), bleeding within the brain and subsequently placed on hospice care. Findings include: The IJ began on 11/24/17, when R3 returned to the facility following a fall at the bar on 11/21/17, while intoxicated and required hospitalization for a closed head injury. The facility did not comprehensively assess R3's alcohol use and develop interventions to minimize the risk of further injury to R3 who continued to independently consume alcohol. The IJ was identified on 1/10/18. The administrator, director of nursing (DON), vice president of quality, and management company nurse consultant were notified of the IJ for R3 at 12:54 p.m. on 1/11/18. The IJ was removed on 1/16/17, at 1:28 p.m. but noncompliance remained at the lower scope and severity of isolated actual harm which is not immediate jeopardy (Level G). The IJ began on 1/11/18, when it was identified R44 had sustained repeated incidents of [MEDICAL CONDITION] her clothing and w/c cushion from unsafe smoking. R44 had been assessed to require supervision with smoking, however, it was not provided and R44 continued to smoking without supervision resulting in a high potential for serious harm or injury. The administrator, director of nursing (DON), vice president of quality and management, and company nurse consultant were notified of the IJ for R44 on 1/11/18, at 12:54 p.m The IJ was removed on 1/16/17, at 1:28 p.m. but non-compliance remained at a lower scope and severity of isolated with no actual harm with potential for more than minimal harm (Level D). ALCOHOL USE: R3's discharge (DC) orders from Hennipen County Medical Center (HCMC) dated as dictated 10/2/17, identified the [DIAGNOSES REDACTED]. The DC orders also identified the [DIAGNOSES REDACTED]. The nurse practitioner (NP) note dated 10/7/17, stated this was, likely secondary to [MEDICAL CONDITION]. The NP note dated 11/13/17, reported the completion of an abdominal ultrasound which revealed hepatomegaly (an abnormal enlargement of the liver). R3's admission Minimum Data Set ((MDS) dated [DATE], identified R3 had intact cognition, moderately severe depression and was independent with all activities of daily living. R3's undated Admission Record identified R3 had [DIAGNOSES REDACTED]. R3's mood state Care Area Assessment (CAA) dated 10/5/17, indicated R3 had an actual problem with mood due to R3's recent move to the nursing home. His mood state would be care planned with a goal of improvement and maintaining current level of functioning. The CAA identified R3 had moderately severe depression; however, R3 denied having depression. Further, R3 endorsed many symptoms of depression and would be referred to psychology services. R3's undated Vulnerable Adult Prevention Assessment indicated R3 had a mental health [DIAGNOSES REDACTED]. The assessment provided a section labeled, Plan of Action, however, the section was not completed and left blank. R3's care plan dated 10/4/17, identified, The resident has a potential for psychosocial well-being problem r/t (related to) Recent Admission, Depression and ETOH abuse. The resident will verbalize feelings related to emotional state by review date. The resident will demonstrate adjustment to nursing home placement by/through review date. Interventions included: Assist/ encourage/support the resident to set realistic goals. Consult with: Pastoral care, Social Services, Psych services, Other. When conflict arises, remove residents to a calm safe environment and allow to vent/ share feelings. The care plan did not identify any interventions on R3's current level of alcohol consumption, how to manage/intervene if he was identified drinking ETOH, how to identify if R3 was intoxicated, or how the facility was minimizing R3's risks related to ongoing alcohol use/abuse. Additionally, there were no interventions in the plan of care related to reviewing available options for alcohol cessation programs. On 1/8/18, at 11:57 a.m. R3 was laying in bed in his room. R3 did not have a shirt on and his lower half was covered with a bed sheet. R3 had a visible pink scar across the bridge of his nose. R3 stated his only vice was drinking alcohol. He walks down to the local bar, which was a few blocks away, two to three times a week and usually drank a couple of bloody (NAME)'s (cocktail containing vodka and vegetable juice) and a couple beers at the bar. R3 stated nobody from the facility had really discussed his alcohol use with him, but it was none of their business. On 1/8/18, at 2:35 p.m. R3 remained in bed with an unopened black and green can (larger than a 12 oz can) by his legs, half covered by the bed sheet. R3 stated it was a can of some sort of alcohol, but he was not going to drink it and did not elaborate further. R3 pulled the bed sheet over the can so it was no longer visible. R3 was talking rapidly and slurring his speech. He stated when he drank too much he fell , but could not remember the incidents due to being too drunk. On 1/8/17, at 4:17 p.m. nursing assistant (NA)-J knocked on R3's door and entered his room. R3 was audibly loud with NA-J asking why she was checking on him. NA-J explained it was her job to check on residents and see if they needed anything to which R3 responded he was fine. R3 was slurring his words while speaking to NA-J, NA-J left the room and closed the door. NA-J stated R3 was slurring his words, but said he was fine and went across the hallway to help another resident without reporting R3's slurred speech to facility staff. On 1/9/17, at 1:24 p.m. R3 was not in his room and out of the facility at an appointment. NA-A was in R3's room changing the bed sheets with the window open. NA-A stated she had the window open because the room smelled of rotten beer. R3's room was noted to have a lingering odor of stale alcohol. R3's Associated Clinic of Psychology (ACP) progress note dated 11/3/17, identified [DIAGNOSES REDACTED]. He reports having depression at baseline levels but his anxiety level has increased. He continues to remain sober and reports having no urges to drink or smoke cannabis. A recommendation included, NH (nursing home) staff are encouraged to provide positive reinforcement regarding (R3's) efforts to remain sober. R3's ACP progress note dated 11/17/17, identified, (R3) reported that he's been walking down to the local bar and drinking with friends. Writer observed that his face was flush and he seemed to be inebriated during this visit. He was reminded that ETOH cannot be brought into the facility and he agreed. We both agreed that his ultimate goal is to find stable housing and learn how to control his drinking. A recommendation included, NH staff are encouraged to provide positive reinforcement regarding (R3)'s efforts to remain sober. R3's medical record did not include an assessment and plan for his current alcohol use. R3's ED (emergency department) Provider Notes dated 11/21/17, identified R3 presented to the emergency department for evaluation of alcohol problem and head injury at 7:41 p.m. The patient had been drinking and hit his head on a barstool. R3's blood alcohol level measured at 0.326 % percent (0.08 percent is the legally intoxicated level in MN, and 0.250-.399% alchol poisioning, loss of consciousness) and R3 endorsed using marijuana. The physician identified R3 was a difficult historian due to his intoxication along with being quite belligerent, had slurring speech and smelled of alcohol and marijuana. R3 had some abrasions to his face. Lab indicated an ETOH level of 326 milligrams (mg) per deciliter (dl) (50 mg/dl indicates mild intoxication) which was flagged as high. A head computerized tomography (CT) scan (series of x-rays at varying angles) showed no evidence of a brain bleed and the note listed a section for, MDM (medical decision making), which dictated as R3 became sober and well enough to walk around, he could go to detox. A detox bed would be sought, and if not available, he could be placed in observation until he sobers. The note listed R3's [DIAGNOSES REDACTED]. No further notes were included to indicate when R3 was discharged or if he was admitted for detox or observation. R3's progress note dated 11/22/17, at 3:03 a.m. identified R3 had signed himself out of the facility at 11:00 a.m. on 11/21/17 and did not return. About 2:00 a.m. staff notified the police and a missing person report was filed. The note indicated management would be notified. There was no recorded progress note in R3's facility medical record on 11/21/17, to identify why he left the facility, where he was going or his condition when he left. R3's Incident Report Summary dated 11/22/17, identified the facility filed a report to the state agency, as R3 signed out of the building and did not return to the facility. The report indicated a missing persons report was filed with the police department. R3's progress note dated 11/24/17, at 11:21 p.m. identified R3 was dropped off at the facility by the police department at 2:30 p.m Police did not say where R3 came from. R3 appeared very tired and weak but denied being intoxicated. Scratches were noted on the forehead and a superficial cut was on the bridge of his nose. R3 refused vital signs and measurement of the cuts. Nursing would continue to monitor. R3's Investigation Report Summary dated 11/28/17, identified the facility filed a follow up investigation to the the state agency in response to the Incident Report Summary dated 11/22/17. The investigation identified on 11/24/17, at 2:30 p.m. the Minneapolis police officers dropped R3 off at the facility. The police officers did not provide information regarding where they had picked up R3, but R3 was visibly intoxicated though stable. R3 had a superficial cut on the forehead but denied pain or discomfort. R3 had been in the facility since that time. The summary identified the medical record was reviewed and staff would continue to follow the care plan for all residents and no harm was done. Also the facility served a high number of residents with a history of alcohol dependence or abuse as well as homelessness. They tend to leave facility against medical advice and sometimes return or end up in the hospital. No additional progress note(s) identified R3 to be intoxicated or attempting to consume alcohol after 11/24/17. R3's ACP progress note dated 12/1/17, included, Today (R3) reported to writer that last Tuesday, 4 days after being brought to the NH by Mpls (Minneapolis) police inebriated and with facial lacerations. (R3) went out into the community again, purchased alcohol and proceeded to get drunk and go downtown. He made it back to the NH (nursing home) on his own . Writer explained why his NH team has determined that he requires in- patient CD (chemical dependency) treatment based on his recent behavior, involving putting himself at risk of harm to self or others. Writer also explained to that if he doesn't go into treatment voluntarily he runs the risk of being placed on a 72 hour hold and being possible court ordered to receive in- patient CD treatment. Therefore it's in his best interest to go into CD treatment voluntarily. Recommendations included, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. NH staff are encouraged to provide positive reinforcement regarding (R3)'s efforts to remain sober. R3's medical record did not identify a discussion with ACP staff about accessing a treatment program, monitoring for increased drinking/acting out, or any other recommendations the consultant may have regarding R3's visit on 12/1/17. Additionally, there was no discussion regarding the potential for voluntary or court ordered treatment. R3's progress note(s) identified the following: - 12/3/17, at 5:27 a.m. R3 signed out of the facility for a leave of absence (LOA) on 12/2/17, at 10:20 a.m. and was not in the building by 2:00 a.m. Police were called and a missing person's report was filed. - 12/4/17, at 7:40 p.m. Resident returned to the facility at approximately 5:55 p.m. Providers and police were updated. The progress note did not identify where R3 was or his condition upon return. There was no other documentation related to R3's use of alcohol prior to the visit with ACP staff. R3's ACP progress note dated 12/8/17, identified, NH staff reported (R3) has been isolating in his room for the past week and hasn't been out of the facility. Today he presented as agitated and angry . Writer reminded him that when a person collapses on the sidewalk in front of the bar, passed out and inebriated, he is unable to make decisions on his own and is at risk of self-harm. Therefore, that person is vulnerable to being placed on a 72 hour hold and subject to Commitment Court Intervention. (R3) expressed resistance to this recommendation. Writer regularly reviews chart for medication changes and consults with staff. Past recommendations remain relevant. Recommendations continued to include, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. R3's medical record continued to lack an assessment/plan related to the in-patient CD recommendation. R3's ACP progress note dated 12/15/17, identified, NH staff reported (R3) was involved in another intoxication event this past week. Today, he presented as agitated and angry and acted inebriated. He repeated over and over that he 'wants to get the hell out of here.' Writer recommended after he is discharged from the NH, that he enter CD treatment voluntarily. (R3) expressed resistance to this recommendation. Writer regularly reviews chart for medication changes and consults with staff. Past recommendations remain relevant. Recommendations continued to include, Writer will consult with NH team and will recommend that (R3) be admitted to inpatient CD treatment. R3's progress note(s) identified the following: - 12/16/17, at 8:06 p.m. At approximately 8:00 p.m. staff reported R3 was drinking. Two empty bottles of vodka were found in R3's bed. R3 denied drinking, his speech was slurred. R3's room smelled of alcohol as well as his breath. At 9:30 p.m. R3 complained of lower back pain and 650 milligrams of Tylenol was given. The incoming staff were notified. - 12/18/17, at 2:34 p.m. R3's nurse practitioner was updated on R3 consuming a large amount of alcohol over the weekend. Staff continue to monitor for any signs of distress. - 12/18/17, at 10:53 p.m. R3's room smells like alcohol, with no empty bottles observed. R3 denied drinking when asked. Will continue to monitor and update provider with changes. - 12/21/17, at 8:46 p.m. Alcohol was observed in R3's room. Resident returned from LOA at approximately 7:00 p.m. Incoming staff notified. R3's ACP progress note dated 12/29/17, identified, (R3) presented sober and alert. He notes that 'everything is under control' referring to his refrain from drinking. He notes being totally depressed because 'I'm here'! We discussed the difference between the AA (alcoholics anonymous) approach vs (versus) harm reduction. (R3) reassured writer that his ultimate goal is to resume being sober. He did it for 6 years he knows he can do it again. Writer regularly reviews chart for medication changes and consults with staff. Recommendations included, NH staff are encouraged to support (R3)'s effort to drink less and remain sober in and out of the facility. R3's ACP progress note dated 1/5/18, identified, (R3) was reading in his room when the writer arrived. He presented as sober and alert . (R3) reassured writer that his ultimate goal is to resume being sober. We discussed his 'triggers' about what makes him have the urge to drink. He notes that his depression has decreased since he's refrained from drinking . Writer regularly reviews chart for medication changes and consults with staff. Recommendations continued to include, NH staff are encouraged to support (R3)'s effort to drink less and remain sober in and out of the facility. R3's medical record was reviewed and lacked a comprehensive assessment, and interventions for addressing R3's ongoing alcohol consumption. The medical record did not identify how to ensure R3 was adequately supervised and monitored for alcohol consumption and resulting intoxication to minimize the risk of negative outcomes. There was no plan in place to monitor for alcohol detoxification should R3 stop drinking alcohol. There were no interventions in place to address the repeated ACP recommendations to obtain treatment for [REDACTED]. R3's care plan dated 10/4/17, was not updated to reflect any ACP recommendations, or interventions developed based on a comprehensive assessment of ongoing alcohol consumption. On 1/9/18, at 3:57 p.m. R3 entered the facility carrying a large black bag over his right shoulder. R3 smelled of alcohol and was slurring his speech. R3 stopped and talked with the health unit coordinator (HUC) at the front desk before going to his room. On 1/9/18, at 7:36 p.m. R3 was lying on his bed watching television. His bed side table was on the right hand side of him, there was a 20 ounce (oz) mug on the bed side table. The mug had approximately 16 oz of green beverage with ice cubes. The beverage smelled strongly of alcohol. R3 stated he was drinking apple stuff. When asked if the green beverage was alcohol R3 smiled and covered the top of the mug with a book and stated he was not supposed to drink alcohol in the facility. R3 was very talkative displaying scattered thought patterns. R3's face was flushed and speech was slurred. R3 directed surveyor to stop at the bar after leaving the facility that evening, and have a good time. During interview on 1/9/18, at 7:46 p.m. licensed practical nurse (LPN)-C stated she had not been in R3's room that evening. LPN-C stated there was not a plan in place for monitoring any residents for alcohol consumption or any facility protocol on what to do if a resident was suspected to be drinking. LPN-C stated if she thought a resident was drinking she would hold any narcotics prescribed for the resident and call the doctor. She stated she was not aware of any incidents related to R3 drinking. When interviewed on 1/9/18, at 7:48 p.m. NA-J stated she was not aware of any incidents of R3 drinking in or out of the facility. NA-J had not been instructed to monitor R3 for alcohol use in the building or when returning from LOA. If she found a resident drinking she would report it to the nurse. On 1/10/18, at 8:23 a.m. NA-H knocked on R3's door and asked if he wanted breakfast. When NA-H opened the door to R3's room it smelled of alcohol. NA-H delivered R3 his breakfast tray, exited the room and shut the door. NA-H stated R3 was very independent and didn't need any help from staff. NA-H stated her nose was plugged and could not smell anything. She had never seen R3 drunk, but was aware some residents go to the bar down the street. She had never been told to monitor any residents for alcohol use or signs of alcohol use to report. Further, if she found alcohol in a residents room she would take it and bring it to the nurse. She had never found alcohol in R3's room. When interviewed on 1/10/18, at 9:37 a.m. HUC-A stated when residents leave the facility they were supposed to sign out in the book and enter an expected time of return. There isn't always staff at the desk and sometimes residents don't sign out or back in. She only worked three to four days a week and can't see everything going on in the facility, so people get missed. HUC-A stated if a resident had a medical appointment they did not have to sign in and out of the facility because it was in the appointment book and it indicated where the resident was going. Residents were able to freely come and go. Of course residents are leaving to go to the bar and liquor store. HUC-A stated when she noticed residents are intoxicated or can smell it she reports it to their nurse. HUC-A stated R3 did not sign out of the facility on 1/9/17, because he had a medical appointment at 10:00 a.m Further, R3 had asked her to cancel his medical ride back to the facility following his appointment because he had personal things to do after his appointment. HUC-A stated he left the facility about 9:30 a.m. on 1/9/17, and came back around 4:40 p.m. and R3 was drunk when he came in yesterday . his demeanor was different. HUC-A clarified when R3 left for his appointment he was more depressed and when he came back he was very excited and jolly. HUC-A stated she reported R3's behavior to registered nurse (RN)-C on 1/9/17. She had never received direction to monitor for signs and symptoms of intoxication for any resident. R3's undated Release of Responsibility For Leave of Absence form identified a paragraph heading which dictated the undersigned person, hereby accept complete responsibility for (R3), while away from the facility. Further, the form delineated the undersigned to, absolve management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away. The form provided a format of seven columns with multiple rows. The columns were broken into signing out, and signing in, sections, labeled accordingly. The signing out section requested the date, time and signature of the person signing out and/or accepting responsibility along with an, Expected time And (sic) date of return. The signing in section requested the date and time of return, and signature. R3 was identified to sign himself out a total of 21 times from October 2017, through January 2018. Of those times, 18 had an identified time of departure and R3's signature varied from a full name to just written quotation marks referencing the reader to see above or same. Further, 12 of the 21 documented episodes had an expected return time listed with the written responses varying from a large ? over several rows, to an exact time or soon. Further, upon his return to the facility, R3 signed back in 17 of the 21 times, not documenting his return date 6 times and not documenting the return time 5 times. The sign out sheet indicated R3 signed out of the facility: - October 2017: R3 left the faciity on e time - November 2017: R3 left the facility eight times - December 2017: R3 left the facility seven times - January 2018: R3 signed himself out of the facility on 1/6/17 and 1/7/17 During interview on 1/10/18, at 9:47 a.m. housekeeper (H)-A stated housekeeping emptied garbage in R3's room daily and she never found any empty alcohol containers. She would let her supervisor know if she came across alcohol in a residents room. H-A was never instructed to look for empty alcohol containers while cleaning R3's room. When interviewed on 1/10/18, at 9:51 a.m. NA-K stated residents in the facility walk to the bar and liquor store then come back to the facility. I thought there was something up with (R3) because of how he acts sometimes. He doesn't want to be bothered or checked on in his room, doesn't allow us to make his bed, we can just drop off his meal tray and leave. NA-K stated she was never told R3 was drinking in and out of the facility. NA-K was unaware empty alcohol bottles have been found in his room. She had never been instructed by nurses or administrative staff on what to do if a resident was drinking or suspected of drinking. She would let a nurse know if she came across situation related to alcohol use. On 1/10/18, at 1:25 p.m. LPN-A stated he worked the morning and evening shifts. LPN-A stated there used to be a lot of residents that walked down to the bar and came back. He stated more often the current residents are walking to the liquor store and bringing it back and hiding it in their rooms. LPN-A stated they don't know if a resident is drinking unless someone reported finding the alcohol or smelling it. Residents have the right to go out and come back and can't search them. LPN-A stated there was no facility protocol on what to do if a resident was drinking in or out of the facility. There was no protocol to monitor residents who were known to be intoxicated. LPN-A stated they call the manager and then watch the resident to make sure they don't hurt themselves or others. They also hold their medications if they take narcotics and call the doctor. LPN-A stated he only knew R3 signed out of the building and came back. Where he goes is up to him, if they sign out and do not return before midnight a missing persons report is filed with the police department. LPN-A has never been instructed to monitor any resident in the facility for alcohol use. When interviewed on 1/10/18, at 1:29 p.m. LPN-D stated there were known issues with residents going to the bar and drinking at the bar. She had never dealt with it, but had heard about it through shift to shift report. Residents were not allowed to have alcohol in the building. She would call the director of nursing (DON) and administrator and hold medications and call the doctor. LPN-D stated she was not aware of R3's drinking, but hadn't recently worked the wing he resided on. LPN-D stated she had never been instructed to monitor any resident regarding alcohol use. During interview on 1/10/18, at 1:33 p.m. registered nurse manager (RNM)-B stated R3 was an alcoholic and was not drinking when he was admitted to the facility in October 2017. R3 was really good about controlling his drinking until recently. RNM-B stated she heard R3 had been going to the local bar down the road and the last time she knew of was on 1/7/18. RNM-B was unsure if R3 was bringing alcohol into the facility and drinking in the facility. She had never found alcohol in his room or heard anyone else had. RNM-B reviewed R3's progress notes and stated there were incidents of R3 leaving the facility and not returning, with missing person reports filed. Progress notes indicated empty vodka bottles were found in R3's room and R3 smelling of alcohol, and having slurred speech. RNM-B stated she was not aware R3 was seen in the emergency department when he was absent from the facility 11/21/17 to 11/24/17. She stated there was no progress note, or reports from staff reflecting he was in the emergency department, therefore, she did not look for documentation in the hard chart. She stated the facility is responsible for residents in and out of the facility, but staff doesn't know where residents are going when they leave the facility. The facility did not have any policies or protocols on alcohol use or intoxication, RNM-B added, it would be a good idea to have protocols and policies so staff know what to do in those situations. The facility is well aware of residents drinking and there is no monitoring for alcohol use for any residents. On 1/10/18, at 1:45 p.m. RNM-A stated residents are discharged from the hospital with active alcohol problems. They come to the facility for rehab and once they are feeling better they go out and start drinking again. There are no protocols for alcohol use with in the facility. During interview on 1/10/18, at 1:56 p.m. with DON and administrator, the administrator stated there had been residents in the past going to the bar and liquor store. The DON added there was currently issues with residents going to the bar and bringing alcohol back to the facility from the liquor store. We do not allow alcohol use in the building and if staff are suspicious of alcohol use in the building, staff should comb the room. However, did not mention receiving the residents' permission prior to searching their room. The administrator stated the facility has a policy stating alcohol is not allowed in the building and everyone receives the information on admission. She was not aware of any alcohol related incidents with R3. The DON reviewed R3's progress notes and was reading the alcohol related progress notes aloud. The administrator, after hearing some of R3's progress notes, stated R3's drinking incidents now ring a bell. The DON stated R3 had a [DIAGNOSES REDACTED]. DON added it is the facility's responsibility to work on interventions to keep R3 safe and work on appropriate discharge. There was a daily interdisciplinary team (IDT) meeting every morning to discuss incidents and how the facility was going to handle the incidents, however, R3's chart did not include any IDT assessment or interventions. DON could not recall any specific conversations in IDT meetings regarding R3's alcohol use. R3 did not have any internal incident reports regarding alcohol use or incidents involving alcohol. Further, DON stated R3's care plan had not been updated since admission, and did not reflect any interventions related to alcohol use. The progress notes definitely put him on the radar. Staff had not told him R3 was having alcohol related incidents. Although the facility struggled with residents drinking, there were no protocols in place related to alcohol use, including intoxication. The administrator stated there definitely needed to be protocols and procedures for staff to follow if alcohol was found on a resident, or if a resident was returning to the building intoxicated or suspected of alcohol use. There was definitely a need with the population the facility serves, however, the administrator was not sure what the protocols should be. She stated ultimately it was the facility's responsibility to ensure a resident's safety in and out of the building. During interview on 1/10/18, at 3:13 p.m. licensed social worker (LSW)-A stated R3's social service files had no alcohol assessment, or referrals for alcohol dependency treatment programs. She reviewed another social worker's notes in a paper tablet indicating R3 was to be referred for chemical dependency, but stated nothing was in progress. R3 was seeing a psychologist with ACP weekly, the facility should have followed through with those recommendations, completed an assessment and care planned R3's alcohol use. On 1/10/18, at 4:32 p.m. NA-M stated she had never seen R3 drinking in the building but she heard he did. If she did, NA-M would tell a nurse, as they deal with it. When interviewed on 1/11/18, at 6:51 a.m. RN-E stated she worked the over night shift. Residents know they are (TRUNCATED)

Based on observation, interview and document review, the facility failed to comprehensively assess, develop appropriate interventions, and adequately monitor efficacy of interventions to promote intact skin integrity and healing of moisture-associated skin damage (MASD) on the buttock for 1 of 1 residents (R57). This resulted in actual harm for R57 whose buttock wounds worsened, becoming larger in size. Findings include: R57's quarterly Minimum Data Set ((MDS) dated [DATE], identified R57 had intact cognition, was totally dependent on staff for transfers, bed mobility, toileting and personal hygiene, and was always continent of bladder. The MDS identified R57 had medical [DIAGNOSES REDACTED]. Further, R57 was identified at risk for pressure ulcer (PU) development with a current stage I PU (affecting the outermost layer of skin, causing redness and irritation) with an onset date of 12/15/17. The MDS did not identify R57 to have MASD. R57's Hennepin County Medical Center (HCMC) Discharge Summary dated 11/28/17, identified R57 was discharging from the hospital system back to the nursing home. The summary included a section with a review of symptoms and listed R57's skin to have no [MEDICAL CONDITION], no rashes, no [MEDICAL CONDITION]. The summary did not have any evidence R57 had any current skin impairment(s) on her buttocks. R57's Admit/Readmit Assessment - HDGR (Health Dimensions Group) dated 11/28/17, identified R57 readmitted with a [DIAGNOSES REDACTED]. R57's skin was described with normal color, turgor and warm temperature. A body grid was provided in the assessment which identified R57 had a gastrointestinal tube and [MEDICAL CONDITION] removed, however, the grid did not identify R57 to have any rashes, MASD or pressure ulcer(s) upon admission back to the facility. Further, the assessment identified R57 was incontinent of bladder one to two times daily with a large amount of urine causing puddles and/or soaking of the bed, clothes or floor. The assessment was completed by a licensed practical nurse (LPN). R57's skin care plan initiated 1/9/18, identified R57 to have a pressure ulcer with potential for additional pressure ulcer development related to immobility. A goal was identified for R57's pressure ulcer to show signs of healing and remain free from infection by/through review date, and several interventions were listed including to remind and assisting to turn and reposition every two hours or as needed, a pressure relieving mattress, to follow facility protocols for prevention and treatment of [REDACTED]. Further, the care plan directed, Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to MD (medical doctor). On 1/9/18, at 2:05 p.m. R57 was attempted to be interviewed however, had company at the time and declined. R57's family member (FM)-A was interviewed at his request using an interpreter from a third-party company used by the facility. FM-A stated R57 had been at the facility for approximately three months, and the care was not that good. FM-A stated R57 had recently developed a sore on her buttocks because she would go to the bathroom (incontinent) and it would take long periods of time before staff would come to help her. This resulted with her being left soiled for long period of time. FM-A stated as a result, he'd started cleaning the skin himself so R57 would get cleaned up faster versus having to wait for staff. FM-A had been living at the facility to help with her care as he expressed repeated concerns with R57's buttocks wound as it had been very small and they've grown, from her being left soiled and un-cared for after being incontinent of urine. FM-A stated he had even tried himself to make an appointment at the medical clinic for R57 however, was unable to do so. FM-A stated R57 really needs help and he was getting concerned about her sores, because R57 was diabetic and they continued to be getting bigger. R57's progress note(s) were reviewed and identified the following entries pertaining to R57's skin wound(s) since her readmission from the hospital on [DATE]: - On 12/17/17, R57 had an existing open area on the left upper buttock, which measured 2 centimeters (cm) by 1.5 cm along with another open area on left buttock, which measured 0.5 cm by 0.5 cm in size. The nurse dictated, wound clean with dermal wound cleaner and cover with foam dressing. Incoming shift notified. A subsequent note on the same date, identified the wound to have scatter granulation tissue visible. Barrier cream had been applied and the dressing was changed with no complications. - On 12/18/17, R57's wound continued to have scattered granulation present. The wound was cleansed using a dermal wound cleanser and covered with a foam dressing. The staff identified, Will continue to monitor and notified provider and family with changes. - On 12/19/17, staff entered, Open area on the left buttock dry. Barrier cream applied. Site left open to air. No further descriptions, measurements or characteristics of the wound were recorded. - On 12/21/17, the wound dressing was changed without complication and scatter granulation tissue noted. The nurse documented, Providers notified to check our wound on 12/22/17. No measurements or further description of the wound was recorded. - On 12/28/17 (11 days after first being identified on 12/17/17), the wound was measured at 2.5 cm by 1.0 cm with no depth, and no drainage observed. The surrounding skin was intact and dry, and no undermining or tunneling was found. The wound was non-odorous. The staff recorded, Resident is (turned and repositioned) (every) 2 hrs (hours) and as needed. Pressure relieving mattress in use and provider notified of wound. See (treatment administration record) for current dressings. No further note(s) about R57's skin wound(s) were recorded until 1/8/18, when staff identified the wound on right buttocks to measure 1.5 cm by 1.5 cm in size with no depth or drainage. However, the wound now had developed, a 2 X 2 (2 by 2) cm excoriated dry region inferior to wound, which would require monitoring. The note identified R57 remained on a 2 hour turning and repositioning schedule and staff awaiting new wound treatment order from provider. An addendum was added as a separate entry dated the same date, which identified R57's significant other brought out what looked like a capsule and attempted to hand it to writer and colleague to put in the wound and he was dissuaded. Staff communicated to him he needed to allow staff to use the current treatment protocol ordered. The significant other then showed staff what appeared to be [MEDICATION NAME] paste (zinc oxide cream used to help soothe and heal diaper rash), and wanted it applied to R57's gluteal wound(s). The staff advised they used barrier cream as moisturizer, adding, it appeared that resident's significant other understood what was communicated to him by nodding his head in agreement. R57's medical record was reviewed and lacked any comprehensive assessments of R57's gluteal MASD which would include determining the type of MASD developed by R57. The National Institute of Health identifies the following types of MASD: incontinent associated [MEDICAL CONDITION], intertriginous ([MEDICAL CONDITION] condition of skin folds) [MEDICAL CONDITION], periwound (around a wound) moisture-associated [MEDICAL CONDITION], and/or [MEDICATION NAME] (around a stoma) moisture-associated [MEDICAL CONDITION]. Additionally, other contributing factors such as ongoing risk factors, family and/or resident preference for treatment, medical conditions or medications which may impact healing, current voiding patterns or incontinence care(s) required, current nutritional status or associated mobility concerns were not reviewed/assessed. The record lacked documented evidence R57's family had been afforded any input into the plan of care regarding R57's developed MASD including with the implementation of assessed, therapeutic, individualized interventions. R57's Treatment Administration Records (TAR) dated 12/2017, to 1/2018, were reviewed. There were no identified treatment(s) listed on the TAR's until 1/8/18, when the following treatment was added: Wash wound (coccyx) with soap and water - Pat Dry and apply Allevyn dressing. Change every other day and as needed until healed. This was signed as completed only on 1/8/18, then was highlighted as discontinued. Further on 1/10/18, an additional treatment was placed on the TAR directing: Wash wounds on right gluteal with soap and water; pat dry and apply Allevyn. Change every other day and as needed until healed. This treatment was signed as completed on 1/10/18. On 1/10/18, at 9:58 a.m. wound care was observed with registered nurse manager (RNM)-B, the director of nursing (DON) and FM-A. R57 was assisted to turn onto her left side and her incontinence product was removed exposing two visible areas of denuded skin on her right upper gluteal cleft, each appearing to be approximately 2.5 cm in diameter and nearly touching. The wounds were asymmetrical in shape. RNM-B cleansed the area with a spray wound cleanser and a 4 X (by) 4 piece of clean gauze which removed a visible white colored cream from her wound and buttocks. RNM-B attempted to measure the wound using a disposable, paper measuring strip and stated the upper area measured 1.5 cm X 2 cm in size, and the lower area measured 2 cm X 1.5 cm, however, an area of the MASD was obscured by the measuring tape and not included in the initial measurements. The surveyor prompted RNM-B to remove the tape and re-measure the entire diameter of denuded skin. RNM-B re-measured the bottom area at 2.5 cm X 2 cm in size. The upper wound base had visible pink, shiny tissue. The lower wound had the same visible pink, shiny tissue in the base, however, also had an area of visible slough (dead, unhealthy) tissue at the center of the wound which covered approximately 25% of the wound base. RNM-B then placed a new incontinence product on R57, with no dressing of the wound completed. The wound was left open to air. The entire wound lacked any odor and there was no undermining or tunneling identified. However, there was a minimal amount of serous drainage. R57 had complaints aloud of pain at times during the treatment, and FM-A stated he had been opening an [MEDICATION NAME] (antibiotic medication) capsule and placing the powder on the wound as he felt it would help it heal. On 1/11/18, at 7:42 a.m. R57 was laying in bed in her room with FM-A present. R57's bed was positioned along the wall and adjacent to it was a bedside dresser with several different tubes of cream on top. Nursing assistant (NA)-D and NA-E assisted R57 to uncover exposing a visibly soiled incontinence product. R57 was assisted to turn onto her left side and the soiled product was removed exposing a torn piece of brown colored paper towel on her right buttock. NA-E stated aloud to FM-A, Who put that there? to which FM-A responded in Spanish. NA-D removed the piece of paper towel exposing the excoriated area on her right buttocks with visible bright colored, red blood seeping from it. The wound had a visible white colored cream on the surrounding skin. NA-E stated aloud, that a pressure sore on her backside or what's going on? NA-D completed peri-cares on R57 using a wet wipe, and secured a new incontinence product on her without applying any barrier cream(s) or ointments to her MASD or buttocks. When interviewed on 1/11/18, at 7:56 a.m. NA-E stated R57 had been incontinent of urine when changed. NA-E stated the pieces of brown tissue they removed from R57's buttock looked like one of them little brown paper towels. NA-E was unaware how long the towels had been on R57's buttocks, or who applied them. NA-E stated FM-A often helped change R57, but felt it was because he liked to be hands on. NA-E was unaware R57 had developed a wound on her buttocks prior to helping her this morning and the visible white cream they helped clean looked like a barrier cream. However, NA-E was not sure which one had been applied, or if staff should be applying cream when helping her. When interviewed on 1/11/18, at 9:06 a.m. NA-D stated R57 had been incontinent of a medium amount of urine when changed. NA-D stated he did not know the last time she was changed. R57 had a sore on her buttocks, however, NA-D was unaware how she obtained it adding, maybe by sitting. NA-D stated R57 had the sore on her buttocks maybe a week and staff had not been using any creams or ointments on it. NA-D thought R57's husband did not want the creams. On 1/11/18, at 9:59 a.m. RNM-A and RNM-B were interviewed about R57's buttock wound and explained the process for what to do when a resident develops a non-pressure related skin injury. They explained the nursing assistant (NA) staff finding a wound should report the wound to the floor nurse right away so the nurse can go in and assess the wound and document it. The floor nurse was responsible to notify the physician and alert the nurse manager staff (RNM-A and RNM-B) so the wound could be added to the routine wound rounds and monitored. RNM-B stated wounds were to be monitored and tracked on a flowsheet which monitored the wound for characteristics, signs and symptoms of infection and overall size. R57's distal right buttock Wound Assessment Flow Sheet dated 12/28/17, to 1/10/18, identified three documented observations: On 12/28/17, the wound was measured at 2.5 cm by 1.5 cm in size with no depth and 100% granulation tissue (beefy red, healthy tissue) present. There was no drainage, no odor and no tunneling or undermining. The surrounding skin was identified as intact. On 1/8/18, the wound was measured at 1.5 cm by 1.5 cm in size with no depth and 100% granulation tissue present. There continued to be no drainage, no odor and no tunneling or undermining. The surrounding skin was still, intact. On 1/10/18, the wound was documented as 1.5 cm by 2 cm in size with no depth and 100% granulation tissue present. However, there was now minimum serous drainage (thin, clear) with no odor. The surrounding skin was still documented as, intact. R57's proximal right buttock Wound Assessment Flowsheet dated 1/10/18, identified one recorded observation. On 1/10/18, the wound was measured at 2.5 cm by 2 cm in size with no depth and 100% granulation tissue present. There was minimum serous drainage present with no odor and the surrounding skin was intact. RNM-A stated the first entry in R57's medical record concerning the developed wound was the progress note on 12/17/17, RNM-A added the RNM staff had not been informed of or observed R57's wound until 12/28/17 as identified on the flowsheet. RNM-B added she was really not sure when (she) heard about this until recently. RNM-B explained when she first observed the wound, she started calling it a pressure injury, despite it being in the inner aspect of the gluteal fold and not directly over a bony prominence, as they considered most wounds to be pressure injuries. Further, wound rounds were to be completed on a weekly basis, however, RNM-B was ill and some rounds had been missed as the facility didn't have a system to address wound rounds if someone was out ill or on leave. RNM-B explained a comprehensive skin assessment would include assessing several factors of the wound and skin, including the type of wound, characteristics of the wound, drainage and any additional potential areas of wound development. RNM-A reviewed R57's medical record and stated it lacked a comprehensive skin assessment and explained what should have occurred when R57's wound was first observed, the floor staff should have notified the nurse managers then we take over and comprehensively assess it and develop a treatment plan with the physician. RNM-B added there was not actually a place, or assessment used where all of the information gets reviewed or we put all that together. The staff just used nursing interventions and reviewed it during the interdisciplinary team (IDT) meeting(s). RNM-B explained the lack of timely assessment and monitoring was a process thing with the addition of a new RNM and added, there should have been some kind of communication, to alert the RNM(s) of R57's developed wound so it could be addressed. RNM-A and RNM-B explained they both were unaware FM-A had been trying to change R57 and apply cream or antibiotic(s) to her bottom to help heal it, adding they just learned of it while you guys (state agency surveyors) were here. RNM-B stated on 12/28/17, the wound was smaller in size and since then the area beside it has been opened. RNM-B felt the wound was worse as the dried, excoriated skin surrounding the wound had opened. RNM-B was unaware the area had visible bleeding and added they felt the wound worsened as a result of placing powder on it, and using certain creams which were hard to remove. RNM-A reviewed the process for physician notification if wounds developed and stated staff were supposed to notify providers right away or use standing orders if the wound was non-urgent. The first time the physician had been notified of R57's developed wound was on 12/28/17, when he personally had called the provider concerning the wound adding, apparently when he came in (before 12/28/17), he didn't look at the wound. RNM-B stated R57's buttocks wound was a breakdown of communication, adding if the wound had been addressed immediately after it developed, if it was comprehensively assessed and a treatment plan devised, the worsening of the wound could have been avoided. R57's physician progress notes [REDACTED]. The notes failed to have any evidence the physician had observed the wounds or contributed to a treatment plan for the MASD. Each note listed a physical examination had been completed including a heading of SKIN identified. However, there were no identified skin concerns for R57. When interviewed on 1/11/18, at 11:21 a.m. the director of nursing (DON) stated newly observed wounds should be brought to the attention of the floor nurse and an incident report should be completed. The information should be communicated to the nurse manager staff as they are responsible to manage the wound care for each unit. The wound should be tracked on a weekly basis. DON stated the nurse manager was responsible to notify the physician of wounds when they were identified and a comprehensive skin assessment should be completed. A treatment plan should be developed based on the assessment. DON felt the wounds were assessed when they were reviewed during the IDT meetings, however, he was not sure if these were ever documented or not. The facility did not have a tool or formal comprehensive assessment of developed non-pressure related skin conditions. DON stated he would have expected the nurse managers to address and assess the wound more timely. However, the unit where R57 resided had a transition of nurse managers and there was a break down of communication, adding the month of December 2017 was a challenging time for us. A facility Pressure Injury/Skin Integrity/Wound Management - HDGR policy dated 11/2016, identified a system was in place for the prevention, identification, treatment, and documentation of non-pressure wounds. The policy listed a procedure which included a section labeled, Monitoring, which identified the facility had a skin monitoring interdisciplinary team (IDT) which met on a weekly basis. The IDT was, to discuss and review the documentation and to assist in the development of a comprehensive prevention and wound management plan for each resident who has a pressure injury or a non-pressure wound. The policy lacked any further information or guidance on how to identify, assess or track non-pressure related skin damage or wounds. A facility policy specific to MASD management was requested and not provided.

Based on observation, interview and document review, the facility failed to comprehensively assess facility acquired pressure ulcers, provide consistent monitoring and implement interventions to promote healing for 1 of 3 residents (R29) that had current pressure ulcers. This caused actual harm to R29 who's pressure ulcer worsened, and acquired a second pressure ulcer. In addition, the facility failed to provide timely repositioning to prevent the development of pressure ulcers for 1 of 7 residents (R52) at risk for pressure ulcer development. Findings include: R29's annual Minimum Data Set ((MDS) dated [DATE], identified R29 had severe cognitive impairment and required extensive assistance for transfers, bed mobility and eating. The MDS identified R29 was always incontinent of bladder and bowel. Further, R29 was at risk to develop pressure ulcers and had one unhealed Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister) facility acquired pressure ulcer, which developed on 10/21/17, and was not present during the previous assessment dated [DATE]. Interventions identified were: pressure reducing device in chair, pressure reducing device in bed and pressure ulcer care. The MDS included [DIAGNOSES REDACTED]. Further, R29 did not have any weight loss of 5 percent or more in the last month or 10 percent or more in the last six months. R29's Admit/Readmit assessment dated [DATE], identified R29's skin color was normal and warm. A Stage II pressure ulcer was documented as located on the right buttock measuring 4 centimeters (cm) by 3 cm with no depth. The assessment provided no further detail. R29's Braden skin risk assessment (tool used to identify risk for pressure ulcer development) dated 11/15/17, identified R29 was at moderate risk to develop pressure ulcers. R29's Tissue Tolerance Test (tool used to determine appropriate repositioning schedule) dated 11/15/17, identified R29 had color alteration after one hour. It did not indicate a frequency of positioning for R29. R29's pressure ulcer Care Area Assessment (CAA) dated 12/4/17, indicated a comprehensive assessment should be completed for the following conditions: extensive assistance with bed mobility, always incontinent of urine, always incontinent of bowel, at risk for developing pressure ulcers, and an unhealed Stage II pressure ulcer, which was not present on the previous assessment. The analysis of findings indicated pressure ulcer's were a potential problem, as she was at risk for pressure ulcers, it did not identify it was an actual problem and R29 had an actual pressure ulcer. R29 needed a special mattress, or seat cushion to reduce or relieve pressure. The CAA identified risk factors of: immobility, incontinence, altered mental status, poor nutrition, [MEDICAL CONDITION], dementia and a recent weight gain. Treatments and other factors that cause complications or increase included newly admitted or readmitted . A care plan would be developed to avoid complications and minimize R29's risks. Further, the CAA indicated R29 had no actual pressure ulcers, but was at risk for development of pressure ulcers. The staff were to assist with mobility, repositioning and all incontinence cares and would be addressed in the care plan. The CAA did not identify the Stage II pressure ulcer identified in the annual MDS dated [DATE]. It did not address how the pressure ulcer developed, what interventions were in place and what interventions were added to prevent worsening of the pressure ulcer. R29's skin integrity care plan revised on 11/15/17, identified R29 was at risk for impaired skin integrity related to : decreased mobility, cognitive deficits, [MEDICAL CONDITIONS], reliance on staff for activities of daily living (ADL) and a Stage II pressure ulcer to the right buttock. Interventions included: check and change before meals, after meals and during the night when rounds are made; nursing to provide treatment to pressure ulcer per provider orders; pressure relieving cushion on wheelchair; provide thorough peri-care after each incontinent episode; dietician to assess and make recommendations as needed and communicate recommendations to the provider; report impaired skin integrity to provider and follow orders; up for one hour meals only and utilize knee abductor when in wheelchair. R29's physician orders [REDACTED]. On 1/8/18, at 10:00 a.m. R29 was seated in her wheelchair with a blanket over her lap in the day room. R29 was brought to the dining room for lunch at approximately 11:55 a.m R29 remained seated in her wheelchair until she was laid down following lunch at approximately 1:15 p.m On 1/8/18, at 2:19 p.m. R29 was in bed lying on her left side on a blue foam mattress. At 2:38 p.m. the director of maintenance (DM) was bringing an air mattress down R29's hall and placed in the hallway outside R29's room. DM stated he was asked to bring to swap out a residents foam mattress for an air mattress, and added he did not have to order it as it was brought from storage. On 1/8/18, at 2:44 p.m. nursing assistant (NA)-P stated they needed to transfer R29 out of bed so maintenance could put an air mattress on her bed because her pressure ulcer was getting worse. NA-P did not know how long R29 had the pressure ulcer and directed questions to the nurse. On 1/8/18, at 2:44 p.m. registered nurse manager (RNM)-B stated R29's mattress was being replaced with an air mattress because the pressure ulcer on her buttocks was getting worse. RNM-B stated the pressure ulcer on her right buttock had worsened and the left buttock now had a pressure ulcer as well. RNM-B stated the new ulcer could be a Kennedy (irregularly shaped and often resembles a pear or butterfly. They usually start as a blister or an abrasion, but quickly get deeper and turn different colors and only appear at the end of life) ulcer; however, R29 was not dying. Further, she did not know what stage either pressure ulcer was, as she was not good at it (staging) and was waiting for someone else to look at it. She had not seen the pressure ulcer personally for over a week because she was out ill. On 1/8/18, at 3:22 p.m. NA-P and NA-J transferred R29 with a total mechanical lift from her wheelchair to her bed, which now had an air mattress on the bed. NA-J with gloved hands removed R29's brief. R29's buttocks did not have a dressing covering either pressure ulcers and were located on the right and left side of her ischial tuberosity (buttocks area where the sitting bones are located.) The right pressure ulcer was unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be totally visualized because it is obscured by slough or eschar) as the wound bed could not be visualized, there was black and gray stringy slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.) covering 100 percent of the wound base. It was approximately 4 cm by 3 cm with an approximate depth of 0.5 cm The left pressure ulcer was also unstageable as the wound bed could not be visualized, there was black and gray stringy slough covering 100 percent of the wound base. The ulcer was slightly irregular; however, it was not pear or butterfly shaped. It was approximately 6 cm by 3 cm with an approximate depth of 1 cm. Both wounds had a foul odor. NA-J stated her pressure ulcers had looked like that for about two weeks and she had reported it to the nurses, but was unable to recall whom. On 1/8/18, at 3:36 p.m. the director of nursing (DON) stated he observed both pressure ulcers today and the nurse practitioner (NP) was called and would be in the facility on Wednesday to observe the pressure ulcers. He stated he would be surprised if the pressure ulcers were this bad for about two weeks because staff were trained to bring any changes in skin to the nurse manager's attention. Further it could be infected as it did not smell good and there was a black and gray substance in the wound bed. DON stated wounds were assessed weekly and documented in the progress notes. Further, the weekly assessments would include a description of the wound, measurements, tissue type and percentage, any drainage and if it was getting better or worse. R29's medical record was reviewed and included the following entries related to skin: A progress note dated 11/8/17, identified wound rounds were completed and the denuded skin area (loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate or friction) to the coccyx was resolved. R29 now had a Stage II cluster area to the right buttock that measured 4 cm by 3 cm. No depth was included. The surrounding skin was intact. Incontinent care was provided every two hours and PRN (as needed). Barrier cream was applied after each incontinent episode and R29 was laid down between meals. There was an air mattress on the bed. Will continue to follow for wound rounds. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock, with an onset date of 11/8/17. The 11/8/17, documentation included the following: measurements of 4 cm by 3 cm the depth section was blank. The wound bed had 100 percent granulation tissue (new vascular tissue) with minimum serous (thin, clear) drainage, the surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, was repositioned every two hours, R29 had no nutrition plan and had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. A provider order was received on 11/15/17 (7 days after first identified), and identified a right buttock treatment. Every day gently cleanse red area to right buttock, apply barrier cream and cover with [MEDICATION NAME] (adhesive dressing to control moisture) until resolved. Also okay to change PRN for a reddened, pressure like area. A progress note dated 11/19/17, identified a wound assessment was completed 11 days after the previous wound assessment. The Stage II pressure ulcer to the right buttock was improving and measured 2.3 cm by 2 cm, no depth was indicated. The surrounding skin was intact. Incontinent care was provided every two hours and PRN Treatment was provided per provider orders. R29 was laid down between meals and turned and repositioned every two hours. There was an air mattress on the bed. Will continue to follow for wound rounds. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 11/19/17, documentation included the following: measurements of 2.3 cm by 2 cm, the depth section was blank. The wound bed had 100 percent granulation tissue with minimum serous (thin, clear) drainage, the surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, R29 had a positioning plan, R29 had no nutrition plan and had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. A progress note dated 11/29/17, identified a wound assessment was completed 10 days after the previous wound assessment. The Stage II pressure ulcer was now larger and measured 4.5 cm by 4.5 cm, no depth was indicated. The surrounding skin was intact. Incontinent care was provided every two hours and PRN treatment was provided per provider orders. R29 was laid down between meals and turned and repositioned every two hours. There was an air mattress on the bed. Will continue to follow for wound rounds. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 11/29/17, documentation included the following: measurements of 4.5 cm by 4.5 cm, the depth section was blank. The wound bed had 100 percent granulation tissue with minimum serosanguinous (thin and tinged with pink or red color) drainage. The surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, R29 had a positioning plan, R29 had no nutrition plan and had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. R29's November 2017 MAR/TAR identified an order for [REDACTED]. The treatment was not identified as completed on 11/27/17 and 11/29/17. The order for house nutritional supplement 180 mL four times daily was not identified as given on 11/18/17, at 4:00 p.m. and 8:00 p.m The Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 12/6/17, documentation included the following: measurements of 5 cm by 4.6 cm, the depth section was blank. The wound bed had 100 percent granulation tissue with minimum serosanguinous drainage. The surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, R29 had a positioning plan, R29 had no nutrition plan and had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. There was no associated progress noted A progress note dated 12/13/17, identified a wound assessment was completed 7 days after the previous wound assessment. The Stage II pressure ulcer measured 4.5 cm by 4.5 cm, no depth was indicated. The surrounding skin was intact. Incontinent care was provided every two hours and PRN. Treatment was provided per provider orders. R29 was laid down between meals and turned and repositioned every two hours. There was an air mattress on the bed. Will continue to follow for wound rounds. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 12/13/17, documentation included the following: measurements of 4.5 cm by 4.5 cm, the depth section was blank. The wound bed had 100 percent granulation tissue with minimum serosanguinous drainage. The surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, R29 had a positioning plan, The nutrition plan section was blank. R29 had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. A provider progress note dated 12/13/17, indicated, Nursing reports o/a (open area) on buttock bigger, measuring 4.5 cm by 4.5 cm. No drainage noted per wound nurse. The assessment an plan section indicated, Stage II pressure ulcer /rt (right) buttock : continues to progress. Continue current treatment. A provider order dated 12/13/17, identified R29 should only be up in her chair for a maximum of one hour at a time. A progress note dated 12/21/17, identified a wound assessment was completed 8 days after the previous wound assessment. The Stage II area on the right buttock measured 4.5 cm x 5 cm, with no depth indicated. The surrounding skin was intact. Incontinent care was provided every two hours and PRN. Treatment was provided per provider orders. R29 was laid down between meals and turned and repositioned every two hours. There was an air mattress on the bed. Will continue to follow for wound rounds. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 12/21/17, documentation included the following: measurements of 4.5 cm by 5 cm, the depth section was blank. The wound bed had 100 percent granulation tissue with minimum serosanguinous drainage. The surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was no odor, no pain, no debridement, R29 had a positioning plan. The nutrition plan section was blank. R29 had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. R29's December 2017, MAR/TAR identified an order for [REDACTED]. The treatment was not identified as completed 10 times. The order for house nutritional supplement 180 ml four times daily was not identified as given 18 times The medical record lacked any evidence of change to her pressure ulcer treatment, since receiving the first treatment dated 11/15/18, 8 days after developing the Stage II pressure ulcer to the right buttock. A progress note dated 1/8/18, identified a wound assessment was completed 18 days after the previous wound assessment. The Stage II pressure ulcer to the right buttock had worsened to a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer. Measurements were 4.5 cm by 2.5 cm, no depth was charted. The ulcer had a large amount of foul smelling drainage. R29 had also developed an unstageable pressure ulcer to her left buttock, with the appearance of a Kennedy/ Terminal ulcer and measured 5 cm by 3 cm The ulcer was black with a large amount of foul drainage. The NA who works with R29 stated she noticed the area worsening this past weekend. A message was left for the NP requesting new treatment orders. The corresponding Wound Assessment Flow Sheet identified a facility acquired Stage II pressure ulcer to the right buttock. The 1/8/18, documentation included the following: measurements of 4 cm by 2.5 cm, the depth section was blank. The wound bed was necrotic (dead tissue) with no percentage indicated. The ulcer had heavy purulent (almost always a sure sign of infection. This type of exudate can be green, yellow, brown or white in color and is a thick liquid) drainage. The surrounding skin was intact, with no undermining or tunneling. Instructions to refer to the TAR for the current treatment. There was a foul odor, no pain, no debridement, R29 had a positioning and nutrition plan. R29 had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. The corresponding Wound Assessment Flow Sheet identified a facility acquired unstageable pressure ulcer to the left buttock, with an onset day of 1/8/18. The 1/8/18, documentation included the following: measurements of 5 cm by 3 cm x 0.4 cm The wound bed was necrotic with no percentage indicated. The ulcer had heavy purulent drainage. The surrounding skin was intact, undermining/tunneling measuring 0.4 cm at 7 - 9 o'clock. Instructions to refer to the TAR for the current treatment. There was a pungent and foul odor, no pain, no debridement, The positioning section was blank. R29 had a nutrition plan, including a supplement. R29 had a pressure relieving mattress/device. The flow sheet was marked yes, indicating the physician was notified. R29's January 2018, MAR/TAR identified an order for [REDACTED]. The treatment was documented as completed daily from 1/1/18 to 1/8/18. The order for house nutritional supplement 180 mL four times daily was not identified as given 4 times from 1/1/18 to 1/8/18. A progress note dated 1/8/18, indicated R29 had worsening pressure ulcers and staff were now directed to turn and reposition R29 every hour and PRN. A progress note dated 1/9/18, indicated the NP was called and gave an order for [REDACTED]. R29 was repositioned every hour and has an air mattress on her bed. During interview on 1/10/18, at 9:28 a.m. NA-K stated R29's pressure ulcer was worse and they were now turning an repositioning her every hour. NA-K stated prior they were repositioning her every two hours. NA-K stated R29's pressure ulcers smelled. R29 received an air mattress yesterday and never had an air mattress before. She had a regular foam mattress, but should have had the air mattress sooner. Further, the NAs were instructed to not get R29 out of bed due to her pressure ulcers. NA-K stated R29 was eating well and other than the pressure ulcer she was stable, without any changes in her condition for at least a year or so. On 1/10/18, at 10:45 a.m. R29's NP-A was visiting with RNM-B in RNM-B's office, getting ready to assess R29's pressure ulcers. RNM-B asked the NP-A if she wanted to do the measuring because RNM-B was not very good at it and not wound certified. NP-A stated she would measure the ulcers. At 10:46 a.m. RNM-B with gloved hands removed R29's brief. R29 had a foam dressing covering both the right and left buttock ulcers. RNM-B removed the dressings. NP-A viewed both ulcers and stated they both were unstageable. Both pressure ulcers had adhered eschar (crusty or leathery dead patches of tissue found on wounds) to both wound beds, which was a change from the previous observation on 1/8/18, at 3:22 p.m NP-A stated the pressure ulcer on the right buttock started as a Stage II and had worsened. The right buttock pressure ulcer measured 5 cm by 3 cm by 0.5 cm Eschar covered 100 percent of the wound base and there was minimal serous drainage. The edges were intact and blanchable. The left buttocks measured 6 cm by 3 cm x 1.5 cm Eschar covered 100 percent of the wound base and there was minimal serous drainage. The surrounding skin was intact and blanchable. Both ulcers were foul smelling. NP-A stated the ulcers looked clean and not infected and the foul odor was likely just dead tissue. NP-A stated the ulcers were not Kennedy ulcers as R29 was healthy and stable. R29 was elderly and thin but eating well and had actually gained some weight over the last few month. These were just pressure ulcers that have got worse. NP-A stated the treatment to the right pressure ulcer had remained the same. NP-A stated it was important to monitor pressure ulcers for changes. She now wanted the pressure ulcers to be monitored and measured twice weekly, and to discontinue the calcium alginate and apply Santyl (debridement agent) instead and would expect to see some healing. R29's undated Weights and Vitals Summary indicated R29 weight was 93.2 pounds (lbs) on 5/18/17. R29's weight on 12/29/17, was 104.2 lbs. R29 had gained 10.2 lbs and was not losing weight. During interview on 1/10/18, at 4:32 a.m. NA-M stated she did not know when R29's pressure ulcer worsened as she has had a dressing covering her ulcers. NA-M stated she was not sure how often she was supposed to be repositioned prior to being told she needed to be repositioned every hour on 1/8/18. She stated she was supposed to lay down except for meals unless she was at an activity then she would stay in her chair longer. Any changes in the residents skin was to be reported to the nurse. During interview on 1/11/18, at 7:58 a.m. registered nurse (RN)-A stated a skin assessment was supposed to be done weekly when residents have their baths. Some nurses chart the skin assessment regardless of the condition of the skin others do not chart unless something irregular was seen. The nurse manager completes the wound rounds weekly and does the measurements and wound assessment. The floor nurses do the dressing changes and are to notify the nurse manager if the wounds are getting worse. When interviewed on 1/12/18, at 10:09 a.m. RNM-A stated the wound assessments were supposed to be completed every week. R29's air mattress was placed on her bed on 1/8/17, for the first time. RNM-B told RNM-A she was not sure why it was not on the bed sooner, and she thought it was. After reviewing the progress notes RNM-A stated the air mattress was documented it was placed on R29's bed, but it was not and he was not sure why. It was not possible to tell when R29's right buttock pressure ulcer worsened and the left buttock ulcer developed because the right buttock wound was not assessed for 18 days and there was no charting to indicate it was worsening before 1/8/18. RNM-A stated it could be possible it was worsening two weeks ago, and there was a communication breakdown between the nurses and the nurse managers. There was no comprehensive assessment when the right pressure ulcer developed, or when the right pressure ulcer worsened and the left pressure ulcer developed. When an ulcer develops it should be discussed in an IDT meeting and the assessment to the cause and interventions specific to the residents needs developed and adding to the care plan. Now an assessment should be completed to determine why R29's right pressure ulcer worsened and a left pressure ulcer developed. If they are not documenting assessments and when the provider was updated and what changes they made, along with assessing a wound weekly then of course we did not do everything we could to prevent the worsening and development of her pressure ulcers. RNM-A stated the facility needs to train the nurses and nurse managers in wound care and expectations. The nurse managers are responsible for identifying the type of wound, measurements and the characteristics of the wounds and had never received any training. R29 had never been referred for wound care management. On 1/12/18, at 11:32 a.m. the rehab director (RD) stated R29 was fitted for a gel cushion wheelchair cushion in early October 2017. R29 had not been referred to occupational therapy since developing a pressure ulcer. RD stated the gel cushion should provide her relief from pressure as long as staff were not leaving the hoyer sheet under her or placing a sheet over the cushion. During interview on 1/12/18, at 1:39 p.m. RN-D who completes the MDS assessment stated R29's pressure area CAA was not accurate and should have included a comprehensive assessment to ensure R29 was receiving appropriate pressure ulcer care. On 1/16/18, at 11:11 a.m. R29's wheelchair was sitting in the hallway outside her room. The wheelchair had a gel Medline cushion on it. There was nothing covering the wheelchair cushion. During interview on 1/16/18, at 11:13 a.m. NA-A stated R29's wounds started getting worse over two weeks ago. She let the nurse know it was getting worse. She was not sure what nurse she told. When interviewed on 1/16/18, at 12:31 p.m. the DON stated the nurse manager was responsible for a comprehensive assessment when a pressure ulcer develops or worsens. The interdisciplinary teams (IDT) meets and determines if any further interventions were warranted. The weekly wound assessments were, very important and were expected to be completed weekly, to identify any changes to the wounds. After reviewing R29's medical record the DON stated a comprehensive assessment when the pressure ulcer developed was not completed and the pressure ulcer CAA was inaccurate and should have included a comprehensive assessment of the pressure ulcer. R29 should have had an air mattress on her bed and it was not placed until 1/8/18, when her existing pressure ulcer worsened and she developed a second pressure ulcer. Further, the worsening of the existing pressure ulcer and development of the second pressure ulcer was avoidable, as everything was not done as expected. During follow up interview on 1/17/18, at 8:36 a.m. RNM-B stated although the weekly Wound Assessment Flow Sheets indicated the provider was updated with each assessment, she stated an update did not happen with each assessment. She thought NP-A was notified when the right buttock pressure ulcer developed on 11/8/17; however, the treatment was not ordered until 11/15/17, and there was no evidence the provider was notified when the pressure ulcer developed. She never consulted with NP-A on trying another wound treatment when the right buttock pressure ulcer was not healing. RNM-B did not know why she did not increase R29's turning and repositioning per the tissue tolerance test on 11/15/17. RNM-B stated she stated she never received any training in identification of wounds, staging of pressure ulcers and measurements of wounds. She did not know the difference between granulation tissue and slough and was unsure how accurate her weekly assessment's of the wound were. RNM-B stated she heard through staff R29's pressure ulcer was definitely worse the weekend prior to 1/8/17, and a staff member overheard a nursing assistant reporting it to a floor nurse multiple times over the weekend. There was no notification to the provider, and no documentation of the worsening ulcer and the development of another, the treatments were signed off as completed and there is no evidence to when it was actually getting worse. If the wound was worsening provider notification was required. When she looked at the wound on 1/8/18, in the afternoon she started to cry, it was so bad. There was a dressing covering both ulcers so someone had to have known she developed a second pressure ulcer. Further, there is no evidence of what R29's right buttocks looked like as the weekly skin assessment following a bath were not documented. The nurses should be documenting weekly on the resident's skin conditions and they have not been. RNM-B stated it was her fault for not ensuring the air mattress was on the bed beginning 11/8/17, as the charting reflects. The weekly wound assessment should have been done weekly and were not. RNM-B stated there were no referrals to OT for positioning, a wound consultation, or the dietician; however, the dietician follows R29 anyway because she is at risk for loosing weight. The facility Pressure Injury/Skin Integrity/Wound Management policy dated 9/11, identified an avoidable pressure ulcer occurs when the facility fails to do one or more of the following: Evaluate the resident's clinical condition and pressure injury risk factors; Define and implement intervention that are consistent with resident needs, resident goals, and recognized standards of practice; Monitor and evaluate the impact of the interventions; and or revise the interventions as appropriate. An assessment should identify specific factors that might increase the risk of pressure ulcer development or affect healing of a pressure injury. Measurements of all pressure ulcers would be done at least weekly and with any noticeable chance by a licensed nurse. R52's diagnoses, as identified on the admission record with a print date of 1/10/18, included left-sided [MEDICAL CONDITIONS] disease (stroke), diabetes, and contractures. The CAA for pressure ulcers, dated 9/26/17, indicated R52 had a healed pressure ulcer to the left, lateral ankle, but had no current skin breakdown. The CAA also indicated R52 was at risk to develop pressure ulcers related to care dependency, immobility, a functional limitation in range of motion, incontinence and history of ulcers. The care plan, revised 10/24/17, identified R52's risk for pressure ulcers and included a goal to have decreased potential for pressure ulcer formation. R52's care plan included interventions to reduce risk for pressure ulcer formation, among which directed to check, chang (TRUNCATED)

Based on interview and record review, the facility failed to provide medication free of significant medication errors for 1 of 5 residents (R4) reviewed for medication errors, when R4's opioid pain medication was not re-ordered timely. This resulted in actual harm, when R4 missed 4 days (12 doses) of [MEDICATION NAME] (opioid pain medication) and developed acute withdrawl symptoms. Findings include: R4's medical record was reviewed and revealed a [DIAGNOSES REDACTED]. R4's physician orders [REDACTED]. R4's Medication Administration Record [REDACTED]. R4 did not receive the scheduled 3 doses of [MEDICATION NAME] on 5/11, 5/12, 5/13, and 5/14, a total of 12 doses. The MAR indicated [REDACTED]. A 5/13/16 medication note on the back of the MAR indicated [REDACTED] R4's medical record lacked documentation of attempts to refill R4's [MEDICATION NAME] until 5/13/16, 3 days after the first missed dose. A progress note dated 5/13/16 at 3:42 p.m. indicated a voice message was left for the nurse practitioner to refill R4's [MEDICATION NAME] with no word back yet. A progress note dated 5/14/16 at 10:21 a.m., indicated the nurse practitioner and pharmacy had not responded to the refill request. At 10:00 a.m. the resident had a moderate amount of emesis and loose stools. The note indicated staff would continue to monitor and put R4 to bed. A progress note dated 5/15/16 at 6:56 a.m. indicated R4 had an emesis at 6:00 a.m. with a temperature of 99.9 degrees Fahrenheit. Tylenol was given for comfort and staff would continue to monitor. A progress note dated 5/15/16 at 7:10 a.m. indicated staff called the on-call nurse practitioner to report R4's emesis and temperature. Order received for [MEDICATION NAME] (anti-nausea and vomiting medication) 4 mg every 6 hours for 48 hours due to possible withdrawal symptoms. R4's Individual Narcotic Record indicated the facility received nine [MEDICATION NAME] 5 mg tablets on 5/15/16 (unknown time.) Staff administered 5 mg of [MEDICATION NAME] to R4 on 5/15/16 at 10:15 a.m. Total missed dosages of [MEDICATION NAME] 4 days (12 doses.)Progress note on 5/16/16 at 2:36 a.m. revealed R4 complained of not feeling well. Staff notified Physician (J). Physician-J ordered to push fluids and ordered a clear liquid diet to advance as tolerated. R4's progress notes revealed R4 remained on a clear liquid diet until 5/18/16. A 5/19/16 physician note indicated Physician-J examined the resident on 5/19/16. The note identified R4 went without the prescribed [MEDICATION NAME] for 3-4 days due to a lapse in the prescription, which resulted in acute withdrawal symptoms. [MEDICATION NAME] was resumed and R4 felt better. When interviewed 8/4/16 at 2:35 p.m. RN-A confirmed R4 missed 4 days (12 doses) of [MEDICATION NAME] due to a lack of supply, when staff did not re-order the medication timely. RN-A also confirmed R4 developed acute withdrawl symtoms due to not receiving the prescribed [MEDICATION NAME]. RN-A stated staff should have contacted the provider for another [MEDICATION NAME] prescription when R4 had 8 tablets left. This would allow time for the provider to respond to the refill request and time to get the medication from the pharmacy before R4's [MEDICATION NAME] ran out. On 8/24/16, drugs.com revealed cessation (stopping) of [MEDICATION NAME] can cause acute withdrawal symptoms. Withdrawal symptoms included; nausea, vomiting, shaking, abdominal cramping and diarrhea. A facility policy titled ORDERING AND RECEIVING CONTROLLED MEDICATION dated 9/10 does not direct staff on how to obtain controlled medication when no refills are remaining on a schedule II narcotic medication. The policy indicated the Drug Enforcement Agency requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. When reordering medication with refills, the prescription would be requested from the pharmacy a minimum of 3 days in advance of the need to assure an adequate supply is on hand.

Based on observation, interview and document review, the facility neglected to provide adequate supervision to residents who had a known history of drug and alcohol use resulting in medical treatment, including hospitalization , for 2 of 11 residents (R37, R129) reviewed. In addition, the facility failed to implement adequate interventions to prevent elopements for 1 of 3 residents (R116) who eloped from the facility with a WanderGuard (a system to alert staff when a resident leaves the facility) in place. This lack of supervision caused an immediate jeopardy situation for R37, R129 and R116. The IJ began on 5/10/14, when R37 was admitted to the hospital following the use of illicit drugs while in the facility and was identified on 5/12/14. The administrator, consulting administrator, and director of nursing (DON) were notified of the IJ at 3:15 p.m. on 5/12/14. The immediate jeopardy was not removed by the exit date of the survey. Findings include: On 5/9/14, the facility had been informed of serious and immediate safety of the residents related to lack of adequate supervision for alleged drug and alcohol use and elopement. Although, the facility was aware of the serious implications on 5/9/14, the facility did not identify and implement interventions to protect the residents from potential harm. On 5/10/14 and 5/11/14, two residents were hospitalized for [REDACTED]. In addition, on 5/11/14, one resident had eloped from the facility three times with a WanderGuard on and no staff were present. R37's Admission Record dated 1/14/14, indicated R37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to documented progress notes, R37 had been found with ETOH/vodka on 2/21/14, 2/22/14, 2/27/14, 3/2/14, 4/13/14, 4/23/14, 4/24/14, 4/25/14, 5/3/14, 5/5/14, 5/6/14, 5/7/14, 5/9/14 and 5/10/14. The record also indicated R37 had required hospitalization s related to the use of alcohol and or drugs on 2/22/14, 4/23/14, and 5/10/14. During observations of R37 the following was observed: -On 5/5/14, at 2:53 p.m. R37 was observed approaching a white minivan parked in front of the facility. - On 5/6/14, at 1:30 p.m. R37 was observed staggering down the hallway with the health unit coordinator (HUC) and in a loud voice stated he was "crazy". - On 5/6/14, 2:02 p.m. R37 went outside without shoes on. Two staff stopped him at the nursing station and sent him back to his room for shoes. R37 left his room and went directly outside without shoes on again, walked to the smoking patio and returned to the facility. - On 5/7/14, at 8:18 a.m. R37 was observed standing next to R117 on the smoking patio with his wallet out. Another resident (R1) arrived and R37 handed his wallet to her. Surveyor was unable to see whether R1 took anything from the wallet before she handed it back to R37. R37 was observed to lean close to R1 and speak to her and gave her his wallet back. At 8:24 a.m. R1 put R37's wallet back in his left rear pant pocket. - On 5/8/14, at 11:48 a.m. R37 was observed in bed with his back to the door. R37 rolled over and looked at surveyor and rolled back towards the wall. R37 stated he did not want to talk now and would talk in an hour or two. - On 5/8/14, at 3:46 p.m. an attempt was made to interview R37 and he refused. - On 5/9/14, at 7:23 a.m. R37 was observed coming out of his room, stated he did not feel good and was going to see if there was any coffee. At 7:28 a.m. R37 was observed coming from the West hallway. R37 was then observed to push another resident back down the West hallway and was observed outside room [ROOM NUMBER] R9. There was no staff with R37 when he was observed. When R37 returned to the nursing station, he told the HUC he had gotten cigarettes from R9. The HUC asked R37 if he was alone and R37 responded that he was and she asked him where his partner was. Nursing assistant (NA)-L approached R37 and stated she was with him today. NA-L verified she was assigned to provide the 1:1 for R37. - On 5/10/14, at 1:07 p.m. R37 was observed being taken out of the facility to an ambulance. The Nutritional Status Care Area Assessments (CAAs) dated 9/26/13, indicated R37 was at risk for impaired nutritional status due to chronic ETOH abuse and [MEDICAL CONDITION]. Review of the Cognitive Loss/Dementia, Mood State, Behavioral Symptoms and [MEDICAL CONDITION] Drug Use CAAs dated 10/7/13, revealed a lack of a summary regarding the triggered areas. The Progress Notes were reviewed and the following was noted: - On 5/2/14, R37 removed the WanderGuard (departure alert system) and refused a new one to be placed. - On 5/3/14, R37 was walking in the hallway "wobbling" and requested staff give him a shower at 3:00 a.m. R37 was unable to maintain his balance and appeared "intoxicated." Two almost empty bottles of vodka were found in his room. - On 5/5/14, at 3:53 p.m. R37 had exhibited signs of intoxication with an unsteady/staggering gait, slurred speech, odor of alcohol and unkempt appearance. R37 was noted to have continually gone outside, stated he had called a limousine and was going to Las Vegas. - On 5/5/14, at 4:56 p.m. R37 had slurred speech, smelled of ETOH and had a staggering gait. - On 5/5/14, at 10:25 p.m. R37 was "intoxicated" and was found with an almost empty bottle of vodka. - On 5/6/14, a notation had been made indicating it was a late entry for 5/5/14, at 6:00 p.m., the note indicated R37 was noted walking outside towards the back of the building. R37 was noted to be walking alone with a staggering gait. When approached by staff, R37 stated he was going to Las Vegas. No odor of ETOH was noted and when asked what he had been doing to become so impaired, R37 reported he had gotten cocaine and heroin from another resident and confirmed he had been injecting the drugs. Several scattered purple bruises were noted on his forearms. At 1:55 a.m. indicated R37 reported his heart was thumping out of his chest and was found to have a blood pressure of 168 /118 with a pulse of 118. At 4:37 a.m. indicated R37 exited his room without clothing and had a strong odor of ETOH on his breath. Four empty bottles and one unopened bottle of ETOH were found in R37's room and were removed by staff. Also noted R37 started having tremors and palpitations with increased pulse and blood pressure due to ETOH withdrawal and demanded medications. - On 5/7/14, at 12:04 p.m. indicated R37 was exhibiting signs and symptoms of intoxication as evidenced by odor of ETOH, unsteady/slow/staggering gait, slurred speech, confusion and unkempt appearance. A pattern of missed pain clinic appointments due to intoxication was noted and indicated further appointments would not be made due to ongoing intoxication and inability to follow through with appointments. In addition, R37 had a full bottle of vodka and refused to give the bottle to staff. The note indicated the administrator directed if R37 was unwilling to willingly give staff the ETOH bottle, it was ok for the resident to keep the ETOH and if he became drunk or disruptive to call the police and have him taken to detox. - On 5/8/14, at 3:42 p.m. indicated R37 was placed on one to one (1:1) (to be within arm's length at all times) observation related to incidences of getting intoxicated. - On 5/9/14, indicated R37 "was clearly intoxicated." An empty pint bottle of vodka was found in his room and was noted as the third empty pint bottle taken from R37's room in a 48 hour span of time. - On 5/10/14, indicated R37 was observed giving his credit card to R117 on 5/9/14. A second note indicated R37 returned from leave of absence (LOA) accompanied by a friend of another resident (R1). R37 was observed to be shaky and verbalized he was unsteady on his feet. R37 was noted to have shakiness, profuse sweating, and sluggish pupils. R37 was noted to have a blood pressure of 178/130 and a pulse of 120s to 140s. - On 5/11/14, indicated R37 had a drug screen positive for [MEDICATION NAME] at the hospital. R37 did not have a prescription for [MEDICATION NAME]. The physician's orders [REDACTED]. - On 1/8/14, included a [DIAGNOSES REDACTED]. - On 2/5/14, indicated R37 recently had a bottle of ETOH hidden in his pillow case and was noted to smell of ETOH. - On 2/28/14, directed to discharge R37 to another facility (that allowed drinking). - On 3/5/14, directed "do not call on-call MD (physician) or NP after hours if resident is intoxicated unless he is medically compromised. Allow resident to go to bed (and) sleep." - On 4/9/14, indicated R37 was hospitalized from [DATE] from 4/8/14, with respiratory distress and pneumonia with pleural effusions requiring chest tube placement, treated for [REDACTED]. A NP note dated 4/9/14, indicated R37 required ongoing Kristalose and Mag-ox for chronic [MEDICAL CONDITION]. - On 4/10/14, included [DIAGNOSES REDACTED]. - On 4/24/14, included "place wander guard (sic) for res. (resident) safety" and "pursue guardianship." A second order dated 4/24/14, indicated NP was aware of R37's ETOH, to encourage R37 not to use and if R37 appeared intoxicated it was ok to administer all medications as ordered. - On 5/6/14, directed to recheck R37's blood pressure in one hour, call NP if diastolic blood pressure was greater than 100, give [MEDICATION NAME] 0.5 milligrams (mg) orally every six hours as needed times three days for withdrawal symptoms (tremors, shaking, and increased heart rate) and a urine toxicology screen. - On 5/7/14, directed no LOA-supervised or other. Also, the NP included an order for [REDACTED]. A Clinical Summary dated 2/3/14, indicated "refer to chemical dependency counselor and pain psychologist." A prescription dated 2/3/14, ordered a behavioral health evaluation for diagnostic evaluation and treatment recommendations for R37. A Physician Visit/Progress Note written by a licensed drug and alcohol counselor (LADC) dated 2/13/14, indicated R37 had been referred for assessment of behavioral health, chemical dependency and pain, and included an order/comment of "strongly recommend a full psychiatric assessment" within 60 days to evaluate medications and therapy. The medical record lacked evidence of the psychiatric assessment having been completed. R37's care plan was reviewed and noted the following: - The vulnerable adult care plan revised on 3/5/14, indicated R37 may leave to go to medical appointments without supervision but was not safe to go on other unsupervised LOAs. - The depression care plan dated 3/11/14, included ETOH abuse and directed to arrange psych services as needed. - A behavioral symptoms care plan revised on 3/16/14, indicated ETOH consumption and concealing ETOH in room with a goal to have fewer episodes of ETOH abuse per week. The interventions included; encourage attending Alcoholics Anonymous (AA) or other substance abuse support programs, assisting with arrangements as needed, may go to medical/dental appointments unsupervised and no other unsupervised LOA. - A risk for elopement related to ETOH abuse and psychoses care plan revised 3/16/14, noted a history of returning to facility after unsupervised LOA displaying signs of ETOH consumption and/or with a supply of ETOH. The goal included R37 would not to leave facility unattended unless a medical appointment and R37's safety will be maintained. The interventions indicated R37 cut off the WanderGuard and refused to have another one placed and was placed on 15 minute checks. Check room if suspected ETOH. - A Mood/Behavior care plan initiated on 4/23/14, indicated R37 had a history of [REDACTED]. The care plan noted R37 was sent to detox on 4/23/14, due to being very intoxicated. The goal indicated R37 would like to stop drinking ETOH with an intervention to check room daily for ETOH and check R37 for signs of intoxication. - An at risk for adverse reaction from medications related to ETOH care plan dated 4/25/14, indicated NP was aware of R37's ETOH use, nursing staff to encourage to restrain from using ETOH and if R37 appeared intoxicated it was ok to administer medications. Another intervention dated 5/8/14, included 1:1 supervision due to ETOH abuse and intoxication. A Vulnerable Adult assessment dated [DATE], indicated R37 had both past and recent substance abuse, was not safe for unsupervised LOA except to appointments and had significant ETOH use when out on unsupervised LOA. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R37's cognitive skills for daily decision making was independent with consistent/reasonable decisions. A Resident Refusal of Medical Treatment Form dated 5/5/14, indicated R37 was "wander guarded (sic)" to the facility for resident safety related to history of ETOH abuse, staggering gait and slurred speech. With the risks of refusal noted as facility wouldn't be aware if R37 left with potential for fall risk and injury off facility grounds with no one to provide aid. A letter dated 5/10/14, indicated the resident had received a first offense of the facility's smoking policy as R37 reported to staff he had gotten cigarettes from R9. On 5/8/14, at 11:51 a.m. licensed practical nurse (LPN)-B stated she was aware R37 had a doctor's order and can drink as long as there are no behaviors and if behaviors occur she can call detox. LPN- B stated she did not know where R37 had obtained the ETOH from. The safety monitor, NA-M was interviewed on 5/8/14, at 11:55 a.m. and stated he has not seen R37 exchange money for ETOH, and stated he has heard about exchanges but could not remember who he'd heard about it from. The HUC was interviewed on 5/8/14, at 12:15 p.m. and stated "it's a nightmare; (R37) is drunk every day." She stated she had her suspicions about where the ETOH was coming from but when she asked R37 he refused to tell her. The HUC said R37 had told her he had given his credit card to R117 to buy things for him. The HUC stated R37 was drunk every day when she left and was drunk when she came in on 5/8/14. She reported that on 5/5/14, or 5/6/14, she had observed R37 in the parking lot, and had been told there was nothing they could do about it by the facility administrator. She said she'd requested assistance from the operations director to get R37 back in the building. The HUC reported she had requested that the safety monitor put R37 on every 15 minute checks but knew that was not enough. She stated other residents were on 1:1 for drug use and wanted to know what the facility was going to do to keep R37 safe. The HUC stated "we're not doing (R37) any justice" and "it's a[***]y plan to keep people on 1:1 forever." On 5/10/14, at 1:30 p.m. the administrator stated R37 had been taken to the hospital for [MEDICAL CONDITION] tremens (DTs-a severe form of ETOH withdrawal that involves sudden and severe mental or nervous system changes). On 5/12/14, at 8:59 a.m. registered nurse (RN)-B and licensed practical nurse (LPN)-A stated R37 had gone to the bank with a friend on 5/10/14, and were not sure if the 1:1 had gone to the bank or not and would have to check. The DON was interviewed on 5/12/14, at 9:05 a.m. and stated a "guy named (friend-A)" who is a friend of R1 went with R37 to the bank. The DON stated both the administrator and the consultant administrator were aware that friend-A was a friend of R1. The DON stated the 1:1 had refused to go to the bank with R37 and that friend-A had signed R37 out. The DON said the consultant administrator had been going to go with R37 and friend-A to the bank until it was decided the facility was not comfortable with her going with to the bank either. The DON stated he had reminded R37 he could not go because he had orders for no LOA and the administrator, consultant administrator and the social worker decided R37 could go anyway. The DON stated he had no idea where R37 had gotten [MEDICATION NAME] from. When interviewed on 5/12/14, at 1:35 p.m. contracted licensed social worker (CLSW)-A stated during a room search a quart bottle of ETOH and three plastic containers with the labels removed, which nursing indicated were [MEDICATION NAME] containers, had been found in R37's room. When interviewed on 5/12/14, at 1:52 p.m. the administrator stated he and CLSW-A were involved in R37's LOA. The administrator stated CLSW-A was under the impression R37 was allowed to go on LOA and that R37 had returned with a card from Walgreens so they knew he had not followed his agreement to only go to the bank. The administrator stated friend-A would not be able to take R37 on LOA again. The administrator stated he was not aware R37 had orders for no LOAs and he believed CLSW-A had not checked the chart. The administrator stated he was also not aware of friend-A's relationship with R1 and stated the DON had not told him about the order for no LOA and friend-A's relationship with R1. Upon interview on 5/13/14, at 8:09 a.m. CLSW-A stated on 5/10/14, prior to R37 having left on LOA, she was told by nursing (she could not remember who) that R37 could leave the facility with supervision. She reported she made it clear to friend-A that R37 could only go to the bank and nowhere else. She stated she told friend-A that R37 would try and talk him into going to the liquor store and that she'd told friend-A that R37 could not go there. CLSW-A said friend-A had reassured her he had been sober for ten years and would never take R37 to a liquor store. The CLSW-A stated after R37 left, nursing (did not remember who) told her R37 had orders for no LOA and had informed her that friend-A was R1's drug dealer. CLSW-A stated it would have been nice to know the information before she had allowed R37 to go on a LOA. She stated she had not looked at R37's chart because she trusted nursing knew the correct information. She also stated R37 had been keeping ETOH under the edge of his mattress and she could not understand why nursing did not find the ETOH when they made the bed. When interviewed on 5/13/14, at 2:20 p.m. the administrator was asked about the discrepancy between what the DON reported had happened on 5/10/14, and what the administrator stated had happened and he verified he was not aware R37 had an order for [REDACTED]. R129 was identified by the facility to have a history of drug seeking and ETOH dependency. Although the facility had determined R129 required a 1:1 staff member since at least 3/18/14, according to a Vulnerable Adult (VA) assessment, the appropriate supervision was not implemented and/or effective. According to review of the progress notes in R129's record, on 5/3/14, R129 had reported to the facility that she had obtained and consumed cocaine. The documentation indicated R129 had a staff assigned as a 1:1 at the time of the incident. An Incident/Accident Report dated 5/3/14, at 11:00 p.m. indicated R129 "told the nurse that she took cocaine earlier during the shift." The note identified R129 to be "very sweaty, weak and tired" and "she looked very sleepy." The resident's pupils were "large and nonreactive to light." The note indicated the nurse asked R129 what she had taken and indicated R129 then "confessed" to having taken cocaine. The report documentation indicated R129 had been sent to the emergency room (ER) and included, "She said, 'I knowingly took cocaine'.. Resident has been sent to ER. She will continue to be on 1:1 when she returns to the nursing home." The report identified R129 had a history of [REDACTED]." A North Memorial Medical Center (NMMC) Emergency Department (ER/ED) note dated 5/3/14, identified R129 had reported she'd taken cocaine at the nursing home. The ER note indicated R129 had taken the cocaine to "help with the pain" in her abdomen. "Patient (R129) is triaged directly back to ED." The Clinician History of Present Illness section of the form identified R129 had reported to hospital staff she had snorted cocaine "5 hours ago." On 5/11/14, at 4:00 a.m. the progress notes indicated R129 had obtained and consumed a life threatening amount of ETOH, causing her to require hospitalization in an intensive care unit (ICU) with subsequent intubation (mechanical ventilator assisted breathing) as a result of a blood ETOH level of 0.323. (According to Minnesota Statute 169A.20, 0.08 is considered impaired for driving). A 1:1 staff was supposed to have been in place at the time of the incident. The resident's record included a note documented by the facility's HUC on 5/11/14, at 10:09 a.m. which indicated NMMC had called the facility "requesting" R129's medication administration records (MARs). The note indicated the registered nurse (RN) from the hospital had notified the HUC that R129 had been admitted to the ICU, and had been intubated "due to acute [MEDICAL CONDITION]." The note indicated R129's toxicology screen was "negative for drugs but positive for alcohol with a level of 0.323." The record also included a note documented by the director of nursing (DON) on 5/11/14, at 10:55 a.m. The DON's note recapitulated R129 had been sent to the hospital, identified the time of transport as "around 4 a.m." on the night shift, and identified R129 had been sent in "for intoxication." The DON's note indicated R129 had "become weak" and needed to be lowered to the floor." The note indicated two licensed practical nurses (LPNs) were contacted and the nursing assistant (NA) staff assigned to the 1:1 was called. The note indicated the NA assigned to R129 "reported that resident has been in and out of (R14's room number) but that she had not noticed any exchange of alcohol. She also reported that resident (R14) was upset because the 1:1 has to be in his room too while resident (R129) is visiting." In addition, the DON's documentation indicated R14 had denied giving or knowing how R129 had obtained the ETOH, and documented R14 had "mentioned that resident had alcohol overnight." An additional progress note, dated 5/11/14, at 2:49 p.m. had been written by the DON indicating NMMC had been contacted to request updates on R129's status. The note indicated, "I also requested to have the resident undergo a chemical dependency assessment to ensure that the resident can be transferred to a residential chemical dependency facility as appropriate, considering the resident's recent hospital trip to the hospital for snorting cocaine." Additional record review revealed an admission MDS dated [DATE], that indicated R129 had a BIMS score of 15, indicating R129 was cognitively intact. The MDS identified R129 was independent with all ADLs. The MDS identified R129 rejected cares and wandered one to three days during the assessment period. R129's comprehensive assessment analysis (CAA) for mood state dated 2/7/14, identified R129 as having intact cognition, with poor decision making and as having [DIAGNOSES REDACTED]." The CAA identified further [DIAGNOSES REDACTED]. Although the CAAs identified R129 had a history of [REDACTED]. A Vulnerable Adult assessment dated [DATE], identified R129 had a history of [REDACTED]." R129 was identified as being susceptible to abuse "r/t (related to) substance use, varies" and required supervision with LOA from the facility. The assessment identified R129 had behaviors including a history of rummaging through others' belongings and "drug use." The assessment indicated R129 had been placed on 1:1 due to rummaging in other resident rooms. R129's care plan for safety/vulnerability dated 3/25/14, identified R129 was able to make her needs known, but was vulnerable due to her history of opioid abuse and drug seeking behavior. A care plan intervention dated as initiated 4/11/14, directed R129 required "1:1 supervision at all times to keep (R129) safe and prevent drug use" Additionally, the care plan directed, "1:1 to discuss CD concerns, encourage (R129) to consider going to a treatment facility." The care plan for mood/behavior dated 3/25/14, identified, "I have a history of opioid abuse and I exhibit drug seeking behavior as evidenced by attempting to see several different MD's to obtain prescription medication. I have a history of walking into other residents rooms and looking thru their personal belongings." Review of the undated Group 7 NA assignment sheets (forms carried by the NA staff for quick reference direction on the resident care plan) indicated R129 was continent, independent with ADLs and required a "1:1" which was spelled out in large bold print. On 5/12/14, at 10:26 a.m. DON was interviewed about R129 having obtained ETOH and/or drugs while on a 1:1. The DON verified the 1:1 should have been within arm's length of R129 at all times. The DON denied having any knowledge of how R129 had obtained ETOH. On 5/13/14, at 2:21 p.m. the administrator stated during interview that the facility lacked a system to ensure residents on 1:1 were supervised to ensure they were not neglected. The administrator verified a thorough investigation regarding resident access to illegal drugs while R129 was on 1:1 should have been completed and documented thoroughly. The administrator verified 1:1 staffing was a short term solution and was not a viable long-term intervention to address R129's drug seeking and ETOH use. On 5/12/14, at 2:43 p.m. contracted licensed social worker (CLSW)-A stated, "I cannot imagine how a resident who was on 1:1 would get that much alcohol in her system and when I got here on Sunday I came to the office to open the computer to see what happened and guess what, there was no nursing notes. I went outside to the desk and told the administrator and director of nursing to get the nurse in to document and have the 1:1 fired. There are so many people here than I have seen on 1:1. For me 1:1 means the person needs to be somewhere else not at the nursing home." The Special Staffing - One to One Assignment policy dated as reviewed 5/2013, indicate 1:1 staffing may be assigned "under special circumstances," must be prior authorized by the Director of Clinical Services (DCS) and "One to One staffing assignments are not permanent but rather in place based on assessed need until appropriate permanent alternative arrangements can be made." The reasons identified for the 1:1 staffing included threat of suicide, altered mentation that may "dislodge treatment lines and devices," escalating exit seeking behavior, altered cognition in an agitated state that "is not easily redirected" and "does not respect boundaries of other residents." The procedure directed to assess the resident, DON and administrator to agree 1:1 was necessary and consult DCS; instruct staff assigned to 1:1 the purpose of assignment, and directed to keep resident at "arm's length at all times." The procedure indicated if resident was not suicidal, privacy with toileting could be provided. The procedure directed to document the 1:1 assignment in the clinical record and revise the care plan. The facility Drug and Alcohol Free Facility Care Environment-Camden Specific effective 5/11/14, directed: "If staff have reasonable suspicion that a resident has used, has in their possession, or has distributed to other residents in the facility ETOH, street drugs, or other pharmacological substances not prescribed by treating physician the facility staff, under the direction of administration, shall: ? Search the residents room and remove such substances ? Notify the physician and obtain an order for [REDACTED]. ? Notify the family and/or responsible party of the event If the tests return positive the resident with the positive results will be immediately discharged for placing the resident population at risk for abuse. If ETOH, street drugs, or pharmacologic substances are found not prescribed by a physician during a room search the resident will be immediately discharged for placing the population at risk for abuse. If the substances found during a room search are suspected of being illegal the police will be notified." The facility's Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy reviewed January 2013, defined neglect as "The failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness." Under item 6, the policy directed; "Supervisors will immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring." The policy also included "Neglect means a failure to provide a vulnerable adult with necessary food, clothing, shelter, health care, or supervision." Appendix A of the policy included examples of neglect including: "Failure of a caregiver to provide a resident with (or the absence or likelihood of absence of) care or services (e.g. food, clothing, shelter, health care or supervision) which are reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety." According to the record, R116 eloped from the facility on 5/11/14, at 9:30 a.m., 11:30 a.m. and 11:52 a.m. while wearing a WanderGuard device which had been implemented to prevent the resident's elopement. Record review indicated R116 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also indicated R116 had Hospice services initiated on 1/21/14. On 4/15/14, at 10:49 p.m. a nursing progress note indicated, "Pt (patient) is declining. He is very weak and needs a lot of assistance." A progress note dated 5/5/14, indicated R116 had been outside with his son and the resident had experienced a fall. R116's son was present at fall. Hospice was notified of fall and a new wheelchair (W/C) was ordered for resident. Staff had also placed a WanderGuard on the resident's chair to alert staff when the resident wanted to go outside to maintain resident's safety. "Resident is allowed to go outside although staff needs to be alerted. Son is aware and in agreement with interventions. Nursing is to continue to monitor." Additionally, a draft progress note dated 5/5/14, at 10:47 p.m. indicated R116 had increased confusion. "He requested going the bank to complete his transaction that he began earlier. He was leaning down to the floor to pick up of stuff which was apparently not there (visual hallucination). He was ambulating around getting out of w/c. Towards the end of shift he was on one to one rotation to prevent him from falling." A progress note dated 5/6/14, at 2:55 p.m. indicated R116 continued to sit at nursing station with staff due to attempts to self-transfer and unsteady gait. R116 was observed on 5/11/14, at 9:30 a.m. to be on the sidewalk west of the facility. The health unit coordinator (HUC) was bringing R116 back into the building. The HUC stated she "had found him as she was driving into work." The HUC stated R116 had a WanderGuard on and she was surprised to find him walking outside since he was not able to walk every day. The HUC said she had called the facility and alerted them to the fact that R116 had left the facility and requested someone bring a wheelchair (w/c) to help bring him back to the facility. NA-R and safety monitor/NA-O had also come outside to look for R116. Two other NA's NA-P and NA-Q came outside with a w/c to meet R116 and return him to the facility. On 5/11/14, at 10:38 a.m. a progress note indicated, "At 9:30 a.m. upon arrival to work this writer found R116 outside the facility walking down the sidewalk. When approached he stated 'I am going

An immediate jeopardy related to neglect of supervision for residents was identified during the revisit survey on 5/12/14. The immediate jeopardy began on 5/10/14, and was removed on 5/21/14. However, noncompliance remained at the lower severity level of G, isolated actual harm that is not immediate jeopardy (IJ). Based on observation, interview and document review, the facility neglected to provide adequate supervision to residents who had a known history of drug and alcohol use resulting in medical treatment, including hospitalization , for 2 of 11 residents (R37, R129) reviewed. In addition, the facility failed to implement adequate interventions to prevent elopements for 1 of 3 residents (R116) who eloped from the facility with a WanderGuard (a system to alert staff when a resident leaves the facility) in place. This lack of supervision caused an immediate jeopardy situation for R37, R129 and R116. The IJ was not removed by exit of the 5/13/14 survey. Findings include: The following deficiency was cited during a revisit conducted on 5/13/14, and was the basis for an IJ to resident's health and safety. On 5/9/14, the facility had been informed of serious and immediate safety of the residents related to lack of adequate supervision for alleged drug and alcohol use and elopement. Although, the facility was aware of the serious implications on 5/9/14, the facility did not identify and implement interventions to protect the residents from potential harm. On 5/10/14 and 5/11/14, two residents were hospitalized for [REDACTED]. In addition, on 5/11/14, one resident had eloped from the facility three times with a WanderGuard on and no staff were present. R37's Admission Record dated 1/14/14, indicated R37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to documented progress notes, R37 had been found with ETOH/vodka on 2/21/14, 2/22/14, 2/27/14, 3/2/14, 4/13/14, 4/23/14, 4/24/14, 4/25/14, 5/3/14, 5/5/14, 5/6/14, 5/7/14, 5/9/14 and 5/10/14. The record also indicated R37 had required hospitalization s related to the use of alcohol and or drugs on 2/22/14, 4/23/14, and 5/10/14. During observations of R37 the following was observed: -On 5/5/14, at 2:53 p.m. R37 was observed approaching a white minivan parked in front of the facility. - On 5/6/14, at 1:30 p.m. R37 was observed staggering down the hallway with the health unit coordinator (HUC) and in a loud voice stated he was "crazy". - On 5/6/14, 2:02 p.m. R37 went outside without shoes on. Two staff stopped him at the nursing station and sent him back to his room for shoes. R37 left his room and went directly outside without shoes on again, walked to the smoking patio and returned to the facility. - On 5/7/14, at 8:18 a.m. R37 was observed standing next to R117 on the smoking patio with his wallet out. Another resident (R1) arrived and R37 handed his wallet to her. Surveyor was unable to see whether R1 took anything from the wallet before she handed it back to R37. R37 was observed to lean close to R1 and speak to her and gave her his wallet back. At 8:24 a.m. R1 put R37's wallet back in his left rear pant pocket. - On 5/8/14, at 11:48 a.m. R37 was observed in bed with his back to the door. R37 rolled over and looked at surveyor and rolled back towards the wall. R37 stated he did not want to talk now and would talk in an hour or two. - On 5/8/14, at 3:46 p.m. an attempt was made to interview R37 and he refused. - On 5/9/14, at 7:23 a.m. R37 was observed coming out of his room, stated he did not feel good and was going to see if there was any coffee. At 7:28 a.m. R37 was observed coming from the West hallway. R37 was then observed to push another resident back down the West hallway and was observed outside room [ROOM NUMBER] R9. There was no staff with R37 when he was observed. When R37 returned to the nursing station, he told the HUC he had gotten cigarettes from R9. The HUC asked R37 if he was alone and R37 responded that he was and she asked him where his partner was. Nursing assistant (NA)-L approached R37 and stated she was with him today. NA-L verified she was assigned to provide the 1:1 for R37. - On 5/10/14, at 1:07 p.m. R37 was observed being taken out of the facility to an ambulance. The Nutritional Status Care Area Assessments (CAAs) dated 9/26/13, indicated R37 was at risk for impaired nutritional status due to chronic ETOH abuse and [MEDICAL CONDITION]. Review of the Cognitive Loss/Dementia, Mood State, Behavioral Symptoms and [MEDICAL CONDITION] Drug Use CAAs dated 10/7/13, revealed a lack of a summary regarding the triggered areas. The Progress Notes were reviewed and the following was noted: - On 5/2/14, R37 removed the WanderGuard (departure alert system) and refused a new one to be placed. - On 5/3/14, R37 was walking in the hallway "wobbling" and requested staff give him a shower at 3:00 a.m. R37 was unable to maintain his balance and appeared "intoxicated." Two almost empty bottles of vodka were found in his room. - On 5/5/14, at 3:53 p.m. R37 had exhibited signs of intoxication with an unsteady/staggering gait, slurred speech, odor of alcohol and unkempt appearance. R37 was noted to have continually gone outside, stated he had called a limousine and was going to Las Vegas. - On 5/5/14, at 4:56 p.m. R37 had slurred speech, smelled of ETOH and had a staggering gait. - On 5/5/14, at 10:25 p.m. R37 was "intoxicated" and was found with an almost empty bottle of vodka. - On 5/6/14, a notation had been made indicating it was a late entry for 5/5/14, at 6:00 p.m., the note indicated R37 was noted walking outside towards the back of the building. R37 was noted to be walking alone with a staggering gait. When approached by staff, R37 stated he was going to Las Vegas. No odor of ETOH was noted and when asked what he had been doing to become so impaired, R37 reported he had gotten cocaine and heroin from another resident and confirmed he had been injecting the drugs. Several scattered purple bruises were noted on his forearms. At 1:55 a.m. indicated R37 reported his heart was thumping out of his chest and was found to have a blood pressure of 168 /118 with a pulse of 118. At 4:37 a.m. indicated R37 exited his room without clothing and had a strong odor of ETOH on his breath. Four empty bottles and one unopened bottle of ETOH were found in R37's room and were removed by staff. Also noted R37 started having tremors and palpitations with increased pulse and blood pressure due to ETOH withdrawal and demanded medications. - On 5/7/14, at 12:04 p.m. indicated R37 was exhibiting signs and symptoms of intoxication as evidenced by odor of ETOH, unsteady/slow/staggering gait, slurred speech, confusion and unkempt appearance. A pattern of missed pain clinic appointments due to intoxication was noted and indicated further appointments would not be made due to ongoing intoxication and inability to follow through with appointments. In addition, R37 had a full bottle of vodka and refused to give the bottle to staff. The note indicated the administrator directed if R37 was unwilling to willingly give staff the ETOH bottle, it was ok for the resident to keep the ETOH and if he became drunk or disruptive to call the police and have him taken to detox. - On 5/8/14, at 3:42 p.m. indicated R37 was placed on one to one (1:1) (to be within arm's length at all times) observation related to incidences of getting intoxicated. - On 5/9/14, indicated R37 "was clearly intoxicated." An empty pint bottle of vodka was found in his room and was noted as the third empty pint bottle taken from R37's room in a 48 hour span of time. - On 5/10/14, indicated R37 was observed giving his credit card to R117 on 5/9/14. A second note indicated R37 returned from leave of absence (LOA) accompanied by a friend of another resident (R1). R37 was observed to be shaky and verbalized he was unsteady on his feet. R37 was noted to have shakiness, profuse sweating, and sluggish pupils. R37 was noted to have a blood pressure of 178/130 and a pulse of 120s to 140s. - On 5/11/14, indicated R37 had a drug screen positive for [MEDICATION NAME] at the hospital. R37 did not have a prescription for [MEDICATION NAME]. The physician's orders [REDACTED]. - On 1/8/14, included a [DIAGNOSES REDACTED]. - On 2/5/14, indicated R37 recently had a bottle of ETOH hidden in his pillow case and was noted to smell of ETOH. - On 2/28/14, directed to discharge R37 to another facility (that allowed drinking). - On 3/5/14, directed "do not call on-call MD (physician) or NP after hours if resident is intoxicated unless he is medically compromised. Allow resident to go to bed (and) sleep." - On 4/9/14, indicated R37 was hospitalized from [DATE] from 4/8/14, with respiratory distress and pneumonia with pleural effusions requiring chest tube placement, treated for [REDACTED]. A NP note dated 4/9/14, indicated R37 required ongoing Kristalose and Mag-ox for chronic [MEDICAL CONDITION]. - On 4/10/14, included [DIAGNOSES REDACTED]. - On 4/24/14, included "place wander guard (sic) for res. (resident) safety" and "pursue guardianship." A second order dated 4/24/14, indicated NP was aware of R37's ETOH, to encourage R37 not to use and if R37 appeared intoxicated it was ok to administer all medications as ordered. - On 5/6/14, directed to recheck R37's blood pressure in one hour, call NP if diastolic blood pressure was greater than 100, give [MEDICATION NAME] 0.5 milligrams (mg) orally every six hours as needed times three days for withdrawal symptoms (tremors, shaking, and increased heart rate) and a urine toxicology screen. - On 5/7/14, directed no LOA-supervised or other. Also, the NP included an order for [REDACTED]. A Clinical Summary dated 2/3/14, indicated "refer to chemical dependency counselor and pain psychologist." A prescription dated 2/3/14, ordered a behavioral health evaluation for diagnostic evaluation and treatment recommendations for R37. A Physician Visit/Progress Note written by a licensed drug and alcohol counselor (LADC) dated 2/13/14, indicated R37 had been referred for assessment of behavioral health, chemical dependency and pain, and included an order/comment of "strongly recommend a full psychiatric assessment" within 60 days to evaluate medications and therapy. The medical record lacked evidence of the psychiatric assessment having been completed. R37's care plan was reviewed and noted the following: - The vulnerable adult care plan revised on 3/5/14, indicated R37 may leave to go to medical appointments without supervision but was not safe to go on other unsupervised LOAs. - The depression care plan dated 3/11/14, included ETOH abuse and directed to arrange psych services as needed. - A behavioral symptoms care plan revised on 3/16/14, indicated ETOH consumption and concealing ETOH in room with a goal to have fewer episodes of ETOH abuse per week. The interventions included; encourage attending Alcoholics Anonymous (AA) or other substance abuse support programs, assisting with arrangements as needed, may go to medical/dental appointments unsupervised and no other unsupervised LOA. - A risk for elopement related to ETOH abuse and psychoses care plan revised 3/16/14, noted a history of returning to facility after unsupervised LOA displaying signs of ETOH consumption and/or with a supply of ETOH. The goal included R37 would not to leave facility unattended unless a medical appointment and R37's safety will be maintained. The interventions indicated R37 cut off the WanderGuard and refused to have another one placed and was placed on 15 minute checks. Check room if suspected ETOH. - A Mood/Behavior care plan initiated on 4/23/14, indicated R37 had a history of [REDACTED]. The care plan noted R37 was sent to detox on 4/23/14, due to being very intoxicated. The goal indicated R37 would like to stop drinking ETOH with an intervention to check room daily for ETOH and check R37 for signs of intoxication. - An at risk for adverse reaction from medications related to ETOH care plan dated 4/25/14, indicated NP was aware of R37's ETOH use, nursing staff to encourage to restrain from using ETOH and if R37 appeared intoxicated it was ok to administer medications. Another intervention dated 5/8/14, included 1:1 supervision due to ETOH abuse and intoxication. A Vulnerable Adult assessment dated [DATE], indicated R37 had both past and recent substance abuse, was not safe for unsupervised LOA except to appointments and had significant ETOH use when out on unsupervised LOA. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R37's cognitive skills for daily decision making was independent with consistent/reasonable decisions. A Resident Refusal of Medical Treatment Form dated 5/5/14, indicated R37 was "wander guarded (sic)" to the facility for resident safety related to history of ETOH abuse, staggering gait and slurred speech. With the risks of refusal noted as facility wouldn't be aware if R37 left with potential for fall risk and injury off facility grounds with no one to provide aid. A letter dated 5/10/14, indicated the resident had received a first offense of the facility's smoking policy as R37 reported to staff he had gotten cigarettes from R9. On 5/8/14, at 11:51 a.m. licensed practical nurse (LPN)-B stated she was aware R37 had a doctor's order and can drink as long as there are no behaviors and if behaviors occur she can call detox. LPN- B stated she did not know where R37 had obtained the ETOH from. The safety monitor, NA-M was interviewed on 5/8/14, at 11:55 a.m. and stated he has not seen R37 exchange money for ETOH, and stated he has heard about exchanges but could not remember who he'd heard about it from. The HUC was interviewed on 5/8/14, at 12:15 p.m. and stated "it's a nightmare; (R37) is drunk every day." She stated she had her suspicions about where the ETOH was coming from but when she asked R37 he refused to tell her. The HUC said R37 had told her he had given his credit card to R117 to buy things for him. The HUC stated R37 was drunk every day when she left and was drunk when she came in on 5/8/14. She reported that on 5/5/14, or 5/6/14, she had observed R37 in the parking lot, and had been told there was nothing they could do about it by the facility administrator. She said she'd requested assistance from the operations director to get R37 back in the building. The HUC reported she had requested that the safety monitor put R37 on every 15 minute checks but knew that was not enough. She stated other residents were on 1:1 for drug use and wanted to know what the facility was going to do to keep R37 safe. The HUC stated "we're not doing (R37) any justice" and "it's a[***]y plan to keep people on 1:1 forever." On 5/10/14, at 1:30 p.m. the administrator stated R37 had been taken to the hospital for [MEDICAL CONDITION] tremens (DTs-a severe form of ETOH withdrawal that involves sudden and severe mental or nervous system changes). On 5/12/14, at 8:59 a.m. registered nurse (RN)-B and licensed practical nurse (LPN)-A stated R37 had gone to the bank with a friend on 5/10/14, and were not sure if the 1:1 had gone to the bank or not and would have to check. The DON was interviewed on 5/12/14, at 9:05 a.m. and stated a "guy named (friend-A)" who is a friend of R1 went with R37 to the bank. The DON stated both the administrator and the consultant administrator were aware that friend-A was a friend of R1. The DON stated the 1:1 had refused to go to the bank with R37 and that friend-A had signed R37 out. The DON said the consultant administrator had been going to go with R37 and friend-A to the bank until it was decided the facility was not comfortable with her going with to the bank either. The DON stated he had reminded R37 he could not go because he had orders for no LOA and the administrator, consultant administrator and the social worker decided R37 could go anyway. The DON stated he had no idea where R37 had gotten [MEDICATION NAME] from. When interviewed on 5/12/14, at 1:35 p.m. contracted licensed social worker (CLSW)-A stated during a room search a quart bottle of ETOH and three plastic containers with the labels removed, which nursing indicated were [MEDICATION NAME] containers, had been found in R37's room. When interviewed on 5/12/14, at 1:52 p.m. the administrator stated he and CLSW-A were involved in R37's LOA. The administrator stated CLSW-A was under the impression R37 was allowed to go on LOA and that R37 had returned with a card from Walgreens so they knew he had not followed his agreement to only go to the bank. The administrator stated friend-A would not be able to take R37 on LOA again. The administrator stated he was not aware R37 had orders for no LOAs and he believed CLSW-A had not checked the chart. The administrator stated he was also not aware of friend-A's relationship with R1 and stated the DON had not told him about the order for no LOA and friend-A's relationship with R1. Upon interview on 5/13/14, at 8:09 a.m. CLSW-A stated on 5/10/14, prior to R37 having left on LOA, she was told by nursing (she could not remember who) that R37 could leave the facility with supervision. She reported she made it clear to friend-A that R37 could only go to the bank and nowhere else. She stated she told friend-A that R37 would try and talk him into going to the liquor store and that she'd told friend-A that R37 could not go there. CLSW-A said friend-A had reassured her he had been sober for ten years and would never take R37 to a liquor store. The CLSW-A stated after R37 left, nursing (did not remember who) told her R37 had orders for no LOA and had informed her that friend-A was R1's drug dealer. CLSW-A stated it would have been nice to know the information before she had allowed R37 to go on a LOA. She stated she had not looked at R37's chart because she trusted nursing knew the correct information. She also stated R37 had been keeping ETOH under the edge of his mattress and she could not understand why nursing did not find the ETOH when they made the bed. When interviewed on 5/13/14, at 2:20 p.m. the administrator was asked about the discrepancy between what the DON reported had happened on 5/10/14, and what the administrator stated had happened and he verified he was not aware R37 had an order for [REDACTED]. R129 was identified by the facility to have a history of drug seeking and ETOH dependency. Although the facility had determined R129 required a 1:1 staff member since at least 3/18/14, according to a Vulnerable Adult (VA) assessment, the appropriate supervision was not implemented and/or effective. According to review of the progress notes in R129's record, on 5/3/14, R129 had reported to the facility that she had obtained and consumed cocaine. The documentation indicated R129 had a staff assigned as a 1:1 at the time of the incident. An Incident/Accident Report dated 5/3/14, at 11:00 p.m. indicated R129 "told the nurse that she took cocaine earlier during the shift." The note identified R129 to be "very sweaty, weak and tired" and "she looked very sleepy." The resident's pupils were "large and nonreactive to light." The note indicated the nurse asked R129 what she had taken and indicated R129 then "confessed" to having taken cocaine. The report documentation indicated R129 had been sent to the emergency room (ER) and included, "She said, 'I knowingly took cocaine'.. Resident has been sent to ER. She will continue to be on 1:1 when she returns to the nursing home." The report identified R129 had a history of [REDACTED]." A North Memorial Medical Center (NMMC) Emergency Department (ER/ED) note dated 5/3/14, identified R129 had reported she'd taken cocaine at the nursing home. The ER note indicated R129 had taken the cocaine to "help with the pain" in her abdomen. "Patient (R129) is triaged directly back to ED." The Clinician History of Present Illness section of the form identified R129 had reported to hospital staff she had snorted cocaine "5 hours ago." On 5/11/14, at 4:00 a.m. the progress notes indicated R129 had obtained and consumed a life threatening amount of ETOH, causing her to require hospitalization in an intensive care unit (ICU) with subsequent intubation (mechanical ventilator assisted breathing) as a result of a blood ETOH level of 0.323. (According to Minnesota Statute 169A.20, 0.08 is considered impaired for driving). A 1:1 staff was supposed to have been in place at the time of the incident. The resident's record included a note documented by the facility's HUC on 5/11/14, at 10:09 a.m. which indicated NMMC had called the facility "requesting" R129's medication administration records (MARs). The note indicated the registered nurse (RN) from the hospital had notified the HUC that R129 had been admitted to the ICU, and had been intubated "due to acute [MEDICAL CONDITION]." The note indicated R129's toxicology screen was "negative for drugs but positive for alcohol with a level of 0.323." The record also included a note documented by the director of nursing (DON) on 5/11/14, at 10:55 a.m. The DON's note recapitulated R129 had been sent to the hospital, identified the time of transport as "around 4 a.m." on the night shift, and identified R129 had been sent in "for intoxication." The DON's note indicated R129 had "become weak" and needed to be lowered to the floor." The note indicated two licensed practical nurses (LPNs) were contacted and the nursing assistant (NA) staff assigned to the 1:1 was called. The note indicated the NA assigned to R129 "reported that resident has been in and out of (R14's room number) but that she had not noticed any exchange of alcohol. She also reported that resident (R14) was upset because the 1:1 has to be in his room too while resident (R129) is visiting." In addition, the DON's documentation indicated R14 had denied giving or knowing how R129 had obtained the ETOH, and documented R14 had "mentioned that resident had alcohol overnight." An additional progress note, dated 5/11/14, at 2:49 p.m. had been written by the DON indicating NMMC had been contacted to request updates on R129's status. The note indicated, "I also requested to have the resident undergo a chemical dependency assessment to ensure that the resident can be transferred to a residential chemical dependency facility as appropriate, considering the resident's recent hospital trip to the hospital for snorting cocaine." Additional record review revealed an admission MDS dated [DATE], that indicated R129 had a BIMS score of 15, indicating R129 was cognitively intact. The MDS identified R129 was independent with all ADLs. The MDS identified R129 rejected cares and wandered one to three days during the assessment period. R129's comprehensive assessment analysis (CAA) for mood state dated 2/7/14, identified R129 as having intact cognition, with poor decision making and as having [DIAGNOSES REDACTED]." The CAA identified further [DIAGNOSES REDACTED]. Although the CAAs identified R129 had a history of [REDACTED]. A Vulnerable Adult assessment dated [DATE], identified R129 had a history of [REDACTED]." R129 was identified as being susceptible to abuse "r/t (related to) substance use, varies" and required supervision with LOA from the facility. The assessment identified R129 had behaviors including a history of rummaging through others' belongings and "drug use." The assessment indicated R129 had been placed on 1:1 due to rummaging in other resident rooms. R129's care plan for safety/vulnerability dated 3/25/14, identified R129 was able to make her needs known, but was vulnerable due to her history of opioid abuse and drug seeking behavior. A care plan intervention dated as initiated 4/11/14, directed R129 required "1:1 supervision at all times to keep (R129) safe and prevent drug use" Additionally, the care plan directed, "1:1 to discuss CD concerns, encourage (R129) to consider going to a treatment facility." The care plan for mood/behavior dated 3/25/14, identified, "I have a history of opioid abuse and I exhibit drug seeking behavior as evidenced by attempting to see several different MD's to obtain prescription medication. I have a history of walking into other residents rooms and looking thru their personal belongings." Review of the undated Group 7 NA assignment sheets (forms carried by the NA staff for quick reference direction on the resident care plan) indicated R129 was continent, independent with ADLs and required a "1:1" which was spelled out in large bold print. On 5/12/14, at 10:26 a.m. DON was interviewed about R129 having obtained ETOH and/or drugs while on a 1:1. The DON verified the 1:1 should have been within arm's length of R129 at all times. The DON denied having any knowledge of how R129 had obtained ETOH. On 5/13/14, at 2:21 p.m. the administrator stated during interview that the facility lacked a system to ensure residents on 1:1 were supervised to ensure they were not neglected. The administrator verified a thorough investigation regarding resident access to illegal drugs while R129 was on 1:1 should have been completed and documented thoroughly. The administrator verified 1:1 staffing was a short term solution and was not a viable long-term intervention to address R129's drug seeking and ETOH use. On 5/12/14, at 2:43 p.m. contracted licensed social worker (CLSW)-A stated, "I cannot imagine how a resident who was on 1:1 would get that much alcohol in her system and when I got here on Sunday I came to the office to open the computer to see what happened and guess what, there was no nursing notes. I went outside to the desk and told the administrator and director of nursing to get the nurse in to document and have the 1:1 fired. There are so many people here than I have seen on 1:1. For me 1:1 means the person needs to be somewhere else not at the nursing home." The Special Staffing - One to One Assignment policy dated as reviewed 5/2013, indicate 1:1 staffing may be assigned "under special circumstances," must be prior authorized by the Director of Clinical Services (DCS) and "One to One staffing assignments are not permanent but rather in place based on assessed need until appropriate permanent alternative arrangements can be made." The reasons identified for the 1:1 staffing included threat of suicide, altered mentation that may "dislodge treatment lines and devices," escalating exit seeking behavior, altered cognition in an agitated state that "is not easily redirected" and "does not respect boundaries of other residents." The procedure directed to assess the resident, DON and administrator to agree 1:1 was necessary and consult DCS; instruct staff assigned to 1:1 the purpose of assignment, and directed to keep resident at "arm's length at all times." The procedure indicated if resident was not suicidal, privacy with toileting could be provided. The procedure directed to document the 1:1 assignment in the clinical record and revise the care plan. The facility Drug and Alcohol Free Facility Care Environment-Camden Specific effective 5/11/14, directed: "If staff have reasonable suspicion that a resident has used, has in their possession, or has distributed to other residents in the facility ETOH, street drugs, or other pharmacological substances not prescribed by treating physician the facility staff, under the direction of administration, shall: ? Search the residents room and remove such substances ? Notify the physician and obtain an order for [REDACTED]. ? Notify the family and/or responsible party of the event If the tests return positive the resident with the positive results will be immediately discharged for placing the resident population at risk for abuse. If ETOH, street drugs, or pharmacologic substances are found not prescribed by a physician during a room search the resident will be immediately discharged for placing the population at risk for abuse. If the substances found during a room search are suspected of being illegal the police will be notified." The facility's Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy reviewed January 2013, defined neglect as "The failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness." Under item 6, the policy directed; "Supervisors will immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring." The policy also included "Neglect means a failure to provide a vulnerable adult with necessary food, clothing, shelter, health care, or supervision." Appendix A of the policy included examples of neglect including: "Failure of a caregiver to provide a resident with (or the absence or likelihood of absence of) care or services (e.g. food, clothing, shelter, health care or supervision) which are reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety." According to the record, R116 eloped from the facility on 5/11/14, at 9:30 a.m., 11:30 a.m. and 11:52 a.m. while wearing a WanderGuard device which had been implemented to prevent the resident's elopement. Record review indicated R116 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also indicated R116 had Hospice services initiated on 1/21/14. On 4/15/14, at 10:49 p.m. a nursing progress note indicated, "Pt (patient) is declining. He is very weak and needs a lot of assistance." A progress note dated 5/5/14, indicated R116 had been outside with his son and the resident had experienced a fall. R116's son was present at fall. Hospice was notified of fall and a new wheelchair (W/C) was ordered for resident. Staff had also placed a WanderGuard on the resident's chair to alert staff when the resident wanted to go outside to maintain resident's safety. "Resident is allowed to go outside although staff needs to be alerted. Son is aware and in agreement with interventions. Nursing is to continue to monitor." Additionally, a draft progress note dated 5/5/14, at 10:47 p.m. indicated R116 had increased confusion. "He requested going the bank to complete his transaction that he began earlier. He was leaning down to the floor to pick up of stuff which was apparently not there (visual hallucination). He was ambulating around getting out of w/c. Towards the end of shift he was on one to one rotation to prevent him from falling." A progress note dated 5/6/14, at 2:55 p.m. indicated R116 continued to sit at nursing station with staff due to attempts to self-transfer and unsteady gait. R116 was observed on 5/11/14, at 9:30 a.m. to be on the sidewalk west of the facility. The health unit coordinator (HUC) was bringing R116 back into the building. The HUC stated she "had found him as she was driving into work." The HUC stated R116 had a WanderGuard on and she was surprised to find him walking outside since he was not able to walk every day. The HUC said she had called the facility and alerted them to the fact that R116 had left the facility and requested someone bring a wheelchair (w/c) to help bring him back to the facility. NA-R and safety monitor/NA-O had also come outside to look for R116. Two other NA's NA-P and NA-Q came outside with a w/c to meet R116 and return him to the facility. On 5/11/14, at 10:38 a.m. a progress note

An immediate jeopardy related to neglect of supervision for residents was identified during the revisit survey on 5/9/14. The immediate jeopardy began on 5/1/14, and was removed on 5/21/14. However, noncompliance remained at the lower severity level of H, isolated actual harm that that is not immediate jeopardy (IJ). Based on observation, interview and document review, the facility failed to ensure adequate supervision was provided to prevent potential injury from alcohol (ETOH) and drug use for 4 of 11 residents (R37, R129, R41, R117). This resulted in an Immediate Jeopardy (IJ) for these four residents. A second IJ component was identified for 2 of 3 vulnerable residents at risk for elopement (R13, R116), due to the facility's failure to ensure adequate supervision and protection to prevent elopement from the facility. In addition to the resident(s) identified in the IJ, the facility failed to ensure adequate supervision was provided to prevent potential injury from ETOH and drug use for 5 of 11 residents (R9, R14, R62, R86, R113) and failed to ensure 3 of 3 residents (R1, R36, R22) who smoked cigarettes did so in a safe manner as determined by their plans of care. The IJ began on 5/1/14, when R41 drove an electric wheelchair off the sidewalk at the facility while intoxicated, requiring medical treatment with hospitalization . The administrator, consulting administrator, and director of nursing (DON) were notified of the IJ on 5/9/14, at 2:14 p.m. The administrator, consulting administrator and DON were informed of the additional IJ concerns related to R13 and R116's elopement behaviors, at 3:15 p.m. on 5/12/14. The IJ was not removed by exit of the 5/13/14 survey. Findings include: The following deficiency was cited during a revisit conducted on 5/13/14, and was the basis for an IJ to resident's health and safety. Alleged substance abuse: R37's progress notes indicated the resident had required hospitalization s 2/22/14, 4/23/14 and 5/10/14, related to ETOH/drug use. The Admission Record dated 1/14/14, indicated R37 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Progress note documentation indicated R37 had been found with ETOH/vodka while in the facility on 2/21/14, 2/22/14, 2/27/14, 3/2/14, 4/13/14, 4/23/14, 4/24/14, 4/25/14, 5/3/14, 5/5/14, 5/6/14, 5/7/1, 5/9/14 and 5/10/14. Observations of R37 revealed the following: - On 5/7/14, at 8:18 a.m. R37 was observed standing next to R117 on the smoking patio with his wallet out. Another resident (R1) arrived and R37 handed his wallet to her. This surveyor was unable to see whether R1 took anything from the wallet before she handed it back to R37. R37 was observed to lean close to R1 and talk to her and gave her his wallet back. At 8:24 a.m. R1 put R37's wallet back in his left pants pocket. - On 5/9/14, at 7:23 a.m. R37 was observed coming out of his room, stated he did not feel good and was going to see if there was any coffee. At 7:28 a.m. R37 was observed coming from the West hallway. R37 was then observed to push another resident's wheelchair down the West hallway and was observed outside R9's room. There was no staff with R37 when during the observation. When R37 returned to the nursing station, he told the HUC he had gotten cigarettes from R9. The HUC asked R37 if he was alone and R37 responded that he was and the HUC asked him where his partner was. Nursing assistant (NA)-L approached at that time and told the HUC she was the 1:1 for R37 today. - On 5/10/14, at 1:07 p.m. R37 was observed being taken to an ambulance. Additional review of R37's record revealed these Progress Notes: - On 11/26/13, the notes indicated chemical dependency (CD) treatment/Alcoholics Anonymous (AA) was discussed. R37 had stated he'd participated in AA services in the past and he'd had success including three years of sobriety before a recent relapse. The note indicated nursing had reported two episodes of ETOH intoxication while in the nursing home since the last visit and R37 had acknowledged the report to be accurate. The assessment/plan included social worker to assist with available CD services, R37 stated he was open to CD services and no ETOH use with nursing to monitor. The NP indicated there were "clear dependency concerns." - On 1/8/14, the notes indicated the resident had a history of [REDACTED]. - On 2/21/14, the notes indicated R37 had been drinking vodka and that an empty bottle had been found. The notes also indicated R37 had been observed to be distributing money to staff and residents. When R37 had noticed he had no money to buy vodka, he had gone to the automatic teller machine (ATM) machine to get money. The notes indicated staff were concerned about his safety and judgment. On 2/21/14, at 7:07 a.m. a note had been documented which indicated R37 was handing out his money to "anyone who would listen" and staff had taken $116.00 dollars from him to lock up. - On 2/22/14, at 10:14 p.m. the notes indicated R37 had called 911 to send himself to the hospital. It was noted R37 had been drinking during the a.m. shift and was drunk. The a.m. shift had taken a bottle of vodka from him. The notes indicated R37 had asked the p.m. shift to return the vodka or pay him $25.00. - On 2/27/14, at 1:13 p.m. the notes indicated R37 wanted to leave on a leave of absence (LOA), was advised he could not go on an unsupervised LOA, but had left the facility. - On 2/27/14, at 10:07 p.m. indicated R37 was "drunk" and had a blood pressure of 147/105. - On 3/2/14, indicated R37 was "drunk" and was noted to have a blood pressure of 176/98 and a pulse of 99. - On 4/1/14, indicated R37 had complained of shortness of breath and chest pain with a blood pressure of 146/102 and a pulse of 109 and was sent to the hospital. - On 4/13/14, the notes indicated R37"seemed intoxicated" and one full bottle of vodka and one quarter full bottle were removed from the room. - On 4/23/14, at 3:44 a.m. indicated R37 was shouting and yelling and appeared intoxicated. One empty bottle of vodka and one 75% emptied were found in R37's room. At 12:04 p.m. staff checked R37's room and found two empty bottles in his room. Staff discussed discharge plans and R37 reported he wanted to stay and the facility and was told it was not ok to drink ETOH at the facility. R37 was offered a transfer to a facility that allowed drinking and he declined. At 3:13 p.m. R37 approached staff and appeared to be intoxicated with slurred speech and smelled of ETOH. R37 stated he would like to get help to have ETOH removed from his body. Staff called 911 and police escorted R37 to detox. - On 4/24/14, at 9:30 a.m. the notes indicated R37 reported chest pain and shortness of breath. R37 was noted to have a blood pressure of 162/103 and a pulse of 88 and was noted to smell of ETOH. At 12:01 p.m. on that day, the notes indicated R37 approached staff and "again was clearly intoxicated." The notes indicated the contracted licensed social worker (CLSW)-A and a police officer had entered R37's room and found an empty vodka bottle under the mattress. The officer told staff he could not remove the resident from the building because R37 was not disturbing anyone and was not aggressive or assaultive in any way. A facility Progress Notes dated 4/25/14, at 3:40 a.m. indicated R37 had been observed earlier walking into and out of R117's room and "seemed to be like an exchange of some transactions." The note indicated staff believed this was a trade and staff would need to monitor R37 for ETOH consumption. Further the note indicated, "A few hours later" R37 was shouting and appeared "intoxicated" and a 75% emptied bottle of vodka was found in R37's room. - On 4/25/14, at 9:58 a.m. notes indicated R37 was "clearly inebriated", had slurred speech and could barely wake up. R37 refused to provide the source where he continued to get ETOH. - On 4/25/14, at 3:24 p.m. notes indicated staff reported R37 appeared intoxicated, was outside swaying back and forth, was very talkative with staff and still smelled like he had ETOH on his breath. - On 5/2/14, notes indicated R37 had removed a wander guard and refused a new one to be placed. - On 5/3/14, notes indicated R37 was walking in the hallway "wobbling" and requested staff give him a shower at 3:00 a.m. R37 was unable to maintain his balance and appeared "intoxicated." Two almost empty bottles of vodka were found in his room. - On 5/5/14, at 3:53 p.m. the notes indicated R37 had exhibited signs of intoxication with an unsteady/staggering gait, slurred speech, odor of ETOH and unkempt appearance. R37 was noted to have continually gone outside, stated he had called a limo and had said he was going to Las Vegas. - On 5/5/14, at 4:56 p.m. the notes indicated R37 had slurred speech, smelled of ETOH and had a staggering gait. - On 5/5/14, at 10:25 p.m. the notes indicated R37 was "intoxicated" and was found with an almost empty bottle of vodka. - On 5/6/14, a note, which indicated it was a late entry for 5/5/14 at 6:00 p.m., indicated R37 was noted walking outside towards the back of the building. R37 was noted to be walking alone with a staggering gait. When approached by staff, R37 had stated he was going to Las Vegas. No odor of ETOH was noted and when asked what he had been doing to become so impaired, R37 reported he had gotten cocaine and heroin from another resident and confirmed he had been injecting the drugs. Several scattered purple bruises were noted on his forearms. At 1:55 a.m. indicated R37 reported his heart was thumping out of his chest and was found to have a blood pressure of 168 /118 with a pulse of 118. At 4:37 a.m. indicated R37 exited his room without clothing and had a strong odor of ETOH on his breath. Four empty bottles and one unopened bottle of ETOH were found in R37's room and were removed by staff. Also noted R37 started having tremors and palpitations with increased pulse and blood pressure due to ETOH withdrawal and demanded medications. - On 5/7/14, at 12:04 p.m. indicated R37 was exhibiting signs and symptoms of intoxication as evidenced by odor of ETOH, unsteady/slow/staggering gait, slurred speech, confusion and unkempt appearance. A pattern of missed pain clinic appointments due to intoxication was noted and indicated further appointments would not be made due to ongoing intoxication and inability to follow through with appointments. In addition, R37 had a full bottle of vodka and refused to give the bottle to staff. The note indicated the administrator directed if R37 was unwilling to willingly give staff the ETOH bottle, it was ok for the resident to keep the ETOH and if he became drunk or disruptive to call the police and have him taken to detox. - On 5/8/14, at 3:42 p.m. the progress notes indicated R37 had been placed on 1:1 observation related to incidences of getting intoxicated. - On 5/9/14, notes indicated R37 "was clearly intoxicated" and that an empty pint bottle of vodka was found in his room and was noted as the third empty pint bottle taken from R37's room in a 48 hour span of time. - On 5/10/14, notes indicated R37 had been observed giving his credit card to R117 on 5/9/14. A second note indicated R37 had returned from LOA accompanied by a friend of another resident (R1). R37 was observed to be shaky and verbalized he was unsteady on his feet. R37 was noted to have shakiness, profuse sweating, sluggish pupils and was noted to have a blood pressure of 178/130 and a pulse of 120s to 140s. - On 5/11/14, the progress notes indicated R37 had a drug screen positive for methadone at the hospital. R37 did not have a prescription for Methadone. The Physician (MD) and Nurse Practitioner (NP) orders indicated they were aware of R37's alcohol use. Notes included: - On 1/8/14, included a [DIAGNOSES REDACTED]. - On 2/5/14, indicated R37 had recently been found with a bottle of ETOH hidden in his pillow case and was noted to smell of ETOH. - On 2/28/14, an order directed staff to discharge R37 to another facility (that allowed drinking). - On 3/5/14, an order directed; "do not call on-call MD or NP after hours if resident is intoxicated unless he is medically compromised. Allow resident to go to bed (and) sleep." - On 4/9/14, notes indicated R37 had been hospitalized from [DATE] from 4/8/14, with respiratory distress and pneumonia with pleural effusions requiring chest tube placement. the notes indicated R37 had been treated for [REDACTED]. A NP note dated 4/9/14, indicated R37 required ongoing Kristalose and Mag-ox for chronic cirrhosis. - On 4/10/14, included [DIAGNOSES REDACTED]. - On 4/24/14, included "place wander guard (sic) for res. (resident) safety" and "pursue guardianship." A second order dated 4/24/14, indicated NP was aware of R37's use of alcohol, to encourage R37 not to use, and that even if R37 appeared intoxicated it was ok to administer all medications as ordered. - On 5/6/14, an order directed to recheck R37's blood pressure in one hour, call NP if diastolic blood pressure was greater than 100, give Ativan 0.5 milligrams (mg) orally every six hours as needed times three days for withdrawal symptoms (tremors, shaking, and increased heart rate) and a urine toxicology screen. - On 5/7/14, an order directed "no LOA-supervised or other". In addition, the NP included an order for [REDACTED]. A Clinical Summary dated 2/3/14, indicated "refer to chemical dependency counselor and pain psychologist." A prescription dated 2/3/14, ordered a behavioral health evaluation for diagnostic evaluation and treatment recommendations for R37. A Physician Visit/Progress Note written by a licensed drug and ETOH counselor (LADC) dated 2/13/14, indicated R37 had been referred for assessment of behavioral health, chemical dependency and pain and included an order/comment of "strongly recommend a full psychiatric assessment" within 60 days to evaluate medications and therapy. The medical record lacked evidence of the psychiatric assessment having been completed. R37's care plan was reviewed and noted the following: - The vulnerable adult care plan revised on 3/5/14, indicated R37 may leave to go to medical appointments without supervision and was not safe to go on other unsupervised LOAs. - The Depression care plan dated 3/11/14, included ETOH abuse and directed to arrange psych services as needed. - A behavioral symptoms care plan revised on 3/16/14, indicated ETOH consumption and concealing ETOH in room with a goal to have fewer episodes of ETOH abuse per week. The interventions included; encourage attending AA or other substance abuse support programs, assisting with arrangements as needed, may go to medical/dental appointments unsupervised and no other unsupervised LOA. - A risk for elopement related to ETOH abuse and psychoses care plan revised 3/16/14, noted a history of returning to facility after unsupervised LOA displaying signs of ETOH consumption and/or with a supply of ETOH. The goal included R37 would not to leave facility unattended unless a medical appointment and R37's safety will be maintained. The interventions indicated R37 cut off the wander guard and refused to have another one placed and was placed on 15 minute checks. Check room if suspected ETOH. - A Mood/Behavior care plan initiated on 4/23/14, indicated R37 had a history of [REDACTED]. The care plan noted R37 was sent to detox on 4/23/14, due to being very intoxicated. The goal indicated R37 would like to stop drinking ETOH with an intervention to check room daily for ETOH and check R37 for signs of intoxication. - An at risk for adverse reaction from medications related to ETOH care plan dated 4/25/14, indicated NP was aware of R37's ETOH, nursing staff to encourage to restrain from using ETOH and if R37 appeared intoxicated it was ok to administer medications. Another intervention dated 5/8/14, included 1:1 supervision due to ETOH abuse and intoxication. A Vulnerable Adult assessment dated [DATE], indicated R37 had both past and recent substance abuse, was not safe for unsupervised LOA except to appointments and had a history of [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R37's cognitive skills for daily decision making was independent with consistent/reasonable decisions. Review of the Interagency Transfer Orders dated 4/1/14, included Non-Hospital Problems of ETOH intoxication and ETOH withdrawal noted 9/23/13, and substance abuse noted 2/23/14. A Care Conference Summary dated 4/1/14, indicated a discharge plan of "discharge to a facility that allows drinking, he declined, has been sober since." The summary indicated R37 had a history of [REDACTED]. A Resident Refusal of Medical Treatment Form dated 5/5/14, indicated R37 was "wander guarded (sic)" to the facility for resident safety related to history of ETOH abuse, staggering gait and slurred speech. With the risks of refusing noted as facility wouldn't be aware if R37 left with potential for fall risk and injury off facility grounds with no one to provide aid. A letter dated 5/10/14, indicated a first offense of the facility smoking policy as R37 reported to staff he had gotten cigarettes from R9. On 5/7/14, at 10:02 a.m. the ombudsman was interviewed and wanted to know if surveyors were aware of residents purchasing ETOH and drugs. Reported she believed residents were giving other residents money and credit cards to go out and purchase things for them. She reported a resident with chemical dependency problems had been drinking, room checks were being completed and staff was finding ETOH bottles. Reported R37 was being found intoxicated and she was involved in discussing abuse prevention planning if intoxicated and the effects of ETOH on R37's medications. She reported the physician was encouraging discharge planning to a facility that allowed drinking. She also indicated a number of residents were accessing illegal drugs at the facility. The ombudsman reported she had been at the facility on 5/6/14, to discuss the concerns. On 5/7/14, at 10:05 a.m. the administrator stated the ombudsman was called 5/6/14, to speak with the facility regarding R37 giving his credit card to R117 to purchase ETOH and R37 had been "drunk for days." On 5/8/14, at 11:51 a.m. licensed practical nurse (LPN)-B stated she was aware R37 had a doctor's order and can drink as long as there are no behaviors and if behaviors occur she can call detox. LPN- B stated she did not know where R37 got ETOH from. The safety monitor, NA-M was interviewed on 5/8/14, at 11:55 a.m. and stated he has not seen R37 exchange money or ETOH and stated he has heard about exchanges but could not remember who he had heard it about. The HUC was interviewed on 5/8/14, at 12:15 p.m. and stated "it's a nightmare; (R37) is drunk every day." She stated she had her suspicions about where the ETOH was coming from but when she asked R37 he refused to tell her. R37 told her he had given his credit card to R117 to buy things for him. The HUC stated R37 was drunk every day when she left and was drunk when she came in on 5/8/14. She reported that on 5/5/14 or 5/6/14, she had observed R37 in the parking lot, was told there was nothing they could do by the facility administrator and requested assistance from the operations director to get R37 back in the building. The HUC reported she had requested the safety monitor to put R37 on every 15 minute checks but knew that was not enough. She stated other residents were on 1:1 for drug use and wanted to know what the facility was going to do to keep R37 safe. The HUC stated "we're not doing (R37) any justice" and "it's a[***]y plan to keep people on 1:1 forever." On 5/10/14, at 1:30 p.m. the administrator stated R37 had been taken to the hospital for Delirium tremens (DTs-significant withdrawal symptoms). During interview on 5/12/14, at 8:59 a.m., registered nurse (RN)- B and LPN-A stated R37 had gone to the bank with a friend on 5/10/14, and were not sure if the 1:1 had gone to the bank or not and would have to check. The DON was interviewed on 5/12/14, at 9:05 a.m. and stated a "guy (stated name) a friend of R1" went with R37 to the bank. The DON stated both the administrator and the consultant administrator were aware of who R1's friend was. The DON stated the 1:1 had refused to go to the bank with R37 and that the friend of R1 had signed R37 out. The DON stated the consultant administrator was going to go with R37 and R1's friend to the bank until it was decided the facility was not comfortable with her (the consultant administrator) going with to the bank either. The DON stated he had reminded R37 he could not go because he had orders for no LOA, but stated the administrator, consultant administrator and the social worker had decided R37 could go anyway. The DON stated he had no idea where R37 had gotten methadone from. When interviewed on 5/12/14, at 1:35 p.m. contracted licensed social worker (CLSW)-A stated during a room search a quart bottle of ETOH had been found in R37's room and 3 plastic containers with the labels removed which nursing indicated were methadone containers. When interviewed on 5/12/14, at 1:52 p.m. the administrator stated he and CLSW-A were involved in R37's LOA. The administrator stated CLSW-A was under the impression R37 was allowed to go on a LOA, and stated R37 had returned with a card from Walgreens so they knew he hadn't followed his agreement to only go to the bank. The administrator stated the friend of R1 would not be able to take R37 on LOA again. The administrator stated he was not aware R37 had orders for no LOA and that he had believed CLSW-A and had not checked the chart himself. The administrator stated he was also not aware of R1's relationship with the friend and that the DON had not told him about the order for no LOA or the relationship between R1 and the friend. Upon interview on 5/13/14, at 8:09 a.m. CLSW-A stated on 5/10/14, prior to R37 leaving on LOA she had been informed by nursing (she could not remember who) that R37 could leave the facility with supervision. CLSW-A reported she'd made it clear to the person taking R37 out, R1's friend, that R37 could only go to the bank and nowhere else. She stated she'd told R1's friend that R37 would try and talk him into going to the liquor store but that R37 could not go there. CLSW-A said R1's friend had reassured her he had been sober for ten years and would never take R37 to a liquor store. CLSW-A stated it was not until after R37 had left, that nursing (did not remember who) told her R37 had orders for "no LOA" and that R1's friend was a drug dealer. CLSW-A said it would have been nice to have known that information before she'd allowed R37 to go on a LOA. She stated she had not looked at R37's chart because she'd trusted nursing to know the correct information. She also stated she was aware R37 had been keeping ETOH under the edge of his mattress and she could not understand why nursing hadn't been finding the ETOH when they made the bed. When interviewed on 5/13/14, at 2:20 p.m. the administrator was asked about the discrepancy between what the DON reported had happened on 5/10/14 and what the administrator stated had happened and he verified he was not aware R37 had an order for [REDACTED]. on an LOA. R129 was identified by the facility to require a staff member to be assigned to follow/accompany R129 one to one (1:1, to be within arms length at all times). R129 reported to the facility she obtained and consumed cocaine on 5/3/14. R129 obtained and consumed ETOH on 5/11/13, at 4:00 a.m. causing her to require hospitalization in the intensive care unit (ICU) and intubation (mechanical ventilator assisted breathing) for a blood ETOH level of .323. The admission MDS dated [DATE], indicated R129 had a Brief Interview of Mental Status (BIMS, a tool to determine potential cognitive losses) score of 15, indicating R129 was cognitively intact. The MDS identified R129 was Independent with all activities of daily living (ADLs). The MDS identified R129 rejected cares and wandered 1-3 days during the assessment period. R129's CAA for mood state dated 2/7/14, identified R129 had poor judgement, impaired cognition and poor decision making and had [DIAGNOSES REDACTED]." The CAA identified further [DIAGNOSES REDACTED]. R129 was identified to be independent with ADLs. Although the CAAs identified R129 had a history of [REDACTED]. The Vulnerable Adult assessment dated [DATE], identified R129 had a history of [REDACTED]." R129 was identified as being susceptible to abuse "r/t (related to) substance use, varies" and required supervision with LOA from the facility. The assessment identified R129 had a behavior and history of rummaging through others belongings and "drug use." The assessment indicated R129 was placed on 1:1 due to rummaging in other resident rooms. R129's Smoking Evaluation dated 3/18/14, identified to "monitor for ETOH use or oversedation." The Pain Evaluation and Management Plan dated 5/1/14, identified R129 had chronic pain daily, identified a history of pain and drug seeking. "Resident is on a restricted recipient program due to drug seeking (a program where only one pharmacy may fill the prescriptions for narcotics, a program to potentially deter drug seeking behaviors)." The evaluation identified R129 had a history of [REDACTED]. MD will not order any more pain medications for resident due to her drug seeking behaviors. Resident is on the restricted recipient program due to drug seeking." A Incident/Accident Report dated 5/3/14, at 11:00 p.m. indicated R129 "told the nurse that she took cocaine earlier during the shift." The note identified R129 to be "very sweaty, weak and tired" and "she looked very sleepy." The resident's pupils were "large and nonreactive to light." The note indicated the nurse asked R129 what she took and indicated R129 then "confessed" to taking cocaine. The report documentation indicated R129 was sent to the emergency room (ER), identified, "She said, 'I knowingly took cocaine'" and, "Resident has been sent to ER. She will continue to be on 1:1 when she returns to the nursing home." The report identified R129 had a history of [REDACTED]." Although the incident occurred on 5/3/14, the form was signed by the DON on 5/5/14. An Emergency Department Chart (a form from the ER) dated 5/3/14, identified R129 reported to have taken cocaine at the facility. The note indicated R129 took the cocaine to "help with the pain" in her abdomen. "Patient (R129) is triaged directly back to ED (emergency department)." The Clinician History of Present Illness section of the form identified R129 reported to hospital staff she snorted cocaine "5 hours ago." Although R129 was identified to go to the ER for a potential drug overdose, the Emergency Department Chart did not address the cocaine use and only addressed R129's pain. The labs indicated various pertinent laboratory values were checked by the ER, but lacked a toxicity screening for cocaine, drug or ETOH use. R129 was given two doses of Dilaudid (a narcotic pain medication) and returned to the facility at 6:00 a.m. with no new orders. The clinical record lacked evidence the administrator, or the State agency (SA) were notified of the incident. The clinical record lacked evidence of new interventions to address R129's report of drug use, such as CD treatment. In addition, the clinical record lacked evidence the use of cocaine by R129 was investigated to determine how the drug may have been obtained while the resident had a staff assigned to her 1:1. A unlabeled typed page insert immediately in the front of R129's paper chart dated 4/15/14, indicated, "If Res goes to the Hospital for any reason she is to go to St. Joes (sic) Hospital Only per primary care MD and the MN (Minnesota) restricted recipient program" and further directed "all scripts (prescriptions) no matter where they come from must be approved by (MD's name) or their oncall MD." On 5/7/14, at 10:24 a.m. the ombudsman was contacted via telephone per an emailed request to be contacted by the surveyor. The ombudsman stated she had been informed by a nurse of the facility of "drug use" and "drugs shared with residents" at the facility "a couple days ago." The ombudsman stated rather than call the nurse back, she came to the facility "yesterday (5/6/14)," had spoken with various residents of the facility and communicated with the facility's management regarding drug, ETOH and discharge planning concerns. The ombudsman stated residents, facility staff and the ombudsman were "suspicious residents may be giving money or credit cards to another (resident) to go out and purchase things (alcohol and drugs) for them." The ombudsman stated the police had been notified and been to the facility "quite often." The ombudsman stated there were problems with residents who were chemically dependent, who were drinking in their rooms and facility staff were conducting room checks per shift and "finding empty alcohol (vodka) bottles" in resident rooms. The ombudsman stated residents had been found by facility staff to be "intoxicated" in the facility. The ombudsman specifically stated R129 was on a 1:1 and had "somehow" obtained and consumed and "illegal drug (cocaine)" in the facility. The ombudsman stated although the facility had employed "three temporary social workers," the ombudsman stated she felt "social services is overwhelmed" due to "no policies and procedures in place." R129's care plan for safety/vulnerability dated 3/25/14, identified R129 was able to make her needs known, but was vulnerable due to her history of opioid abuse and drug seeking behavior. A care plan intervention dated as initiated 4/11/14, directed R129 required "1:1 supervision at all times to keep (R129) safe and prevent drug use" Additionally, the care plan directed, "1:1 to discuss CD concerns, encourage (R129) to consider going to a treatment facility." The care plan for mood/behavior dated 3/25/14, identified, "I have a history of opioid abuse and I exhibit drug seeking behavior as evidenced by attempting to see several different MD's to obtain prescription medication. I have a history of walking into other residents rooms and looking thru their personal belongings." Review of the undated Group 7 NA assignment sheets (forms carried by the NA staff for quick reference direction on the resident care plan) indicated R129 was continent, independent with ADLs and "1:1" in larger bold print. Nursing Progress Notes: - On 3/14/14, at 6:18 p.m. a note indicated R129 "had an appointment yesterday and was immediately transferred to the hospital." The note indicated "while on the way home (unclear on prior destination)" R129 "stopped at Cub foods" and picked up a prescription for eight tablets of Norco 5/325 mg (a narcotic and Tylenol pain medication). The note indicated R129 "failed to alert staff and stated that there were no new orders." The hospital, oncall MD and triage nurse were called and updated on R129's "history of narcotic use." - On 3/16/14, at 6:34 a.m. a note indicated R129 was "caught going through another resident's belonging." The note indicated a resident o

Based on observation, interview and document review, the facility failed to provide adequate supervision and interventions to ensure safe smoking practices for 3 of 28 residents (R36, R1, R22) who currently smoked unsupervised in the facility, and failed to ensure they utilized mechanical devices in a safe manner for transfers for 1 of 2 residents reviewed (R64). The facility's failure to provide supervision and a safe environment to prevent potential burns from unsafe smoking practices constituted an Immediate Jeopardy (IJ) for R36, R1, and R22. In addition, the facility's failure to safely utilize a mechanical lift constituted an IJ for R64. The immediate jeopardy began on 3/12/14, and the administrator and director of nursing (DON) were notified of the IJ on 3/12/14, at 5:00 p.m. In addition, the facility did not ensure the safe use of a mechanical stand lift (a mechanical device used for transfers) for 1 of 2 residents (R64) in the sample. This practice resulted in an IJ which was identified on 3/13/14, and the administrator and DON were notified of this IJ on 3/13/14, at 1:50 p.m. Although the IJ was removed on 3/16/14, at 12:17 p.m. non-compliance remained at the lower scope and severity (s/s) of an E. Findings include: R36 was observed with multiple cigarette burn holes on his clothing on 3/11/14. The facility did not identify that or other safety concerns related to the resident independently smoking unsupervised. R36 was observed to smoke unsafely on 3/11/14, 3/12/14, and on 3/13/14. R36's smoking observations were as follows: On 3/10/14, at 1:00 p.m. R36 was observed to be smoking unsupervised in the front designated smoking area. R36 was observed to propel his wheelchair (w/c) independently, while smoking. No smoking apron was observed on R36 or in the smoking area. On 3/11/14, at 11:18 a.m. R36 was interviewed and he reported he had been assessed for smoking. He stated the staff came and watched him light up and watched him smoke. R36 stated the burn hole in his new glove was from a month ago. R36 stated he had never needed a smoking apron or any other smoking interventions. On 3/11/14 at 1:27 p.m. R36 was observed to be smoking unsupervised in the front designated smoking area. R36 was observed to propel his w/c independently while smoking with an approximately one inch long cigarette ash. No smoking apron was observed in the area. R36 was observed to have burn holes on his left glove, on the left chest of the coat and the right thigh of R36's pants. R36 stated the burn in his glove had occurred "one month ago (2/2014)" from "sleeping" with the cigarette in his hand. R36 further stated the gloves were newly purchased and the burn hole on the pants was "old." R36 stated, "I'm getting careless." On 3/12/14, at 7:45 a.m., R36 was observed to be propelling the w/c to enter the building of the facility from the front designated smoking area while holding a cigarette in his mouth. The cigarette was observed to have an approximate one inch long ash. R36 was observed to notice the ash, flick the ash off and extinguish the cigarette in the ash tray. No staff was observed in the smoking area and no smoking apron was observed. On 3/12/14 at 1:58 p.m. R36 was observed to be smoking unsupervised in a front designated smoking area. R36 was observed to be dozing in the w/c while the cigarette was lit. The cigarette was observed to be nearly burnt out and was held over the previous burn hole in R36's sweat pants. R36 awakened and discarded the cigarette on the pavement. The cigarette was extinguished. No smoking apron was observed. On 3/12/14 at 2:28 p.m. R36 stated during interview, that he retrieved his own clothes in the morning and dressed independently. R36 reported the burn holes in his coat were from being "careless" and stated he was "new to the facility within the last six months". On 3/13/14, at 9:42 a.m. R36 was observed to be with the facility administrator in a front designated smoking area with a smoking apron on. R36 was observed to have papers in his hand. At 9:50 a.m. R36 was overheard by the surveyor to inform another resident the facility had given him (R36) a copy of the smoking policy. At 9:54 a.m. R36 was observed to remove the smoking apron, threw it to the ground while stating "F###!" loudly. R36 immediately lit a cigarette. At 10:04 a.m. R36 picked up the smoking apron and wheeled back into the building. In a loud voice R36 stated, "Here! I'm going to give that to you (and threw the smoking apron on the reception desk)." R36 then stated, "I cannot safely roll with that on." On 3/13/14, at 3:35 p.m. R36 was observed to be in the front designated smoking area without the smoking apron on and was unsupervised. The smoking apron was lying next to R36. R36 had a lit cigarette with an inch long ash. R36 was sleeping in the w/c. The DON was summoned by the surveyor and notified of the observation. The DON immediately started a conversation with R36, picked up the smoking apron and folded it. R36 finished smoking at that time. R36's record was reviewed. The Admission Record dated 5/26/12, indicated R36's [DIAGNOSES REDACTED]. A Camden Care Center Smoking Contract dated 5/31/12, was signed by R36's guarantor and included: - "I have received a copy of the Camden Care Center Smoking Policy/Procedure and agree to comply with all the rules set by this policy." - "I understand that smoking is NEVER allowed in resident rooms or anywhere inside the building." - "I understand that smoking is ONLY allowed in designated smoking areas." - "I understand that failure to comply with the Camden Care Center Smoking Policy/procedure may result in a 30 day discharge notice from the facility." The care plan lacked evidence the smoking interventions were ever put into place. R36's Smoking Evaluation dated 5/28/13, was completed by social services. Although the evaluation indicated R36 had a history of [REDACTED]. The evaluation indicated R36 was cognitively intact, and had no behaviors. Although the evaluation had identified unsafe smoking practices in the past, the evaluation indicated R36 understood the safe storage of smoking materials, understood where smoking was allowed, and was deemed an independent smoker. R36's three consecutive Smoking Evaluations dated 8/29/13, 11/17/13, and for 2/18/14, all noted no changes from the Smoking Evaluation on 5/28/13. The unsafe smoking history still remained undetermined and all four assessments indicated R36 was deemed an safe smoker. The Nursing Assessment Packet Review for the reference period of 2/12/ (no year) through 2/18/ (no year) lacked any documentation of the safety risks regarding R36's smoking. The care plan dated 2/16/14, indicated on 5/27/13, R36's guardian requested a WanderGuard (departure from facility alert system) be applied to R36 "to prevent him from leaving the facility" and alerting staff R36 went out of the building, to smoke. The care plan indicated R36 had a WanderGuard applied on 11/28/12, then on 6/2/13, the care plan indicated R36 refused the WanderGuard and it had been "cut off " by R36. The care plan still indicated the WanderGuard as an intervention and further indicated the WanderGuard was "not effective at this time." A behavior contract had been signed by R36 on 6/6/13, which indicated R36 would not drink alcohol while residing in the facility and would follow all policies in the facility. The contract specified the smoking policy and identified R36 would "only smoke on the back patio of the facility." The care plan was not revised for the smoking contract as R36 smoked in the front of the building unsupervised. Record review indicated that on 6/18/13, a letter had been presented by the facility to R36 to notify R36 he would be discharged in 30 days effective 6/18/13, for non-compliance with the facility's smoking policy, for non-compliance with the facility's (alcohol) drinking policy and non-compliance with other facility policies. However, the medical record lacked any evidence of why the facility had not discharged R36. Nursing notes documented on the Camden Care Center Quarterly Care Conference summary for R36 dated 9/17/13, indicated R36 had been assessed by the licensed nurse and deemed to be an independent smoker, risks versus benefits had been explained, and R36 had refused a smoking cessation program. The care conference summary written by the social worker designee on 11/26/13, indicated, "(R36) requires supervision with smoking; however he does not follow it. (R36) has had difficulty following facility policy for smoking in designated area of back patio of facility, but over the last quarter he has improved greatly." During the survey, R36 was never observed to be smoking in the supervised smoking area on the back patio. R36 was always observed to smoke in the designated "unsupervised" smoking area in the front and to the side of the building. It could not be determined if R36 was deemed a safe smoker as the summary from nursing conflicted with the summary from the social worker. R36's most current quarterly Minimum Data Set ((MDS) dated [DATE], indicated R36 had no behaviors and had a Brief Interview for Mental Status (BIMS) score of 13 which noted R36 was cognitively intact. The MDS also indicated R36 received one person assist with transfers, dressing, hygiene, and R36 used a wheelchair for mobility. R36's smoking care plan dated 2/18/14, identified R36 as an independent smoker, and indicated R36 would remain safe while smoking and would follow all guidelines regarding smoking. The care plan also indicated R36 was directed to smoke only in the designated areas and would not smoke around those with oxygen. The care plan conflicted with the social worker designee's most current summary dated 2/18/14, which indicated R36 was an unsafe smoker and needed supervision. The physician's orders [REDACTED]. -Methadone 10 milligrams (mg) twice a day (BID) for vascular pain. The package insert from Lake Erie Medical DBA Quality Care Products dated 10/2013, noted, "Patients receiving other opioid analgesics, general anesthetics, phenothiazines, other tranquilizers, sedatives, hypnotics or other CNS (central nervous system) depressants (including alcohol) concomitantly with methadone may experience respiratory depression, hypotension, profound sedation, or coma." -Zolpidem (Ambien) 10 mg daily at bedtime insomnia. The package insert from "ECR Pharmaceuticals" last revised 5/7/13 noted, "Zolpimist (Zolpidem), like other sedative-hypnotic drugs, has central nervous system (CNS) depressant effects. Co-administration with other CNS depressants (e.g., benzodiazepines, opioids, tricyclic antidepressants, alcohol) increases the risk of CNS depression." -Oxycodone 10 mg three times a day (TID) for pain. The package insert from St. Mary's Medical Park Pharmacy last revised 1/10/13 noted, "CNS Depressants: Patients receiving narcotic analgesics, general anesthetics, phenothiazines, other tranquilizers, sedative-hypnotics or other CNS depressants (including alcohol) concomitantly with oxycodone hydrochloride tablets may exhibit an additive CNS depression. Interactive effects resulting in respiratory depression, hypotension, profound sedation, or coma may result if these drugs are taken in combination with the usual dosage of oxycodone hydrochloride tablets." R36's medical record lacked evidence of an assessment in regards to R36's medications as a safety risk for R36's unsafe smoking, as R36 was observed to be sleeping (dozing) while smoking on 3/12/14, at 1:58 p.m. On 3/12/14, at 2:35 p.m. the laundry supervisor was interviewed and stated she had "noticed a couple (burn holes) and tried to get rid of them (clothing that had burn holes) last year." The laundry supervisor stated they let facility staff know about the burn holes, but "they are already aware of it." When the surveyor clarified who "They" were, the laundry supervisor stated "the nursing department and the aides." On 3/12/14, at 3:01 p.m. the DON and administrator were interviewed. The DON verified she was aware of the burn holes in R36's coat. The DON stated she was told in the interdisciplinary team (IDT) "all that stuff is old that's he's got." The administrator stated, "He has new gloves in his closet, glove burn happened one month ago." The administrator also verified she had been informed "the aides know about it." The administrator stated R36 just liked the old coat and stated the new coat was "just put on." The administrator stated R36 was given a discharge notice in June of last year. The administrator verified assessments were not accurate or up to date and stated the facility had started to redo all of the assessments. The administrator indicated the social worker designee (SSD) was not trained on how to do the assessments and no plan had been identified to ensure R36's safety. On 3/13/14, at 10:12 a.m. the DON stated R36 was one of the "IJs" and R36 had been given a 30 day notice due to his refusal to comply with smoking restrictions. The DON also stated R36 should wear a smoking apron, required supervised smoking, and R36 did not want to comply. On 3/13/14, at 2:17 p.m. during an environmental tour the administrator verified the facility had two resident smoking areas. The first was the designated as an unsupervised smoking area located in the front of the building, to the left of the entrance to the facility. The second area was designated as a supervised resident smoking area located adjacent to the dining room. On 3/14/14, at 10:56 a.m. a nursing assistant (NA)-B indicated R36 was independent with dressing and staff only assisted him with his incontinent products. NA-B indicated they had never noticed burn holes in R36's clothing and stated they would let the nurse know right away about any burn holes. On 3/14/14, at 11:21 a.m. the physical therapist (O)-J stated she had noticed burn holes in R36's clothes and had noticed "more (burn holes)" recently. O-J did not recall if she had reported the burn holes to nursing. During an interview on 3/14/14 at 12:14 p.m., the guardian for R36 verified they were not aware of burn holes from unsafe smoking in R36's clothing and stated R36 had money to purchase new clothing. The guardian stated "burn holes in his (R36's) clothing would be a health and safety issue." R1 was observed to smoke unsafely on 3/12/14, 3/13/14, and on 3/14/14; the clinical record lacked development of a smoking care plan and Smoking Contract to potentially ensure safe smoking. In addition, R1 received multiple medications and unknown extra doses of Methadone (a synthetic opioid used to treat moderate to severe pain. Also used together with medical supervision and counseling to treat narcotic drug addiction, with a potential side effect of sedation), which potentially contributed to excessive sedation and observations of unsafe smoking. In addition, R1 was observed to provide smoking materials to other residents in the unsupervised smoking area. R1's smoking observations were as follows: On 3/12/14, at 12:52 p.m. R1 was observed sitting on a motorized wheelchair (w/c) and smoking in the designated unsupervised smoking area outside the front of the facility. R1 was observed to be falling asleep while smoking as she held a lit cigarette with her right hand. - At 12:53 p.m. R1 was observed to doze off with her eyes closed, and her head jerking up and down. R1 then spontaneously woke up, looked at the lit cigarette, then shortly after appeared to fall asleep and spontaneously wake up. At the time of the observation, the surveyor alerted a licensed practical nurse (LPN)-D of the safety concern. LPN-D went outside spoke briefly with R1, and retrieved R1 back into the building. - At 1:03 p.m. surveyor observed R1 sitting on her bed. R1 stated she was tired "all the time" and had told the facility staff of feeling tired. R1 stated she thought the tired feeling was related to her "Hepatitis-C." R1 stated she was waiting for a particular medicine to address the Hepatitis-C. R1 verified she had burn holes on her clothing and stating the burn holes were from her cigarette, "The ashes flicking off." R1 further stated she had never had a burn from the smoking. R1 acknowledged she had neuropathy and stated being tired was just not working with her smoking at times. R1 declined the surveyor's request to observed the clothing stored in the closet for burn holes. - At 2:29 p.m. R1 was observed on the motorized w/c outside in the designated smoking area. R1 removed a cigarette pack from her pocket, removed the wrapper, her eyes closed, her head drooped and she stopped all movements. R1's head jerked and then she continued to take out a lighter, her head was observed to droop and her eyes closed for several seconds. R1's head then suddenly jerked up, R1 lit her cigarette and proceeded to smoke as her eyes remained closed, holding the cigarette in her right hand. - At 2:34 p.m. a male resident walked to R1 with a cigarette in his mouth, R1 retrieved a lighter, handed it to him. The male resident lit his cigarette and both residents remained next to each other talking. R1's eyes were observed to droop while she spoke with the male resident, her head jerked up as if she was suddenly being awaken. R1 was observed to have approximately half (1/2) inch long ash on the held lit cigarette. At the time of the observation, the lit cigarette and ash were held over a faux fur leopard print blanket folded over her lap (a potentially flammable cloth). - At 2:35 p.m. R1 rested the right hand holding the cigarette on her lap, leaned forward and spoke to the male resident. - At 2:36 p.m. R1's head slowly drooped, and R1 was observed to be leaning far forward in the w/c. R1's chin drooped onto her chest, her head bobbed and jerking as R1 tried to keep her eyes open and appeared to struggle to remain awake. - At 2:38 p.m. R1 rested both hands in her lap (lit cigarette remained in her hand), her chin drooped against her chest, then lifted the cigarette and held it at face level; R1's head drooped, her eyes closed. The ash length had increased to approximately an inch long. - At 2:39 p.m. the male resident got up and walked away. R1 spontaneously turned the motorized wheelchair around in circle, faced the windows of the facility, switched the cigarette to her left hand and flicked the ash. R1 then spontaneously turned the motorized wheelchair around in circle again and faced the windows. - At 2:40 p.m. R1 handed an orange lighter to another male resident in a derby type hat, the male resident lit his cigarette. R1's head and chin drooped to her chest, her head jerked up then drooped immediately down. R1's eyes were closed, the ash was approximately a half an inch long again. - At 2:42 p.m. the cigarette was observed to be burned to the filter. R1 disposed of the burnt filter in the ashtray. On 3/13/14, at 8:20 a.m. R1 was observed smoking alone outside at the designated unsupervised smoking area. R1 was observed to be dozing off; dropping her chin down and up. R1 was sitting on her wheelchair at the corner of the brick wall almost bumping self on the wall, but would catch herself dozing. - At 8:33 a.m. R1 was observed continually dozing with the cigarette ash approximately a half (1/2) inch long and burning near the filter. R1 spontaneously woke up flicked the ash and continued dozing. - At 8:35 a.m. R1 continued holding the cigarette in her right hand, her head was hung over while dozing. R1 spontaneously woke up flipped the cigarette into the ashtray, then stayed in the smoking area. - At 8:36 a.m. another resident came to the smoking area, R1 then returned to the facility building. - 8:55 a.m. R1 was observed to return outside to the designated unsupervised smoking area. R1 lit a cigarette, was not wearing a smoking apron. R1's lap was covered with a folded pink, red, fluffy blanket (a potentially flammable fabric). - At 8:58 a.m. R1's eyes were observed to be shut and R1 appeared to be dozing; jerking her head up and down. R1 was holding the lit cigarette in her right hand with an approximately half (1/2) inch ash on the end of the lit cigarette. - At 8:59 a.m. R1 spontaneously woke up and was observed to talk to another resident in the smoking area. R1 flicked the ash on the ground. - At 9:03 a.m. R1 continued dozing, head jerking up and down, holding the lit cigarette on her right hand. - At 9:04 a.m. R1 spontaneously woke up and then left the unsupervised smoking area and returned to the building. On 3/14/14, at 11:00 a.m. R1 was observed in her motorized wheelchair outside the designated unsupervised smoking area with her eyes shut, dozing off, jerking her head up and down and holding a lit cigarette. R1 was observed to almost drop the lit cigarette on her lap, but spontaneously opened her eyes and caught it. On 3/12/14, at 3:01 p.m. the administrator and DON stated they were not aware of holes in R1's clothing but DON indicated laundry notified staff "nurses and aides." DON stated, "I talked with the laundry supervisor about another resident this morning and she said nothing." When asked about R1's medications, DON stated, "She seems to be on a significant amount of medications." When asked if a medication review had been completed DON stated she was not aware of any. Both the administrator and DON indicated they were not aware R1 was sleeping outside while smoking. The administrator stated R1 was very alert, "I have never seen her fall asleep in public." When asked who takes R1 to the Methadone Clinic and if there was potential R1 was accessing more drugs, DON stated R1 was getting medical transportation and added, "I don't believe so, they are fast trips to the Methadone Clinic." On 3/13/14, at 9:23 a.m. a registered nurse (RN)-C stated she was the only one doing all the MDS assessments for all the residents in the building and she had not developed a nursing care plan for R1 to address smoking. RN-C verified the temporary care plan had not been developed and stated, "The temporary care plan is supposed to be completed a few days after admission and the comprehensive care plan one by twenty one days after a resident is admitted to the facility." On 3/18/14, at 8:25 a.m. DON stated the facility had just learned R1 was going to another Pain Clinic (located in Eagan, Minnesota) and was receiving additional Methadone. DON verified R1 went to this clinic twice a week. DON stated the Methadone doses (unclear on the dose)received from the Pain Clinic was in addition to receiving 100 milligrams (mg) of Methadone six times per week from a different Methadone Clinic (located in Minneapolis, Minnesota). On 3/18/14, at 8:28 a.m. R1 approached and requested to speak to the surveyors. When asked about the Pain Clinic, R1 stated she was going to another clinic because it provided other services such as therapy, acupuncture and massage. R1 was hesitate to answer when asked if she was receiving any pain medications at the clinic and immediately changed the subject. R1 stated, "I relapsed three years ago and I now go to the Methadone Clinic (in Minneapolis) to receive my medication there daily." On 3/18/14, at 8:40 a.m. an other staff (O)-E stated during a telephone conversation, the transportation driver had reported in addition to the six times the driver was bringing R1 to the Methadone Clinic, the driver was also transporting R1 to another Pain Clinic two times a week on "Tuesday and Thursday afternoon." O-E stated they contacted the physician at the Pain Clinic in Eagan via telephone. O-E stated the physician was not aware R1 was going to the Methadone Clinic in Minneapolis daily. O-E stated the physician would not have known R1 was receiving "Liquid Methadone," and liquid methadone was not listed on the Narcotic Registry. R1's admission MDS dated [DATE], indicated R1 had [DIAGNOSES REDACTED]. The MDS indicated R1 had no behaviors and had a BIMS score of 15 which noted R1 was cognitively intact. The MDS indicated R1 required supervision with dressing, eating, toilet use and personal hygiene. Additionally the MDS indicated R1 was independent with locomotion on and off the unit, she used a wheelchair for mobility. R1 did not have a temporary nor a comprehensive care plan developed since being admitted at the facility on 11/30/13. R1's medical record lacked evidence of a Camden Care Center Smoking Contract, when a copy of a contract was requested on 3/12/14, at 3:12 p.m. from the social worker designee (SSD), a copy of the contract was not provided. A Smoking Evaluation dated 12/2/13, indicated R1 had no history of unsafe smoking practice, was able to utilize a lighter/matches safely, was able to safely handle lit smoking material; R1 was identified as cognitively intact, had no behaviors, understood the safe storage of smoking materials. The evaluation indicated R1 understood where smoking was allowed and was deemed an independent smoker. The next Smoking Evaluation dated 3/4/14, noted there were no changes from the 12/2/13, and R1 was deemed a safe smoker. physician's orders [REDACTED]. -Methadone 100 mg daily for pain; -Trazadone (an antidepressant used to treat insomnia with potential side effects of dizziness and drowsiness) 300 mg at bedtime for insomnia; -MS (morphine sulfate, a narcotic used for pain with potential side effect of drowsiness) Contin 15 mg at bedtime for muscle spasms; -Venlafaxine (Effexor, an serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant with potential side effects of dizziness and drowsiness) 150 mg daily for depression; -Gabapentin (Neurontin, an antiseizure drug also used to treat pain with potential side effects of dizziness, drowsiness or sleepiness) 800 mg three times daily (TID) for neuropathy related to diabetes mellitus; -Zolpidem (Ambien, a sedative drug used to treat insomnia and known to cause sleepiness) 5 mg at bedtime as needed (PRN) for insomnia; -Oxycodone (a narcotic used to treat pain and known to have potential side effects of dizziness and drowsiness) 30 mg three times daily as needed for pain; -Diphenhydramine (Benadryl, an antihistimine drug used for treatment of [REDACTED]. - Hydroxyzine (Atarax, an antihistimine drug used to treat allergic type symptoms such as itching with potential side effects of dizziness and drowsiness) 25 mg two caps by mouth every six hours prn (as needed) for itching. A Medication Review Communication dated and signed on 3/17/14 (after concerns of potential medications causing the observed sedation while smoking were brought to the facility's attention), by the consultant pharmacist indicated R1's medications such as Trazadone, Gabapentin, Ambien, Atarax and Venlafaxine would decrease alertness, increase confusion, cause sedation, and dizziness. A physician progress notes [REDACTED]. The physician progress notes [REDACTED]. R22 was unsupervised and lacked a smoking apron during observations of R22 smoking on 3/11/14, 3/12/14, 3/13/14, and 3/14/14; R22 was observed to have possession of smoking materials throughout all observations and was observed to have multiple burn holes in his clothing. R22's smoking observations were as follows: On 3/11/14, at 11:34 a.m. R22 was observed leaving the building in his motorized scooter wearing a light weight blue jacket. - At 11:37 a.m. R22 was observed parking his motorized scooter outside in the front designated unsupervised smoking area. R22 then took a cigarette and lighter out of a black glove and R22 lit the cigarette. R22 was not wearing a smoking apron and was unsupervised. - At 11:42 a.m. R22 was observed return to the building and to his room. On 3/12/14, at 1:15 p.m. R22 was observed to be smoking in front designated unsupervised smoking area. R22 was observed steering his motorized scooter while holding a lit cigarette in his mouth. R22 nearly hit a pool in front, the cigarette ash was noted to be approximately half (1/2) inch long. No smoking apron was observed on R22 or available in the unsupervised smoking area. On 3/13/14, from 8:15 a.m. to 8:46 a.m. R22 was observed in the dining room (DR) sitting on a regular straight back chair eating breakfast. R22 was wearing a gray half sweater and blue sweat pants. Both were observed to have burn holes at the front. - At 9:10 a.m. R22 was observed to leave the DR and go back to his room. R22 was observed watching television while lying in his bed. R22's legs were observed to dangle on the edge of bed. Several burn holes were observed in his sweater and pants. The black glove holding the cigarettes and lighter was observed to be lying on the seat of the motorized scooter. - At 11:10 a.m. R22 was observed to drive the motorized scooter out of his room and exit the building. R22 was observed to sit in his scooter in the front designated unsupervised smoking area. R22 retrieved his cigarette and lighter from a black glove, lit his cigarette and started smoking. R22 did not wear an apron and was unsupervised as he smoked. - At 1:30 p.m. R22 was observed outside in the front designated unsupervised smoking area smoking a cigarette. R22 did not wear a smoking apron. R22 was observed to hit a bench while maneuvering his motorized scooter as he was smoking the cigarette. The heavy blue jacket R22 was wearing was observed to have several burn holes to both sides of the jacket zip line. - At 2:15 p.m. R22 was observed outside in the designated unsupervised smoking area smoking sitting on his scooter and smoking a cigarette. On 3/14/14, at 12:12 p.m. was observed outside at the front designated unsupervised smoking area. R22 retrieved his cigarettes and lighter from the black glove then a staff applied a smoking apron and remained in the area supervising R22. - At 12:23 a.m. R22 returned to the building. The black glove with the cigarette and light in side was observed to be on R22's lap. R22 drove his motorized scooter down the hallway passing several facility staff and eventually entered his room. On 3/14/14, at 3:39 p.m. the SSD verified R22's Smoking Evaluation was not in the clinical record, but stated since R22 had been at the facility since 2011, it would be downstairs in his social service thinned chart and needed to go get it. On 3/14/14, at 3:43 p.m. SSD returned with the Smoking Evaluation dated 4/17/12. SSD stated she had not looked at it prior to completing the Smoking assessment dated [DATE], but had thought if there were changes another assessment would have been completed by the previous social service person. SSD verified according to the assessment dated [DATE], R22 was supposed to be a supervised smoker and smoking materials were to be secured by staff. SSD verified the assessment indicated R22 had a history of [REDACTED]. SSD verified R22 was currently considered an independent smoker and kept his own smoking materials with him. Although the assessment dated [DATE], contradicted, SSD verified the care plan dated 11/1/12, identified R22 as an independent smoker. SSD verified there was no other comprehensive assessment of R22's smoking ability. On 3/17/14, at 8:19 a.m. the DON stated she believed there was a more recent smoking assessment. DON stated the assessment should not have been thinned in the from the clinical record and SSD should have looked back to see what the previous assessment directed, prior to completing the smoking assessment on 1/9/14. On 3/17/14, at 9:11 a.m. RN-C was questioned regarding updating R22's care plan. RN-C stated she had updated R22's smoking care plan on 3/16/14, to reflect R22 required supervision with smoking and verified the prior care plan identified R22 was an independent smoker. Review of R22's med

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R34) was free from verbal and physical abuse from another resident (R36). Findings include: On 5/6/14, at 9:49 a.m., 5/6/14, at 11:32 a.m., 5/6/14, at 2:48 p.m., 5/7/14, at 1:40 p.m., 5/8/14, at 9:29 a.m., 5/8/14, at 2:08 p.m., 5/10/14, at 12:45 a.m. R34 and R36 were both observed on the smoking patio. The annual Minimum Data Set ((MDS) dated [DATE], for R34 included a Brief Interview of Mental Status (BIMS) score of nine which indicated moderate cognitive impairment and a Patient Health Questionnaire (PHQ-9) score of five which indicated mild depression. The MDS indicated R34 did not have delusions or hallucinations. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 4/3/14, lacked a summary regarding R34's cognitive status. A Vulnerable Adult Assessment date 3/18/14, indicated R36 was verbally abusive and condescending towards others. A Vulnerable Adult assessment dated [DATE], indicated R34 had behaviors which made her susceptible to abuse by others. A Social Service Note dated 4/17/14, indicated R34 had reported on 4/15/14, R36 was verbally abusive towards her. The note indicated when R36 was interviewed on 4/16/14, he stated he calls R34 "a parasite every time I see her because that is what she is." The note indicated R36 was told calling other residents names was verbal abuse and verbal abuse was not tolerated. A Progress Notes dated 4/17/14, indicated the contracted licensed social worker (CLSW) met with R34 on 4/16/14, and R34 indicated R36 "calls her every name in the book, he is just mean." A Progress Notes dated 4/17/14, indicated social services met with R36 and R36 stated he was going to "do what he wants" and would continue to call R34 a parasite. R36 was informed calling R34 names was verbal abuse and R36 responded "I don't care." The Admission Record dated 4/28/14, indicated R34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A copy of an Incident/Accident Report dated 5/5/14, was provided on 5/8/14. The Incident/Accident Report indicated R34 had reported R36 had pushed her into a patio chair and R34 had become stuck when the patio chair fell over. It was noted the incident had occurred on 5/4/14, at night with no exact time. R36 was noted to have denied the incident; the police were called and spoke with R34. On 5/7/14, at 3:10 p.m. a copy of the facility investigation was requested. The Incident/Accident Report lacked any additional investigation into the incident. A Progress Note dated 5/9/14, indicated R34 reported she did not like R36 because "he is an old drunk." The note indicated R34 had agreed to stay away from R36 and that R34 had stated she was used to handling old drunks, and had showed staff an old scar she reported was from when her late husband broke her leg. When interviewed on 5/7/14, at 2:41 p.m. R34 stated R36 called her names "all the time." When asked how being called names made her feel, R34 stated she had filed a police report because R36 had "assaulted her" two nights ago. When asked what she meant by assaulted, R34 stated R36 waited until nobody was around and then pushed her. R34 reported the director of operations helped her file a police report. Review of the medical records for R34 and R36, lacked documentation regarding the incident which was allegedly reported on 5/5/14, and lacked indication of how R34 would be protected from R36. When interviewed on 5/7/14, at 3:10 p.m. the director of operations reported he was aware of the incident which had occurred during the evening of 5/5/14, and confirmed he'd helped R34 call the police. During the interview, the administrator stated he was aware of the incident and that it had been reported to him on 5/6/14. The administrator reported R34 and R36 "spar all the time." Upon interview on 5/8/14, at 11:36 a.m. the director of nursing (DON) reported he had received the Incident/Accident Report on 5/8/14. The DON stated he was not sure whether the incident was reportable because it had occurred on 5/5/14, and it was a "resident to resident altercation." The director of operations was interviewed on 5/12/14, at 9:20 a.m. and stated R34 was very upset about the incident from 5/5/14, and had wanted the police called because it was not the first time, and that R34 had felt assaulted and wanted to press charges. Upon interview on 5/12/14, at 9:24 a.m. the administrator stated the incident on 5/5/14, had been reported to the state agency and that he would provide documentation regarding the report made. R34 was interviewed on 5/12/14, at 1:31 p.m., R34 stated R36 was abusive to her every day but that she'd heard he had gotten sent to another nursing home. R34 stated she felt what R36 was doing to her was both verbal and physical abuse. When interviewed on 5/12/14, at 1:52 p.m. the administrator and consultant administrator reported R34 and R36 have had an ongoing fight going on. The administrator stated R34 and R36 allege physical things and then change their stories. The consultant administrator stated that although the police had been called regarding the incident on 5/5/14, R36 had denied it happened and R34 had no visible injuries noted. The administrator stated when allegations of abuse are made, an incident report was to be filled out and a supervisor consulted to determine whether a report was needed. The administrator said the residents would be separated, an assessment would be made, the incident would be reported to the Common Entry Point (CEP) if appropriate, would be presented at their stand-up meeting the next day, and an investigation would be started. The administrator stated incidents were reported to the administrator, DON or CLSW but verified, "that system has not always been working." The administrator stated the incident form 5/5/14, had not been reported to the State Agency (SA) or to the CEP and acknowledged things needed to be reported right away and then investigated. Minneapolis Police Department officer (MPD)-E was interviewed on 5/12/14, at 3:38 p.m. and confirmed the police department had come to the facility regarding the incident between R34 and R36 on 5/5/14. MPD-E stated the facility was aware the residents called each other names and stated it was a facility problem. The facility Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy dated May 2012, indicated staff must not permit "anyone" to engage in verbal or physical abuse. The policy indicated the facility would implement policies and procedures to ensure that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. The definition of verbal abuse was described in the policy as, "the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability." The policy indicated the facility would protect residents from harm during the investigation and would "report allegations to the state survey and certification agency and any other state agencies pursuant to state regulations."

Based on observation, interview and document review, the facility failed to ensure 1 of 4 residents (R56) reviewed for resident to resident abuse, was free from verbal and physical abuse as R56 was not protected from the willful abusive actions of resident (R63) in the sample. The facility's failure to protect R56 from abuse constituted an immediate jeopardy (IJ) for R56. The IJ began on 3/9/14, when staff became aware of R63's threats to R56. The administrator and director of nursing (DON) were notified of the IJ on 3/12/14, at 5:00 p.m. The IJ was removed on 3/18/14, at 1:00 p.m. but noncompliance remained at scope and severity of a D, no actual harm with potential for more than minimum harm. Findings include: According to review of R56's medical record, and interview, R56 had reported to facility staff that R63 had caused emotional, physical and verbal abuse. However, the facility failed to investigate and intervene to protect R56 from the alleged physical, verbal and emotional abuse. R56 was observed and the following was noted: - On 3/11/14, at 1:54 p.m. R63 was observed to have yelled at R56 repeatedly and called her a liar. Registered nurse (RN)-B was immediately notified of R63 yelling at R56. He said "ok" and did not leave the desk. - On 3/11/14, at 4:00 p.m. R56 had to be approached five different times to get an interview completed due to R63 not allowing R56 talk without R63 becoming upset. R63 pointed at R56 and stated "You better not talk." - On 3/12/14, at 8:00 a.m. upon entering R56's room for an interview, R56 pointed towards R63 and stated to the surveyor, "Maybe you should come back." At that time R63 started to yell at R56 in a loud and angry tone of voice, "You're already here, I'm gonna leave!" R63 looked at R56 and said, "Oh, Girl you better keep your mouth shut!" R63's facial expression was angry and tone of voice was low and deep. R56 rolled her eyes and R56 recoiled back into the bed as if to guard herself at the time R63 made the verbal threat. - On 3/12/14, at 8:10 a.m. R56 stated during an interview with the surveyor, that her roommate (R63) was verbally abusive and caused her to be very afraid. R56 stated that on Sunday (3/9/14) R63 had slammed the foot of R56's bed with her hand, and had told her she knew "what murder feels like." R56 stated the police had been called and came in. The resident said when she had reported the issue to the facility staff, they had told her to keep her stuff on her bed, and R56 said she tried not to make any noise. - Review of R56's record on 3/12/14, at 8:14 a.m. revelaed the facility still had not investigated or identified the emotional, physical or verbal abuse and threats towards R56 from R63. - On 3/12/14, at 8:23 a.m. R56 was again interviewed by the surveyor and R63 was out of the room. R56 stated, "I'm so glad she's (R63) not here." - On 3/12/14, at 1:53 p.m. R56 told the surveyor she "felt like s**t" when R63 verbally abused her and stated again that she was afraid of R63. - On 3/13/14, at 9:54 a.m. R56 was observed to be laying in bed in her room. R63 was also observed to by in the room on her own side. Maintenance staff was in the room setting up headphones for the television and the activity director was sitting outside the room. At the start of a conversation with R56, her roommate (R63) yelled with an angry voice "Oh God" and R63 got up and left the room. The activity director followed R63 down the hall. - On 3/14/14, at 8:12 a.m. R56 was observed to be laying in her bed. R56 stated to the surveyor, "they took her (R63) away last night." R56 said she felt safer now and reported she had been bedfast for the past one to two months. R56's Progress Notes were reviewed from 1/25/14, going forward to 3/14/14. On 3/14/14, the notes indicated the social services designee (SSD) had met with R56 "as a follow up to provide an ongoing support." There was no supporting evidence regarding what "ongoing support" meant. The medical record lacked evidence of how the facility had intervened to keep R56 safe from R63's physical, verbal, and emotional abuse. The medical record lacked any evidence of the SSD having met with R56 prior to her becoming a roommate with R63 on 3/5/14, to discuss the new roommate and/or since to discuss any issues with adjustment to the room. R56's care plan dated 3/14/14, had a focus area initiated 3/6/13 indicating R56 had a "need for adjustment", with interventions in place to indicate R56 required social worker (SW) interventions due to her "recent admission to facility". The interventions noted the SW was to visit monthly and as needed (PRN), introduce self to others, encourage R56 to attend activities and the SW would make outside referrals to mental health professional(s) as needed. In addition there was another focus area initiated 3/6/13, with target date of 3/17/14, which indicated R56 was a "vulnerable adult related to physical limitations." The goal was to ensure R56 was "safe within Camden Care Center at all times" and the interventions included, "Nursing to provide cares, services according to resident needs, POS (physician's orders [REDACTED]." The Vulnerable Adult Assessment (VAA) dated 11/21/13, indicated R56 had physical limitations which made the resident susceptible to abuse. The physical limitations include wheelchair (w/c) bound and history of [MEDICAL CONDITION]. The form also identified R56 did not "have a history of any type of abuse towards others or self-abuse." The VAA was updated on 2/20/14, and noted the VAA was still current with no changes. R56's most recent Minimum Data Set ((MDS) dated [DATE], identified R56 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R56 was totally dependent upon staff for transfers and bed mobility. behaviors directed towards staff only, no delusions, Patient Health Questionnaire (PHQ)-9 was 12 which noted moderate depression (PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively). R56's [DIAGNOSES REDACTED]. The MDS also noted R56 received no antipsychotic medication. The physician's orders [REDACTED]. Also according R56's physician's orders [REDACTED]. R63's record was reviewed. It was determined R63 was aware of the facility's policy for abuse as R63 had signed the Acknowledgement of Vulnerable Adult and Abuse Prevention Policies on 10/5/11. The Acknowledgement form read, "Camden Care Center strives to support and protect all of our residents. To ensure our resident's needs are met, we have established Vulnerable Adult and Abuse Prevention Policies. All residents have the right to report concerns or suspected abuse without fear of retaliation." R63's care plan last reviewed 2/16/14, included a focus area for R63 which indicated the resident needed an "opportunity to express feelings/ concerns regarding placement/life situations. (R63) tends to keep to herself. (R63) has a dx (diagnosis) of depression." The interventions included encourage R63 to attend activities, refer to outside mental health professional(s), and remind R63 of the positives in life and to have the SW visit monthly and PRN. The care plan had not been updated with the room change and the addition of a roommate as of 3/5/14, nor was the care plan revised to reflect the physical, verbal and emotional abuse towards R56. A Care Conference Quarterly note dated 10/22/13, depicted R63 as having behaviors which included "becomes irritated with staff at times, barricades herself in her room with boxes, she also isolates her self (sic) in her room." The continued to note R63 "is very sensitive to noise and that causes 'nausea'." The note revealed R63 independent in ambulation to all destinations. R63's most recent quarterly MDS dated [DATE], noted R56's [DIAGNOSES REDACTED]. The MDS identified R63 as being cognitively intact with a BIMS score of 15. R63's PHQ-9 was 10 which noted moderate depression. According to the MDS, R63 had trouble sleeping, had a poor appetite, had little interest, trouble concentrating, felt tired, and felt down. R63 was depicted as having no behaviors. R63's last comprehensive assessment was dated 10/10/12. R63's medical record lacked a current comprehensive assessment that would have identified her current functional capacity and develop a current care plan with interventions to care for R63. R63's Progress Notes were reviewed from 9/27/13, going forward and the following was noted: - On 3/9/14, at 5:34 a.m. noted staff was aware that R63 had threatened R56. "She (R63) stated 'I will kill you now', and she pounded very hard on her bed. This resident verbally attacked this writer for changing her room where she was having a good slumber. Updated the authority for a threatening comment directed towards coresident. We will continue to monitor the situation closely and vigilantly at this moment." - On 3/9/14, at 12:50 p.m. noted R63 was "not fine with present roommate and room environment. according to her (R63), her roommate is very in appropriate, like to put call light on, turn television loud, and calling nar (nursing assistant/registered) in the room to assist her with cares etc." The police had been called previously and resident needed to be separated before something happen (sic) beyond our reach." The note indicated the facility staff was going to monitor the situation every 15 minutes, however, the medical record lacked evidence of the monitoring. R63 was unavailable for interview related to the untoward behavior towards R56 as R63 was transferred out of the building on the evening of 3/13/14. On 3/12/14, at 1:50 p.m. the Minneapolis Police Department was called. In speaking with the support technician, he indicated no official report had been filed. The comments on a report made by the officer who came to the facility on [DATE], at 5:34 a.m. recommended the facility separate the two women (R56 and R63) as "they were irritable and could not tolerate each other." On 3/12/14, at 2:37 p.m. an interview was conducted with the SSD (social services director). She indicated R56 and R63 became roommates on 3/5/14, as both women were private pay and could not afford to pay the private pay fee for a private room. The SSD indicated she was first made aware of the 3/9/14, altercation during the Monday morning report meeting on 3/10/14. The SSD revealed she did speak with R63 and stated, "(R63) is used to being in her own room. She did warn us, I would not be able to get along with a roommate. 'I was brought into a private room and will not be able to get along.'" The SSD was not aware of R63's "I now know what murder feels like." and was aware of the police being called on 3/9/14. The SSD expected the staff to inform her of any situation that needed her attention. SSD stated she did meet with R63 on 3/11/14, and R63 stated "things were getting better, they are avoiding communicating with each other and talking to each other." The SSD did not put any interventions into place for the altercations between the two roommates and she was unaware if nursing had put any interventions in place to prevent the emotional, physical and verbal abuse of R63 towards R56. The medical record lacked evidence of the communication between R63 and the SSD as the SSD did not document any of the follow up conversations. It could not be determined whether R63 had received the monthly SW visits as indicated on the care plan revised 4/18/12. R56 had not received the monthly visits by the SSD as directed by the care plan nor was R56's care plan revised to reflect a new roommate and the need for a new adjustment period for the new roommate. On 3/12/14, at 2:46 p.m. licensed practical nurse (LPN)-A and the administrator were interviewed regarding the altercation between R56 and R63. The administrator was not aware of the incident that took place on 3/9/14, and was not aware that the police came. LPN-A was aware and stated she'd informed the SSD about the incident. Neither party was aware of the police recommendation to separate the women, and both acknowledged no interventions were put into place to protect R56 from R63. Neither party was aware of R63's comment on 3/11/14, "I now know what murder feels like." Both parties acknowledged they would have expected staff to report that incident to them. On 3/12/14, at 2:53 p.m. the DON was interviewed. The DON indicated she was not made aware of the 3/9/14, altercation between R56 and R63. She also indicated she did not know the police had come that morning or the recommendation of separating the women. The DON was unaware of the R63's abusive remark to R56 "I now know what murder feels like." The DON admitted there have been no interventions put into place since 3/9/14, to monitor R63's abusive verbal and emotional behavior towards R56. On 3/13/14, at 3:30 p.m. the DON reported she was not aware that R63 was verbally aggressive towards R56 during observations that a.m. She reported the facility had received an order for [REDACTED]. On 3/14/14, at 10:56 a.m. nursing assistant (NA)-B stated they had never heard of any altercations between R56 and R63. NA-B further commented R63 just moved to that room recently. The undated Behavior Monitoring procedure directed staff to report all incidents of abusive behavior, such as physical, verbal, theft, etc. The staff was to report to the supervisor immediately. New behaviors were to be reported to the nurse for appropriate follow up. The procedure indicated the nurse and social worker were to review the information weekly and follow up as needed. The IJ that began on 3/9/14, was removed on 3/18/14, at 1:00 p.m., when the facility had implemented an IJ removal plan that included: review and revision of the abuse prevention plan, training was provided to all staff on each shift prior to resident contact, the facility initiated a thorough investigation of ongoing incidents that involved R56 and R63, and R63 was transferred to an inpatient acute care hospital for behavioral assessment. In addition, direct care staff and licensed nursing staff were interviewed and were able to explain their responsibility for identification of incidents of potential mistreatment; internal reporting; resident protection, investigation and external reporting as defined in the facility's revised Abuse Prevention Plan, the plan included how the facility would monitor for resident to resident physical, verbal and emotional abuse. Although the IJ was removed, noncompliance remained at the lower scope and severity (s/s) of a D.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R34) was free from verbal and physical abuse from another resident (R36). Findings include: On 5/6/14, at 9:49 a.m., 5/6/14, at 11:32 a.m., 5/6/14, at 2:48 p.m., 5/7/14, at 1:40 p.m., 5/8/14, at 9:29 a.m., 5/8/14, at 2:08 p.m., 5/10/14, at 12:45 a.m. R34 and R36 were both observed on the smoking patio. The annual Minimum Data Set ((MDS) dated [DATE], for R34 included a Brief Interview of Mental Status (BIMS) score of nine which indicated moderate cognitive impairment and a Patient Health Questionnaire (PHQ-9) score of five which indicated mild depression. The MDS indicated R34 did not have delusions or hallucinations. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 4/3/14, lacked a summary regarding R34's cognitive status. A Vulnerable Adult Assessment date 3/18/14, indicated R36 was verbally abusive and condescending towards others. A Vulnerable Adult assessment dated [DATE], indicated R34 had behaviors which made her susceptible to abuse by others. A Social Service Note dated 4/17/14, indicated R34 had reported on 4/15/14, R36 was verbally abusive towards her. The note indicated when R36 was interviewed on 4/16/14, he stated he calls R34 "a parasite every time I see her because that is what she is." The note indicated R36 was told calling other residents names was verbal abuse and verbal abuse was not tolerated. A Progress Notes dated 4/17/14, indicated the contracted licensed social worker (CLSW) met with R34 on 4/16/14, and R34 indicated R36 "calls her every name in the book, he is just mean." A Progress Notes dated 4/17/14, indicated social services met with R36 and R36 stated he was going to "do what he wants" and would continue to call R34 a parasite. R36 was informed calling R34 names was verbal abuse and R36 responded "I don't care." The Admission Record dated 4/28/14, indicated R34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A copy of an Incident/Accident Report dated 5/5/14, was provided on 5/8/14. The Incident/Accident Report indicated R34 had reported R36 had pushed her into a patio chair and R34 had become stuck when the patio chair fell over. It was noted the incident had occurred on 5/4/14, at night with no exact time. R36 was noted to have denied the incident; the police were called and spoke with R34. On 5/7/14, at 3:10 p.m. a copy of the facility investigation was requested. The Incident/Accident Report lacked any additional investigation into the incident. A Progress Note dated 5/9/14, indicated R34 reported she did not like R36 because "he is an old drunk." The note indicated R34 had agreed to stay away from R36 and that R34 had stated she was used to handling old drunks, and had showed staff an old scar she reported was from when her late husband broke her leg. When interviewed on 5/7/14, at 2:41 p.m. R34 stated R36 called her names "all the time." When asked how being called names made her feel, R34 stated she had filed a police report because R36 had "assaulted her" two nights ago. When asked what she meant by assaulted, R34 stated R36 waited until nobody was around and then pushed her. R34 reported the director of operations helped her file a police report. Review of the medical records for R34 and R36, lacked documentation regarding the incident which was allegedly reported on 5/5/14, and lacked indication of how R34 would be protected from R36. When interviewed on 5/7/14, at 3:10 p.m. the director of operations reported he was aware of the incident which had occurred during the evening of 5/5/14, and confirmed he'd helped R34 call the police. During the interview, the administrator stated he was aware of the incident and that it had been reported to him on 5/6/14. The administrator reported R34 and R36 "spar all the time." Upon interview on 5/8/14, at 11:36 a.m. the director of nursing (DON) reported he had received the Incident/Accident Report on 5/8/14. The DON stated he was not sure whether the incident was reportable because it had occurred on 5/5/14, and it was a "resident to resident altercation." The director of operations was interviewed on 5/12/14, at 9:20 a.m. and stated R34 was very upset about the incident from 5/5/14, and had wanted the police called because it was not the first time, and that R34 had felt assaulted and wanted to press charges. Upon interview on 5/12/14, at 9:24 a.m. the administrator stated the incident on 5/5/14, had been reported to the state agency and that he would provide documentation regarding the report made. R34 was interviewed on 5/12/14, at 1:31 p.m., R34 stated R36 was abusive to her every day but that she'd heard he had gotten sent to another nursing home. R34 stated she felt what R36 was doing to her was both verbal and physical abuse. When interviewed on 5/12/14, at 1:52 p.m. the administrator and consultant administrator reported R34 and R36 have had an ongoing fight going on. The administrator stated R34 and R36 allege physical things and then change their stories. The consultant administrator stated that although the police had been called regarding the incident on 5/5/14, R36 had denied it happened and R34 had no visible injuries noted. The administrator stated when allegations of abuse are made, an incident report was to be filled out and a supervisor consulted to determine whether a report was needed. The administrator said the residents would be separated, an assessment would be made, the incident would be reported to the Common Entry Point (CEP) if appropriate, would be presented at their stand-up meeting the next day, and an investigation would be started. The administrator stated incidents were reported to the administrator, DON or CLSW but verified, "that system has not always been working." The administrator stated the incident form 5/5/14, had not been reported to the State Agency (SA) or to the CEP and acknowledged things needed to be reported right away and then investigated. Minneapolis Police Department officer (MPD)-E was interviewed on 5/12/14, at 3:38 p.m. and confirmed the police department had come to the facility regarding the incident between R34 and R36 on 5/5/14. MPD-E stated the facility was aware the residents called each other names and stated it was a facility problem. The facility Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy dated May 2012, indicated staff must not permit "anyone" to engage in verbal or physical abuse. The policy indicated the facility would implement policies and procedures to ensure that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. The definition of verbal abuse was described in the policy as, "the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability." The policy indicated the facility would protect residents from harm during the investigation and would "report allegations to the state survey and certification agency and any other state agencies pursuant to state regulations."

Based on observation, interview and document review, the facility neglected to provide adequate supervision to residents who had a known history of drug and alcohol use resulting in medical treatment, including hospitalization , for 2 of 11 residents (R37, R129) reviewed. In addition, the facility failed to implement adequate interventions to prevent elopements for 1 of 3 residents (R116) who eloped from the facility with a WanderGuard (a system to alert staff when a resident leaves the facility) in place. This lack of supervision caused an immediate jeopardy situation for R37, R129 and R116. The IJ began on 5/10/14, when R37 was admitted to the hospital following the use of illicit drugs while in the facility and was identified on 5/12/14. The administrator, consulting administrator, and director of nursing (DON) were notified of the IJ at 3:15 p.m. on 5/12/14. The immediate jeopardy was not removed by the exit date of the survey. Findings include: On 5/9/14, the facility had been informed of serious and immediate safety of the residents related to lack of adequate supervision for alleged drug and alcohol use and elopement. Although, the facility was aware of the serious implications on 5/9/14, the facility did not identify and implement interventions to protect the residents from potential harm. On 5/10/14 and 5/11/14, two residents were hospitalized for [REDACTED]. In addition, on 5/11/14, one resident had eloped from the facility three times with a WanderGuard on and no staff were present. R37's Admission Record dated 1/14/14, indicated R37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to documented progress notes, R37 had been found with ETOH/vodka on 2/21/14, 2/22/14, 2/27/14, 3/2/14, 4/13/14, 4/23/14, 4/24/14, 4/25/14, 5/3/14, 5/5/14, 5/6/14, 5/7/14, 5/9/14 and 5/10/14. The record also indicated R37 had required hospitalization s related to the use of alcohol and or drugs on 2/22/14, 4/23/14, and 5/10/14. During observations of R37 the following was observed: -On 5/5/14, at 2:53 p.m. R37 was observed approaching a white minivan parked in front of the facility. - On 5/6/14, at 1:30 p.m. R37 was observed staggering down the hallway with the health unit coordinator (HUC) and in a loud voice stated he was crazy. - On 5/6/14, 2:02 p.m. R37 went outside without shoes on. Two staff stopped him at the nursing station and sent him back to his room for shoes. R37 left his room and went directly outside without shoes on again, walked to the smoking patio and returned to the facility. - On 5/7/14, at 8:18 a.m. R37 was observed standing next to R117 on the smoking patio with his wallet out. Another resident (R1) arrived and R37 handed his wallet to her. Surveyor was unable to see whether R1 took anything from the wallet before she handed it back to R37. R37 was observed to lean close to R1 and speak to her and gave her his wallet back. At 8:24 a.m. R1 put R37's wallet back in his left rear pant pocket. - On 5/8/14, at 11:48 a.m. R37 was observed in bed with his back to the door. R37 rolled over and looked at surveyor and rolled back towards the wall. R37 stated he did not want to talk now and would talk in an hour or two. - On 5/8/14, at 3:46 p.m. an attempt was made to interview R37 and he refused. - On 5/9/14, at 7:23 a.m. R37 was observed coming out of his room, stated he did not feel good and was going to see if there was any coffee. At 7:28 a.m. R37 was observed coming from the West hallway. R37 was then observed to push another resident back down the West hallway and was observed outside room [ROOM NUMBER] R9. There was no staff with R37 when he was observed. When R37 returned to the nursing station, he told the HUC he had gotten cigarettes from R9. The HUC asked R37 if he was alone and R37 responded that he was and she asked him where his partner was. Nursing assistant (NA)-L approached R37 and stated she was with him today. NA-L verified she was assigned to provide the 1:1 for R37. - On 5/10/14, at 1:07 p.m. R37 was observed being taken out of the facility to an ambulance. The Nutritional Status Care Area Assessments (CAAs) dated 9/26/13, indicated R37 was at risk for impaired nutritional status due to chronic ETOH abuse and [MEDICAL CONDITION]. Review of the Cognitive Loss/Dementia, Mood State, Behavioral Symptoms and [MEDICAL CONDITION] Drug Use CAAs dated 10/7/13, revealed a lack of a summary regarding the triggered areas. The Progress Notes were reviewed and the following was noted: - On 5/2/14, R37 removed the WanderGuard (departure alert system) and refused a new one to be placed. - On 5/3/14, R37 was walking in the hallway wobbling and requested staff give him a shower at 3:00 a.m. R37 was unable to maintain his balance and appeared intoxicated. Two almost empty bottles of vodka were found in his room. - On 5/5/14, at 3:53 p.m. R37 had exhibited signs of intoxication with an unsteady/staggering gait, slurred speech, odor of alcohol and unkempt appearance. R37 was noted to have continually gone outside, stated he had called a limousine and was going to Las Vegas. - On 5/5/14, at 4:56 p.m. R37 had slurred speech, smelled of ETOH and had a staggering gait. - On 5/5/14, at 10:25 p.m. R37 was intoxicated and was found with an almost empty bottle of vodka. - On 5/6/14, a notation had been made indicating it was a late entry for 5/5/14, at 6:00 p.m., the note indicated R37 was noted walking outside towards the back of the building. R37 was noted to be walking alone with a staggering gait. When approached by staff, R37 stated he was going to Las Vegas. No odor of ETOH was noted and when asked what he had been doing to become so impaired, R37 reported he had gotten cocaine and heroin from another resident and confirmed he had been injecting the drugs. Several scattered purple bruises were noted on his forearms. At 1:55 a.m. indicated R37 reported his heart was thumping out of his chest and was found to have a blood pressure of 168 /118 with a pulse of 118. At 4:37 a.m. indicated R37 exited his room without clothing and had a strong odor of ETOH on his breath. Four empty bottles and one unopened bottle of ETOH were found in R37's room and were removed by staff. Also noted R37 started having tremors and palpitations with increased pulse and blood pressure due to ETOH withdrawal and demanded medications. - On 5/7/14, at 12:04 p.m. indicated R37 was exhibiting signs and symptoms of intoxication as evidenced by odor of ETOH, unsteady/slow/staggering gait, slurred speech, confusion and unkempt appearance. A pattern of missed pain clinic appointments due to intoxication was noted and indicated further appointments would not be made due to ongoing intoxication and inability to follow through with appointments. In addition, R37 had a full bottle of vodka and refused to give the bottle to staff. The note indicated the administrator directed if R37 was unwilling to willingly give staff the ETOH bottle, it was ok for the resident to keep the ETOH and if he became drunk or disruptive to call the police and have him taken to detox. - On 5/8/14, at 3:42 p.m. indicated R37 was placed on one to one (1:1) (to be within arm's length at all times) observation related to incidences of getting intoxicated. - On 5/9/14, indicated R37 was clearly intoxicated. An empty pint bottle of vodka was found in his room and was noted as the third empty pint bottle taken from R37's room in a 48 hour span of time. - On 5/10/14, indicated R37 was observed giving his credit card to R117 on 5/9/14. A second note indicated R37 returned from leave of absence (LOA) accompanied by a friend of another resident (R1). R37 was observed to be shaky and verbalized he was unsteady on his feet. R37 was noted to have shakiness, profuse sweating, and sluggish pupils. R37 was noted to have a blood pressure of 178/130 and a pulse of 120s to 140s. - On 5/11/14, indicated R37 had a drug screen positive for [MEDICATION NAME] at the hospital. R37 did not have a prescription for [MEDICATION NAME]. The physician's orders [REDACTED]. - On 1/8/14, included a [DIAGNOSES REDACTED]. - On 2/5/14, indicated R37 recently had a bottle of ETOH hidden in his pillow case and was noted to smell of ETOH. - On 2/28/14, directed to discharge R37 to another facility (that allowed drinking). - On 3/5/14, directed do not call on-call MD (physician) or NP after hours if resident is intoxicated unless he is medically compromised. Allow resident to go to bed (and) sleep. - On 4/9/14, indicated R37 was hospitalized from [DATE] from 4/8/14, with respiratory distress and pneumonia with pleural effusions requiring chest tube placement, treated for [REDACTED]. A NP note dated 4/9/14, indicated R37 required ongoing Kristalose and Mag-ox for chronic [MEDICAL CONDITION]. - On 4/10/14, included [DIAGNOSES REDACTED]. - On 4/24/14, included place wander guard (sic) for res. (resident) safety and pursue guardianship. A second order dated 4/24/14, indicated NP was aware of R37's ETOH, to encourage R37 not to use and if R37 appeared intoxicated it was ok to administer all medications as ordered. - On 5/6/14, directed to recheck R37's blood pressure in one hour, call NP if diastolic blood pressure was greater than 100, give [MEDICATION NAME] 0.5 milligrams (mg) orally every six hours as needed times three days for withdrawal symptoms (tremors, shaking, and increased heart rate) and a urine toxicology screen. - On 5/7/14, directed no LOA-supervised or other. Also, the NP included an order for [REDACTED]. A Clinical Summary dated 2/3/14, indicated refer to chemical dependency counselor and pain psychologist. A prescription dated 2/3/14, ordered a behavioral health evaluation for diagnostic evaluation and treatment recommendations for R37. A Physician Visit/Progress Note written by a licensed drug and alcohol counselor (LADC) dated 2/13/14, indicated R37 had been referred for assessment of behavioral health, chemical dependency and pain, and included an order/comment of strongly recommend a full psychiatric assessment within 60 days to evaluate medications and therapy. The medical record lacked evidence of the psychiatric assessment having been completed. R37's care plan was reviewed and noted the following: - The vulnerable adult care plan revised on 3/5/14, indicated R37 may leave to go to medical appointments without supervision but was not safe to go on other unsupervised LOAs. - The depression care plan dated 3/11/14, included ETOH abuse and directed to arrange psych services as needed. - A behavioral symptoms care plan revised on 3/16/14, indicated ETOH consumption and concealing ETOH in room with a goal to have fewer episodes of ETOH abuse per week. The interventions included; encourage attending Alcoholics Anonymous (AA) or other substance abuse support programs, assisting with arrangements as needed, may go to medical/dental appointments unsupervised and no other unsupervised LOA. - A risk for elopement related to ETOH abuse and psychoses care plan revised 3/16/14, noted a history of returning to facility after unsupervised LOA displaying signs of ETOH consumption and/or with a supply of ETOH. The goal included R37 would not to leave facility unattended unless a medical appointment and R37's safety will be maintained. The interventions indicated R37 cut off the WanderGuard and refused to have another one placed and was placed on 15 minute checks. Check room if suspected ETOH. - A Mood/Behavior care plan initiated on 4/23/14, indicated R37 had a history of [REDACTED]. The care plan noted R37 was sent to detox on 4/23/14, due to being very intoxicated. The goal indicated R37 would like to stop drinking ETOH with an intervention to check room daily for ETOH and check R37 for signs of intoxication. - An at risk for adverse reaction from medications related to ETOH care plan dated 4/25/14, indicated NP was aware of R37's ETOH use, nursing staff to encourage to restrain from using ETOH and if R37 appeared intoxicated it was ok to administer medications. Another intervention dated 5/8/14, included 1:1 supervision due to ETOH abuse and intoxication. A Vulnerable Adult assessment dated [DATE], indicated R37 had both past and recent substance abuse, was not safe for unsupervised LOA except to appointments and had significant ETOH use when out on unsupervised LOA. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R37's cognitive skills for daily decision making was independent with consistent/reasonable decisions. A Resident Refusal of Medical Treatment Form dated 5/5/14, indicated R37 was wander guarded (sic) to the facility for resident safety related to history of ETOH abuse, staggering gait and slurred speech. With the risks of refusal noted as facility wouldn't be aware if R37 left with potential for fall risk and injury off facility grounds with no one to provide aid. A letter dated 5/10/14, indicated the resident had received a first offense of the facility's smoking policy as R37 reported to staff he had gotten cigarettes from R9. On 5/8/14, at 11:51 a.m. licensed practical nurse (LPN)-B stated she was aware R37 had a doctor's order and can drink as long as there are no behaviors and if behaviors occur she can call detox. LPN- B stated she did not know where R37 had obtained the ETOH from. The safety monitor, NA-M was interviewed on 5/8/14, at 11:55 a.m. and stated he has not seen R37 exchange money for ETOH, and stated he has heard about exchanges but could not remember who he'd heard about it from. The HUC was interviewed on 5/8/14, at 12:15 p.m. and stated it's a nightmare; (R37) is drunk every day. She stated she had her suspicions about where the ETOH was coming from but when she asked R37 he refused to tell her. The HUC said R37 had told her he had given his credit card to R117 to buy things for him. The HUC stated R37 was drunk every day when she left and was drunk when she came in on 5/8/14. She reported that on 5/5/14, or 5/6/14, she had observed R37 in the parking lot, and had been told there was nothing they could do about it by the facility administrator. She said she'd requested assistance from the operations director to get R37 back in the building. The HUC reported she had requested that the safety monitor put R37 on every 15 minute checks but knew that was not enough. She stated other residents were on 1:1 for drug use and wanted to know what the facility was going to do to keep R37 safe. The HUC stated we're not doing (R37) any justice and it's a[***]y plan to keep people on 1:1 forever. On 5/10/14, at 1:30 p.m. the administrator stated R37 had been taken to the hospital for [MEDICAL CONDITION] tremens (DTs-a severe form of ETOH withdrawal that involves sudden and severe mental or nervous system changes). On 5/12/14, at 8:59 a.m. registered nurse (RN)-B and licensed practical nurse (LPN)-A stated R37 had gone to the bank with a friend on 5/10/14, and were not sure if the 1:1 had gone to the bank or not and would have to check. The DON was interviewed on 5/12/14, at 9:05 a.m. and stated a guy named (friend-A) who is a friend of R1 went with R37 to the bank. The DON stated both the administrator and the consultant administrator were aware that friend-A was a friend of R1. The DON stated the 1:1 had refused to go to the bank with R37 and that friend-A had signed R37 out. The DON said the consultant administrator had been going to go with R37 and friend-A to the bank until it was decided the facility was not comfortable with her going with to the bank either. The DON stated he had reminded R37 he could not go because he had orders for no LOA and the administrator, consultant administrator and the social worker decided R37 could go anyway. The DON stated he had no idea where R37 had gotten [MEDICATION NAME] from. When interviewed on 5/12/14, at 1:35 p.m. contracted licensed social worker (CLSW)-A stated during a room search a quart bottle of ETOH and three plastic containers with the labels removed, which nursing indicated were [MEDICATION NAME] containers, had been found in R37's room. When interviewed on 5/12/14, at 1:52 p.m. the administrator stated he and CLSW-A were involved in R37's LOA. The administrator stated CLSW-A was under the impression R37 was allowed to go on LOA and that R37 had returned with a card from Walgreens so they knew he had not followed his agreement to only go to the bank. The administrator stated friend-A would not be able to take R37 on LOA again. The administrator stated he was not aware R37 had orders for no LOAs and he believed CLSW-A had not checked the chart. The administrator stated he was also not aware of friend-A's relationship with R1 and stated the DON had not told him about the order for no LOA and friend-A's relationship with R1. Upon interview on 5/13/14, at 8:09 a.m. CLSW-A stated on 5/10/14, prior to R37 having left on LOA, she was told by nursing (she could not remember who) that R37 could leave the facility with supervision. She reported she made it clear to friend-A that R37 could only go to the bank and nowhere else. She stated she told friend-A that R37 would try and talk him into going to the liquor store and that she'd told friend-A that R37 could not go there. CLSW-A said friend-A had reassured her he had been sober for ten years and would never take R37 to a liquor store. The CLSW-A stated after R37 left, nursing (did not remember who) told her R37 had orders for no LOA and had informed her that friend-A was R1's drug dealer. CLSW-A stated it would have been nice to know the information before she had allowed R37 to go on a LOA. She stated she had not looked at R37's chart because she trusted nursing knew the correct information. She also stated R37 had been keeping ETOH under the edge of his mattress and she could not understand why nursing did not find the ETOH when they made the bed. When interviewed on 5/13/14, at 2:20 p.m. the administrator was asked about the discrepancy between what the DON reported had happened on 5/10/14, and what the administrator stated had happened and he verified he was not aware R37 had an order for [REDACTED]. R129 was identified by the facility to have a history of drug seeking and ETOH dependency. Although the facility had determined R129 required a 1:1 staff member since at least 3/18/14, according to a Vulnerable Adult (VA) assessment, the appropriate supervision was not implemented and/or effective. According to review of the progress notes in R129's record, on 5/3/14, R129 had reported to the facility that she had obtained and consumed cocaine. The documentation indicated R129 had a staff assigned as a 1:1 at the time of the incident. An Incident/Accident Report dated 5/3/14, at 11:00 p.m. indicated R129 told the nurse that she took cocaine earlier during the shift. The note identified R129 to be very sweaty, weak and tired and she looked very sleepy. The resident's pupils were large and nonreactive to light. The note indicated the nurse asked R129 what she had taken and indicated R129 then confessed to having taken cocaine. The report documentation indicated R129 had been sent to the emergency room (ER) and included, She said, 'I knowingly took cocaine'. Resident has been sent to ER. She will continue to be on 1:1 when she returns to the nursing home. The report identified R129 had a history of [REDACTED]. A North Memorial Medical Center (NMMC) Emergency Department (ER/ED) note dated 5/3/14, identified R129 had reported she'd taken cocaine at the nursing home. The ER note indicated R129 had taken the cocaine to help with the pain in her abdomen. Patient (R129) is triaged directly back to ED. The Clinician History of Present Illness section of the form identified R129 had reported to hospital staff she had snorted cocaine 5 hours ago. On 5/11/14, at 4:00 a.m. the progress notes indicated R129 had obtained and consumed a life threatening amount of ETOH, causing her to require hospitalization in an intensive care unit (ICU) with subsequent intubation (mechanical ventilator assisted breathing) as a result of a blood ETOH level of 0.323. (According to Minnesota Statute 169A.20, 0.08 is considered impaired for driving). A 1:1 staff was supposed to have been in place at the time of the incident. The resident's record included a note documented by the facility's HUC on 5/11/14, at 10:09 a.m. which indicated NMMC had called the facility requesting R129's medication administration records (MARs). The note indicated the registered nurse (RN) from the hospital had notified the HUC that R129 had been admitted to the ICU, and had been intubated due to acute [MEDICAL CONDITION]. The note indicated R129's toxicology screen was negative for drugs but positive for alcohol with a level of 0.323. The record also included a note documented by the director of nursing (DON) on 5/11/14, at 10:55 a.m. The DON's note recapitulated R129 had been sent to the hospital, identified the time of transport as around 4 a.m. on the night shift, and identified R129 had been sent in for intoxication. The DON's note indicated R129 had become weak and needed to be lowered to the floor. The note indicated two licensed practical nurses (LPNs) were contacted and the nursing assistant (NA) staff assigned to the 1:1 was called. The note indicated the NA assigned to R129 reported that resident has been in and out of (R14's room number) but that she had not noticed any exchange of alcohol. She also reported that resident (R14) was upset because the 1:1 has to be in his room too while resident (R129) is visiting. In addition, the DON's documentation indicated R14 had denied giving or knowing how R129 had obtained the ETOH, and documented R14 had mentioned that resident had alcohol overnight. An additional progress note, dated 5/11/14, at 2:49 p.m. had been written by the DON indicating NMMC had been contacted to request updates on R129's status. The note indicated, I also requested to have the resident undergo a chemical dependency assessment to ensure that the resident can be transferred to a residential chemical dependency facility as appropriate, considering the resident's recent hospital trip to the hospital for snorting cocaine. Additional record review revealed an admission MDS dated [DATE], that indicated R129 had a BIMS score of 15, indicating R129 was cognitively intact. The MDS identified R129 was independent with all ADLs. The MDS identified R129 rejected cares and wandered one to three days during the assessment period. R129's comprehensive assessment analysis (CAA) for mood state dated 2/7/14, identified R129 as having intact cognition, with poor decision making and as having [DIAGNOSES REDACTED]. The CAA identified further [DIAGNOSES REDACTED]. Although the CAAs identified R129 had a history of [REDACTED]. A Vulnerable Adult assessment dated [DATE], identified R129 had a history of [REDACTED]. R129 was identified as being susceptible to abuse r/t (related to) substance use, varies and required supervision with LOA from the facility. The assessment identified R129 had behaviors including a history of rummaging through others' belongings and drug use. The assessment indicated R129 had been placed on 1:1 due to rummaging in other resident rooms. R129's care plan for safety/vulnerability dated 3/25/14, identified R129 was able to make her needs known, but was vulnerable due to her history of opioid abuse and drug seeking behavior. A care plan intervention dated as initiated 4/11/14, directed R129 required 1:1 supervision at all times to keep (R129) safe and prevent drug use Additionally, the care plan directed, 1:1 to discuss CD concerns, encourage (R129) to consider going to a treatment facility. The care plan for mood/behavior dated 3/25/14, identified, I have a history of opioid abuse and I exhibit drug seeking behavior as evidenced by attempting to see several different MD's to obtain prescription medication. I have a history of walking into other residents rooms and looking thru their personal belongings. Review of the undated Group 7 NA assignment sheets (forms carried by the NA staff for quick reference direction on the resident care plan) indicated R129 was continent, independent with ADLs and required a 1:1 which was spelled out in large bold print. On 5/12/14, at 10:26 a.m. DON was interviewed about R129 having obtained ETOH and/or drugs while on a 1:1. The DON verified the 1:1 should have been within arm's length of R129 at all times. The DON denied having any knowledge of how R129 had obtained ETOH. On 5/13/14, at 2:21 p.m. the administrator stated during interview that the facility lacked a system to ensure residents on 1:1 were supervised to ensure they were not neglected. The administrator verified a thorough investigation regarding resident access to illegal drugs while R129 was on 1:1 should have been completed and documented thoroughly. The administrator verified 1:1 staffing was a short term solution and was not a viable long-term intervention to address R129's drug seeking and ETOH use. On 5/12/14, at 2:43 p.m. contracted licensed social worker (CLSW)-A stated, I cannot imagine how a resident who was on 1:1 would get that much alcohol in her system and when I got here on Sunday I came to the office to open the computer to see what happened and guess what, there was no nursing notes. I went outside to the desk and told the administrator and director of nursing to get the nurse in to document and have the 1:1 fired. There are so many people here than I have seen on 1:1. For me 1:1 means the person needs to be somewhere else not at the nursing home. The Special Staffing - One to One Assignment policy dated as reviewed 5/2013, indicate 1:1 staffing may be assigned under special circumstances, must be prior authorized by the Director of Clinical Services (DCS) and One to One staffing assignments are not permanent but rather in place based on assessed need until appropriate permanent alternative arrangements can be made. The reasons identified for the 1:1 staffing included threat of suicide, altered mentation that may dislodge treatment lines and devices, escalating exit seeking behavior, altered cognition in an agitated state that is not easily redirected and does not respect boundaries of other residents. The procedure directed to assess the resident, DON and administrator to agree 1:1 was necessary and consult DCS; instruct staff assigned to 1:1 the purpose of assignment, and directed to keep resident at arm's length at all times. The procedure indicated if resident was not suicidal, privacy with toileting could be provided. The procedure directed to document the 1:1 assignment in the clinical record and revise the care plan. The facility Drug and Alcohol Free Facility Care Environment-Camden Specific effective 5/11/14, directed: If staff have reasonable suspicion that a resident has used, has in their possession, or has distributed to other residents in the facility ETOH, street drugs, or other pharmacological substances not prescribed by treating physician the facility staff, under the direction of administration, shall: ? Search the residents room and remove such substances ? Notify the physician and obtain an order for [REDACTED].>? Notify the family and/or responsible party of the event If the tests return positive the resident with the positive results will be immediately discharged for placing the resident population at risk for abuse. If ETOH, street drugs, or pharmacologic substances are found not prescribed by a physician during a room search the resident will be immediately discharged for placing the population at risk for abuse. If the substances found during a room search are suspected of being illegal the police will be notified. The facility's Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy reviewed January 2013, defined neglect as The failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Under item 6, the policy directed; Supervisors will immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. The policy also included Neglect means a failure to provide a vulnerable adult with necessary food, clothing, shelter, health care, or supervision. Appendix A of the policy included examples of neglect including: Failure of a caregiver to provide a resident with (or the absence or likelihood of absence of) care or services (e.g. food, clothing, shelter, health care or supervision) which are reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety. According to the record, R116 eloped from the facility on 5/11/14, at 9:30 a.m., 11:30 a.m. and 11:52 a.m. while wearing a WanderGuard device which had been implemented to prevent the resident's elopement. Record review indicated R116 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record also indicated R116 had Hospice services initiated on 1/21/14. On 4/15/14, at 10:49 p.m. a nursing progress note indicated, Pt (patient) is declining. He is very weak and needs a lot of assistance. A progress note dated 5/5/14, indicated R116 had been outside with his son and the resident had experienced a fall. R116's son was present at fall. Hospice was notified of fall and a new wheelchair (W/C) was ordered for resident. Staff had also placed a WanderGuard on the resident's chair to alert staff when the resident wanted to go outside to maintain resident's safety. Resident is allowed to go outside although staff needs to be alerted. Son is aware and in agreement with interventions. Nursing is to continue to monitor. Additionally, a draft progress note dated 5/5/14, at 10:47 p.m. indicated R116 had increased confusion. He requested going the bank to complete his transaction that he began earlier. He was leaning down to the floor to pick up of stuff which was apparently not there (visual hallucination). He was ambulating around getting out of w/c. Towards the end of shift he was on one to one rotation to prevent him from falling. A progress note dated 5/6/14, at 2:55 p.m. indicated R116 continued to sit at nursing station with staff due to attempts to self-transfer and unsteady gait. R116 was observed on 5/11/14, at 9:30 a.m. to be on the sidewalk west of the facility. The health unit coordinator (HUC) was bringing R116 back into the building. The HUC stated she had found him as she was driving into work. The HUC stated R116 had a WanderGuard on and she was surprised to find him walking outside since he was not able to walk every day. The HUC said she had called the facility and alerted them to the fact that R116 had left the facility and requested someone bring a wheelchair (w/c) to help bring him back to the facility. NA-R and safety

An immediate jeopardy related to administrative failures was identified during the revisit survey on 5/12/14. The immediate jeopardy began on 5/10/14 and was removed on 5/21/14. However, non-compliance remained at the lower severity level of F (wide spread with no actual harm). Based on observation, interview and document review, the administrator failed to provide adequate supervision and oversight for residents who had known drug and alcohol (ETOH) use for 2 of 11 residents (R37, R129). In addition, the administrator failed to provide adequate supervision to residents to prevent elopement from the facility for 1 of 3 residents (R116). These administrative failures resulted in Immediate Jeopardy (IJ) issues being identified at F490. In addition to the IJ issues, the facility was not administered in a manner to maintain compliance with other regulations specific to meet the needs of residents for 15 of 40 residents (R34, R129, R37, R116, R41, R70, R13, R117, R62, R56, R123, R22, R1, R36, R9) reviewed for various deficient practices; 3 of 5 employees (E1, E2, E3) reviewed whose annual evaluations were not completed; 1 of 5 nursing assistants (NA-Z) did not meet the required inservice hours; 5 of 11 employees (RN-C, RN-D, LPN-A, NA-U, NA-Q) did not have current license verification. These administrative failures had the potential to affect all residents of the facility. The following deficiency was cited during a revisit conducted on 5/13/14, and was the basis for an IJ to resident's health and safety. The IJ began on 5/10/14, when R37 was admitted to the hospital for acute [MEDICAL CONDITION] requiring medical treatment including intubation to assist with breathing. The administrator, consulting administrator, and director of nursing (DON) were notified of the IJ on 5/12/14, at 3:15 p.m. The IJ was not removed by exit of the 5/13/14 survey. Findings include: On 5/9/14, the facility had been informed of serious and immediate safety and supervision issues related to a lack of adequate supervision for residents, specifically related to resident's with known drug and alcohol use issues, and elopements. The facility had been informed these issues constituted an immediate jeopardy situation. Although, the facility was aware of the serious implications on 5/9/14, the facility did not identify and implement interventions to protect residents from potential harm. On 5/10/14 and 5/11/14, two residents were hospitalized for [REDACTED]. In addition, on 5/11/14, a vulnerable resident was able to elope from the facility on three separate occasions without staff present even though the facility had implemented a WanderGuard device. Refer to F223: the facility failed to ensure 1 of 1 resident (R34) was free from verbal and physical abuse. Refer to F224: the facility neglected to provide adequate supervision to residents who had a known history of drug and alcohol use resulting in medical treatment, including hospitalization , for 2 of 11 residents (R37, R129) reviewed. In addition, the facility failed to implement adequate interventions to prevent elopements for 1 of 3 residents (R116) who eloped from the facility with a WanderGuard (a system to alert staff when a resident leaves the facility) in place. This lack of supervision caused an IJ situation for R37, R129 and R116. Refer to F225: the facility failed to ensure incidents of potential abuse, neglect and mistreatment were immediately reported to the administrator and State agency (SA) for 7 of 7 residents (R129, R37, R116, R41, R10, R70, and R13). Refer to F226: the facility failed to ensure the facility reported allegations of potential abuse/neglect immediately to the administrator and State agency (SA) and to thoroughly investigate potential situations of abuse/neglect/elopement for 4 of 5 residents (R37, R129, R13, and R116); the facility failed to screen new employees for reference checks, back ground studies and license/certification verification for 5 of 5 newly hired employees (registered nurse (RN)-C, RN-D, licensed practical nurse (LPN)-A, nursing assistant (NA)-U, and NA-Q). Refer to F250: the facility failed to aggressively identify, assess, develop and implement interventions for medically-related social services, for residents known to provide and/or use illegal drugs and ETOH in the facility for 6 of 6 residents (R129, R13, R117, R41, R62, R37, and R9). Refer to F309: the facility failed to coordinate hospice services for 1 of 1 resident (R56) reviewed for hospice. Refer to F314: the facility failed to develop interventions for 1 of 3 residents (R123) identified with pressure ulcers on admission to the facility reviewed for pressure ulcers. Refer to F319: the facility did not ensure treatment and services were provided for chemical dependency for 1 of 1 resident (R37) identified as having concerns related to ETOH abuse. Refer to F323: the facility failed to ensure systems were in place to support patient care, and supervise staff. An IJ was identified on 5/9/14, for lack of supervision related to drug and ETOH use for R37, R129, R41, R117, and for the lack of supervision for residents who were at risk for elopements, R13. On 5/9/14 the administrator, On 5/12/14, at 2:51 p.m. the administrator and consultant administrator were notified that R116 was added to the IJ at elopement (F323). Refer to F353: the facility failed to provide adequate staff to prevent harm from occurring. In addition the facility did not retain the required staff schedule and was not able to provide documentation of staff schedules from 3/18/14 through 4/5/14. Refer to F492: the facility failed to ensure nurses and nursing assistants (NAs) from a supplemental nursing services agency (Soul Care) had the necessary screening and clearance for [MEDICAL CONDITION] (TB) before they were assigned to work. Refer to F497: the facility failed to provide annual performance evaluations for 3 of 3 employees (E1, E2, E3) reviewed for staff that have worked in the facility for greater than 12 months. Refer to F499: the facility failed to ensure license was verified for 2 of 3 licensed nurses (licensed practical nurse (LPN)-A and registered nurse (RN)-C and background check was completed for 1 of 3 nursing assistants (NA)-U before they were allowed to work. These had the potential to affect all 67 residents residing in the facility. Refer to F520: the facility did not ensure the quality committee met as required, and did not identify quality concerns, and did not develop/implement policies and systems to ensure quality of life and quality of care for 13 of 67 (R34, R37, R129, R116, R41, R10, R70, R13, R117, R62, R9, R56, R123) residents residing in the facility and 3 of 5 employees (E1,E2,E3) reviewed during the initial survey and 5 of 11 employees RN-C, RN-D, LPN-A, NA-U, NA-Q ) reviewed during the revisit. This had the potential to affect all 67 residents in the facility. A letter was provided to surveyors on 5/19/14 by an employee who wished to remain anonymous. The letter indicated that as of that date, the President and CEO of Videll Healthcare was informing employees that their healthcare benefits had ended on March 17, 2014. The letter stated that the LLC (limited liability company) would make an accounting of the monies deducted from individual checks and put together a plan to return the money as soon as possible. The letter encouraged staff to go the the healthcare.gov/marketplace to register for insurance. The letter further stated Videll continues to work with the insurer to put an alternative solution together. This letter had also been posted at the employee time clock. The IJ that began on 5/10/14, was removed on 5/21/14, when the facility had implemented an IJ removal plan which included the development and/or revision of policies related to obtaining a drug and alcohol free facility and policies related to prevention of elopements. The facility initiated assessments for reisdents who had been identified at risk for drug/alcohol issues and elopements; The facility also developed a system for investigation of ongoing incidents; Staff were educated to their responsibilities for how to supervise, care for and protect residents; Direct care staff and licensed nursing staff were interviewed and were able to explain their responsibilities for identification of residents who were elopement risk. Administration convened an interdisciplinary team meeting to discuss and determine how to effectively monitor resident safety and care needs, and how to prevent any future occurrence of such serious and immediate concerns. However, non-compliance remained at the lower scope and severity (s/s) of an F (no actual harm with potential for more than minimal harm that is not immediate jeopardy) because of the number of deficient practices that remained uncorrected at the time of the revisit 5/21/14.

Based on observation, interview and document review, the facility failed to aggressively identify, assess, determine interventions and implement the interventions for medically-related social services, and pursue the provision of these services for residents known to provide and use illegal drugs and alcohol in the facility for 4 of 11 residents (R129, R86, R41, R37) who sustained harm due to lack of social services interventions; for 5 of 11 residents (R14, R56, R117, R62, R9) for alleged substance abuse, and for 2 of 11 residents (R13, R103) who allegedly eloped from the facility. Findings include: Alleged substance abuse: On 5/8/14, at 8:02 a.m. a list of residents allegedly bringing drugs and alcohol (ETOH) into the facility, as well as a list of residents known to use drugs or alcohol in the facility was requested. A list provided by the administrator at 11:00 a.m. included R129, R86, R41, R37, R14, R56, R117, R62 and R9 as alleged substance users. R129 was not provided consistent medically related social services to address ongoing drug seeking behaviors and sustained harm. Although R129 was assigned a one to one (1:1) as of 3/14, the clinical record lacked evidence of social service assessment and interventions. On 5/3/14, R129 reported to facility staff, that she had obtained and consumed cocaine while under 1:1 supervision. On 5/11/14, at 4:00 a.m. R129 had obtained and consumed ETOH while supervised 1:1 by facility staff. This resulted in harm when R129 required hospitalization in an intensive care unit (ICU) where she was intubated (mechanical ventilator assisted breathing) for a blood ETOH level of 0.323. R129's admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS--a tool to determine cognitive status) score of 15, indicating the resident was cognitively intact. In addition, it was noted R129 was independent with all activities of daily living (ADLs), rejected cares, and wandered 1-3 days during the assessment period. R129's Care Area Assessment (CAA) for mood state dated 2/7/14, identified R129 displayed poor judgment, and had impaired cognition and poor decision making skills. The CAA identified [DIAGNOSES REDACTED]. Although the history of drug and ETOH dependence was identified, the CAAs lacked documentation of interventions to promote sobriety, such as but not limited to offering chemical dependency (CD) treatment. The Vulnerable Adult Assessment (VAA) dated 3/18/14, identified R129 had a history of [REDACTED]." R129 was identified as being susceptible to abuse related to substance use and required supervision with leaves of absence (LOAs) from the facility. It was noted R129 had a history of [REDACTED]. R129's Smoking Evaluation dated 3/18/14, directed staff to "monitor for ETOH use or over sedation." A Pain Evaluation and Management Plan dated 5/1/14, identified R129 had daily chronic pain, and a history of pain and seeking drugs. "Resident is on a restricted recipient program (where only one pharmacy may fill narcotic prescriptions to deter drug seeking behavior) due to drug seeking...MD (medical doctor) is aware of drug seeking behaviors and aware pain is not controlled. MD will not order any more pain medications for resident due to her drug seeking behaviors. Resident is on the restricted recipient program due to drug seeking." An Incident/Accident Report dated 5/3/14, at 11:00 p.m. indicated R129 "told the nurse that she took cocaine earlier during the shift." R129 was described as "very sweaty, weak and tired...she looked very sleepy," and pupils were "large and nonreactive to light." When the nurse asked the resident what she'd taken, she "confessed" to taking cocaine. The report noted, "She said, 'I knowingly took cocaine'...Resident has been sent to ER (emergency room ). She will continue to be on 1:1 when she returns to the nursing home." The resident's history of drug use and receipt of drugs from others was noted, as well as the fact that the resident had current 1:1 staffing. Although the incident occurred on 5/3/14, the form was signed by the director of nursing (DON) on 5/5/14. An Emergency Department Chart (from the hospital ER) dated 5/3/14, identified R129 reported to have taken cocaine while residing at the facility to "help with the pain" in her abdomen. "Patient (R129) is triaged directly back to ED (emergency department)." The Clinician History of Present Illness section of the form identified R129 reported to hospital staff she snorted cocaine "'5 hours ago.'" Although R129 was identified as requiring the ER for a potential drug overdose, the Emergency Department Chart did not address the cocaine use, only pain. The laboratory (lab) reports indicated various pertinent lab values were checked, but lacked a toxicity screening for cocaine, drug or alcohol use. R129 was given two doses of Dilaudid (narcotic pain medication) and returned to the facility at 6:00 a.m. with no new orders. The clinical record lacked evidence the administrator, or the designated State agency (SA) were notified of the incident. The clinical record lacked evidence of new interventions to address R129's report of drug use, such as CD treatment. In addition, the clinical record lacked evidence the use of cocaine by R129 was investigated to determine how the drug had been obtained while the resident had 1:1 staff supervision. A unlabeled typed page insert in the front of R129's paper chart dated 4/15/14, read "If Res (resident) goes to the Hospital for any reason she is to go to St. Joes (sic) Hospital Only per primary care MD and the MN (Minnesota) restricted recipient program...All scripts (prescriptions) no matter where they come from must be approved by (MD's name) or their on call MD." On 5/7/14, at 10:24 a.m. the a return call was made to the ombudsman who had requested contact. The ombudsman stated she had been informed by a nurse of the facility of "drug use" and "drugs shared with residents" at the facility "a couple days ago." The ombudsman stated rather than call the nurse back, she visited the facility on 5/6/14, and spoke with various residents as well as management staff regarding drug, alcohol and discharge planning concerns. The ombudsman, facility staff, and residents were "suspicious residents may be giving money or credit cards to another (resident) to go out and purchase things (cigarettes, alcohol and drugs) for them." The ombudsman stated the police had been notified and responded "quite often." Allegedly residents who were chemically dependent were drinking in their rooms and facility staff were conducting room checks each shift and "finding empty alcohol (vodka) bottles" in resident rooms, and residents had been found "intoxicated." The ombudsman specifically reported R129 had 1:1 staffing, yet had "somehow" obtained and consumed an illegal drug (cocaine). Although the facility had employed "three temporary social workers, social services is overwhelmed" due to "no policies and procedures in place." R129's care plan for safety/vulnerability dated 3/25/14, identified the resident was able to make her needs known, but was vulnerable due to her history of opioid abuse and drug seeking behavior. A care plan intervention dated 4/11/14, directed staff to provide "1:1 supervision at all times to keep (R129) safe and prevent drug use" Additionally, the care plan directed, "1:1 to discuss CD concerns, encourage (R129) to consider going to a treatment facility." The care plan for mood/behavior dated 3/25/14, identified, "I have a history of opioid abuse and I exhibit drug seeking behavior as evidenced by attempting to see several different MD's to obtain prescription medication. I have a history of walking into other residents rooms and looking thru (sic) their personal belongings." Review of the undated Group 7 nursing assistant (NA) assignment sheet (for quick reference guide providing care-related direction) indicated R129 was independent with ADLs and "1:1" was noted in larger bold print. Pertinent Nursing Progress Notes read as follows: 1) On 3/14/14, at 6:18 p.m. R129 "had an appointment yesterday and was immediately transferred to the hospital...while on the way home (unclear on prior destination) stopped at Cub foods" and picked up a prescription for eight tablets of Norco 5/325 milligrams (mg) (a narcotic and Tylenol pain medication)...failed to alert staff and stated that there were no new orders." The hospital, on call MD and triage nurse were updated on R129's "history of narcotic use." 2) On 3/16/14, at 6:34 a.m. R129 was "caught going through another resident's belonging...opening her purse." The note indicated R129 admitted going in the room but denied taking "any money." 3) On 3/17/14, at 3:34 p.m. "Resident still remains on 1:1 observation." Although the note identified R129 was assigned a 1:1 staff, the record lacked documentation when the 1:1 staffing was initiated. At 10:17 p.m. "called on call (physician)," reported two incontinent episodes, "lower extremities (sic) hurts" and edema (abnormal build up of fluid in the tissues). Was encouraged to "sit and rest the leg" but refused and reported the pain was "unbearable." R129 wanted to be evaluated at the hospital, and "called 911 herself." Although a previous note indicated R129 required 1:1 staffing, it was noted R129 planned to "take care of her own transportation to ER...left the facility" at 10:20 p.m. The note did not indicate if a staff person accompanied R129 to the appointment. 4) On 3/18/14, at 3:56 a.m. R129 returned from the ER at 3:30 a.m. with a "New order. No new concern at this time." At 2:31 a.m. R129 reported to the business office manager she felt "depressed due to being on a 1:1." The concern was reported to social services and the nurse on duty. 5) On 3/20/14, at 10:08 a.m. the physician R129 identified as her new primary care physician (PCP) was contacted to inform the provider R129 lived in a health care facility, and orders needed to be coordinated with the facility. The PCP was provided an update regarding R129 changing her PCP, trips to the ER and drug seeking behavior. The note further indicated, "Transport informed to bring pt (patient) to/from the clinic and no other stops to include the pharmacy." At 2:45 p.m. R129 "Went for her appointment to her care provider today. At the appointment, resident was given script for Ambien (hypnotic used to promote sleep). "Resident said she filled the prescriptions at the pharmacy but she misplaced the pills. Patient will be monitored for increased sedation." Although the previous note indicated the transportation company was directed not to make any stops during transport, R129 had been brought to the pharmacy. At 3:11 p.m. a note indicated R129 reported she "lost" the Ambien. The note indicated the "escort" assigned to go with R129 to the appointment, reported R129 "went to the pharmacy and filled her script." The escort reported R129 would not allow the staff to "see the script" or the filled prescription. "Per the escort (R129) went to the bathroom. On the ride home (R129) reported that she lost the bottle of pills. Upon return she reported that same story to this writer and requested that staff get a new script." The physician was contacted and verified a prescription had been written and a report the script was lost had been reported by R129. The physician denied taking R129 on as a patient, however, and referred the facility to R129's current PCP. 6) On 3/28/14, at 11:52 a.m. R129 met with social services and "Also spoke with resident regarding her drug seeking. (R129) admits that she is addicted to pain medication." The note indicated R129 was scheduled to see psychologist and encouraged R129 to discuss her concerns and her "addiction." 7) On 4/4/14, at 7:11 p.m. R129 met with psychologist, as well as the DON and social worker after the appointment. The note indicated R129 "does not like being on 1:1's...informed her she was on 1:1's because of her frequent drug seeking...admits that she has urges to seek medications to manager her pain...denies addiction." Inpatient treatment was discussed such as drug and emotional counseling, which R129 rejected. The note indicated the psychologist agreed with the need for treatment, "However, should resident continue to display behaviors of drug seeking and declines treatment a CD commitment maybe considered to be in her best interest." 8) On 4/7/14, at 10:47 a.m. R129 remained, but requested she be removed from 1:1 supervision, which was noted as required "for going into other resident rooms." 9) On 5/4/14 12:03 a.m. R129 "told the nurse that she took cocaine earlier during this shift." The note recapitulated the data from the incident report dated 5/3/14. "The nurse asked the resident what she had taken and where she got it from or (who) gave it to her. She took the nurse to (R1's room number). She also report that the package that resident in room (R14's room) swallowed earlier was marijuana." R129 accepted to to the ER for evaluation. "The nurse requested for toxicology screen and a copy should be send (sic) to the nursing home per the administrator order." Although the note indicated R129 obtained cocaine from another resident and identified R129's involvement with a second resident and a different illegal drug, the clinical record lacked evidence law enforcement was notified,and toxicology screening was obtained. Although R129 had an assigned 1:1, the record lacked evidence as to how the resident obtained and ingested the drugs, the incident was not immediately reported to the administrator and SA, nor was it investigated. In addition, the record lacked evidence R129 had received a CD evaluation or were immediate changes made in the monitoring and supervision provided for the resident's safety. At 7:23 a.m. a corporate nurse documented R129 approached the nurse and "admitted to writer that she took drugs given to her by another resident in this building. She was able to verbalize insight related to why she regretted this choice...remains on 1:1. 1:1 was present during this conversation." The clinical record lacked evidence 1:1 monitoring of R129 was reviewed after being identified to have accessed illegal drugs twice while on 1:1 monitoring. 10) On 5/4/13, at 12:12 p.m. an attempt was made to notify R129's doctor regarding the incident from 5/3/14. The operator at the doctor's office informed writer that they were only accepting on-call emergencies. Staff would notify doctor the morning of 5/5/14. The resident returned from the hospital at 6:00 a.m. with no new orders. Although R129 had two doses of Dilaudid administered at the ER, she immediately requested pain medication upon return to the facility (the note was not closed or signed by the writer). On 5/5/14, during the initial tour of the facility NA-K was observed to be sitting in a chair directly outside R129's room. The door was open and R129 was dressed and was lying in bed with her eyes closed. NA-K reported she was assigned as a 1:1 for R129. NA-K stated she needed to remain with R129 and the 1:1 was due to R129 going into "other resident rooms." The following day at 8:30 a.m. NA-M (1:1 staff) followed R129 down the hallway and out to the smoking patio. R129 retrieved a cigarette from her front pocket, lit the cigarette and replaced the lighter in the side pocket (right). NA-M stood on the side walk outside the designated smoking area with a large cinder landscape block planter between R129 and NA-M. NA-M remained out of arm's length and looking in the opposite direction from R129 and talked with another staff person in the smoking area. R129 stood with other residents and smoked out of direct sight of NA-M. At 8:33 a.m. R129 sat on a bench with another resident on the other side of the smoking patio and out of sight of NA-M. NA-M stood on the edge of the cinder landscape block planter edge and chatted across the smoking area to the same staff person. NA-M was not near enough to R129 to intervene should there have been a concern. At 8:37 a.m. staff spoke to each other and then NA-M turned his back on all smokers (including R129) and spoke to a male who was in a car in the parking lot. NA-M then jumped down and entered the smoking area to speak to the staff directly. NA-M was not within arm's length or direct eye sight of R129. At 8:38 a.m. R129 stood up and walked to the front entrance of the facility. NA-M jumped to catch up with R129 and followed directly behind her into the facility. R129 then pushed the wheelchair of a male resident entering the building and walked rapidly down the hallway. At 9:34 a.m. R129 pushed R62 in her wheelchair out of the facility and onto the smoking patio. R62 held out a cigarette for R129 ask she pushed the chair, and R129 concealed the cigarette. NA-M followed behind R129 and did not appear to notice or intervene when R129 took the cigarette. NA-M immediately turned his back to R129 once on the smoking patio, applied a surgical mask and talked to the female staff assigned to monitor the smoking patio. Both staff had their backs to R129. At 9:35 a.m. a staff pushed R22 back into the facility and pulled the smoking cart behind her. NA-M remained outside with R129 near the smoking patio watching a van in the parking area. NA-M had his back to R129 and was approximately 14 feet away from R129. Multiple other residents were observed to come and go from the smoking patio. R129 interacted freely with the other residents who were unsupervised. At 9:37 a.m. R117 came out of the facility, lit a cigarette at the front entrance, jumped up onto the cinder landscape block planter with ease, and walked across the top of the planters with a skipping gait. Neither the smoking monitor nor another female staff in the area intervened. R117 was observed to speak briefly with the female smoking monitor, approached R36, pulled out a large wad of cash and exchanged money with R36. R117 then went to R129 and R62. R117 remained with both residents smoking and talking. R129 sat on the edge of the cinder landscape block planter. NA-M was not within arms reach nor eyesight of R129, and was not supervising the resident. NA-M remained with the other female staff, with his back to R129. At 9:40 a.m. R129 stood and pushed R62's wheelchair towards the front entrance of the facility. Although NA-M followed, NA-M did not come into arms reach of R129 until the front door of the facility. R129 pushed the wheelchair down the hallway with NA-M walking beside R129. At 10:19 a.m. R120 walked out to the designated smoking area. NA-M followed approximately ten feet behind outside, then stood on the sidewalk. NA-M then left the area and returned into the facility. R129 retrieved a cigarette from a pack. Multiple residents were observed to be coming out to smoke. The smoking monitor was on the patio but did not watch R129. R129 sat on planter side and spoke with R14. At 10:23 a.m. NA-M returned to the smoking area from inside and immediately stood on sidewalk on other side of planter approximately 20 feet away from R129. NA-M made no attempt to make eye contact with R129 and was not in arms reach as he spoke with the smoking monitor. At 10:25 a.m. NA-M and R129 went inside with NA-M walking within arms reach of the resident. On 5/8/14, at 11:22 a.m. R129 was observed lying in bed, NA-E was making the roommate's bed. NA-E verified she was assigned to be the 1:1 with R129. NA-E offered to stand outside the door while R129 was interviewed and the door to the room was closed. R129 stated she was waiting for an apartment and verified she "snorted cocaine" on 5/3/14, which she had reported to facility staff. When asked when this occurred, R129 stated it was "on Saturday" (5/3/14)." When asked where she snorted the the cocaine, R129 replied, "not in the facility...down the block." When asked if she received the cocaine from another resident (as indicated in the clinical record), R129 stated "someone from the street" gave it to her, but denied being able to remember the person's name, description, or gender. R129 said she snorted "about $20 worth." When asked what happened then R129 stated, "They sent me to the hospital...They accused me of giving it to someone else." R129 explained she was accused of giving R14 cocaine on the same day by the 1:1 assigned to her that day. R129 stated the 1:1's name (NA-G) who was to be with her at all times. She said the reason for the 1:1 was because she was accused of "rummaging" in other residents rooms. R129 reported she had a 1:1 was assigned to be with her "since March." When asked where the 1:1 was when she received the cocaine from the person on the street, R129 shrugged looked up and away and stated, "I don't know. She wasn't with me." R129 said she was "a recovering addict," but denied social services had been provided by facility staff, including assistance to obtain CD treatment. R129 stated she would like to go to outpatient rehabilitation for drug addiction. R129 further added she was "not checked" for cocaine use at the ER, but was given two shots of Dilaudid. R129 explained she "thought" that was going to happen, yet admitted she was "surprised" to have received the narcotic pain medication. Although R129 was relaxed during the interview, she was hesitant to answer some questions and did not make eye contact. On 5/8/14, at 11:30 p.m. NA-G verified the responsibility of the 1:1 staff was to remain at arms length with R129 at all times. On 5/8/14, at 11:41 a.m. NA-J verified she worked on R129's unit and stated was unaware of alcohol or drugs were being exchanged on "my shift," but stated was aware of situation "weeks ago" when she came to work and noticed R14 was not in his room. NA stated she asked where he was and a NA "who was (R129's) 1:1" saw R129 go into R14's room and "exchange something." She stated she learned R14 was sent to the hospital for "eating something." Stated had not witnessed any exchanges and stated if she had she would have reported it to the nurse. On 5/8/14, at 11:40 a.m. NA-S reported seeing alcohol bottles in residents' rooms and smelled alcohol on a resident and reported it to a nurse, but was unclear when it had occurred. NA-S "heard rumor" of a resident dealing drugs in the facility, and recalled seeing a resident with marijuana in January or February, and "could smell it." NA-S further stated when she was assigned to be the smoking monitor, she overheard residents talk about it. NA-S believed R117 was a drug dealer, as the resident left the facility "a lot" and went to the gas station. NA-S further stated she believed R117 was talking money from residents to also "buy cigarettes." NA-S stated she was unclear what happened to the resident after she reported the marijuana, but stated the nurse was from an "agency" and told her the resident "could have it." On 5/8/14, at 11:55 a.m. housekeeper (H)-A when asked, reported she had seen "empty pint bottles" of vodka in the trash by the front doors. The last time had been, "a few months ago," and she had reported any bottles she found. " H-A was unsure which resident was drinking, but believed the pint bottles were placed in the front trash so they "wouldn't get caught." When asked if H-A knew how the bottles had been obtained, she was unsure, but thought they may have been brought in by family members. On 5/8/14, at 12:03 p.m. LPN-H stated she had confiscated alcohol from R37. LPN-H verified alcohol was provided to R37 and suspected to other residents of the facility, as well, but it was unclear how it was being provided. LPN-H verified R129 was on 1:1 which meant within arms reach. LPN-H was unaware R129 had obtained cocaine in the facility. On 5/8/14, at 12:10 p.m. the health unit coordinator (HUC) stated she was aware of resident drug and alcohol use in the facility. The HUC stated there was "always hearsay between residents...their selling (drugs and alcohol) to each other...it's always stories," including hearsay stories regarding heroin and cocaine. The HUC had put "a lot of time in" reporting to hospitals, clinics and ER if a resident was a "drug seeker" and on restrictive recipient program, and R129 was going to ER, calling herself and getting Ambien, oxycodone and "is happy after." R129 "refuses to tell" about the prescriptions, and the HUC went to the social worker to report these concerns. R129 denied having pills, "but I know she did get them...every week" R129 was finding a new doctor, and not providing the correct paperwork, or altering paperwork. The HUC was aware residents consumed alcohol in the facility, and some became intoxicated, however, it was unclear how they had obtained it. "I feel like we're supposed to do something, 'cuz no one will take charge." The HUC was aware R129 obtained cocaine and was sent to the ER, but was unsure if a toxicology screen had been done, although she had asked for them in the past. The HUC said she and other staff believed R129's (making quotation gestures) "son" was R129's dealer, and described him as a man she referred to as her son, who was at the facility at the time the resident snorted the cocaine. Further review of the nursing progress notes also revealed indicated the following: 1) On 5/9/14, at 7:31 p.m. the pharmacy was contacted regarding R129's Percocet (narcotic pain medication) refills and determined 110 Percocet tablets had been delivered and outlined the delivery dates and the amounts provided. The note indicated R129 was informed of the information. 2) On 5/11/14, at 10:09 a.m. a note written by the HUC indicated North Memorial Medical Center (NMMC) called "requesting" R129's Medication Administration Records (MARs). The note indicated the RN from the hospital notified HUC R129 had been admitted to the ICU, had been intubated "due to acute alcohol intoxication." R129's toxicology screen was "negative for drugs but positive for alcohol with a level of .323." Although R129 had a staff person assigned as 1:1, R129 had been able to obtain and ingest a life threatening amount of alcohol. Although the administrator was updated, the clinical record lacked evidence the SA was also immediately notified of the incident. The record lacked documentation at the time of the incident, as well as pertinent assessment information such as vital signs and symptom descriptions. In addition, the record lacked evidence of an immediate determination of how, when or where R129 obtained the alcohol and/or if the assigned 1:1 was interviewed at the time. 2) On 5/11/14, at 10:55 a.m. a note written by the DON, recapitulated R129 was sent to the hospital, identified the time of transport as "around 4 am" on the night shift, and identified R129 was sent in "for intoxication." R129 had "become weak" and needed to be lowered to the floor." Two LPNs were contacted and the NA staff assigned to the 1:1 was called. The NA assigned to R129 "reported that resident has been in and out of (R14's room number) but did not notice any exchange of alcohol. She also reported that resident (R14) was upset because the 1:1 has to be in his room too while resident is visiting...." R14 denied giving R129 alcohol, but "mentioned that resident had alcohol overnight." R14 denied knowledge of where R129 could have obtained the alcohol. 3) On 5/11/14, at 2:49 p.m. a note written by DON indicated NMMC was contacted to receive updates on R129's status. "I also requested to have the resident undergo a chemical dependency assessment to ensure that the resident can be transferred to a residential chemical dependency facility as appropriate, considering the resident's recent hospital trip to the hospital for snorting cocaine." 4) On 5/12/14, at 12:07 a.m. a late entry note (no indication for the date or time the late entry was for) indicated an NA staff "report to this writer that resident was in the bathroom longer than usual, came out and appeared drowsy, unsteady gait." R129 was identified at risk for falling, was verbally aggressive to staff and stated, "'I'm drunk.'" The room was checked and no evidence of alcohol was found. R129 "threw herself to the floor" and was sent to the ER at 4:00 a.m. On 5/12/14, at approximately 2:00 p.m. contracted licensed social workers (CLSW)-A and CLSW-B both verified upon hire to the facility, they had been working on "re-writing care plans and discharge planning." CLSW-A stated there was a third social worker who no longer came to the facility and a part time social worker on evening that was "reducing her hours to once a week." Both verified they had not specifically worked with R129 regarding CD treatment and verified was last offered to R129 on 4/4/14 and had not revisited CD treatment options after R129 reported cocaine use on 5/3/14. Neither was aware R129 had been hospitalized for [REDACTED]." CLSW-A and B had not worked the previous few days, as facility had not paid the contracted company's bill. CLSW-B expressed concern for the residents, and said R129 should have been reassessed after she had obtained and used cocaine, and both SWs felt R129 had been harmed. At 2:43 p.m. CLSW-A stated, "I cannot imagine how a resident who was on 1:1 would get that much alcohol in her system and when I got here on Sunday I came to the office to open the computer to see what happened and guess what, there was no nursing notes. I went outside to the desk and told the administrator and DON to get the nurse in to document and have the 1:1 fired. There are so many people here than I have seen on 1:1. For me 1:1 means the person needs to be somewhere else not at the nursing home." R86 was committed as mentally ill and chemically dependent per Hennepin County Commitment papers dated 3/12/13, to include admission to a nursing home for rehabilitation and when completed and/or mentally stable, again participate in chemical dependency treatment. The facility Resident List Report, provided 5/8/14, at 11:00 a.m. identified R86 as a known pot smoker. R86 was placed at harm as R86 was hospitalized due to alleged substance abuse. On 3/16/13, R86 was admitted to the facility per the Admission Record. [DIAGNOSES REDACTED]. A care conference dated 1/2/13 (sic -2014), lacked mention of commitment to facility for chemical dependency and mental illness, or need for treatment when stable. A progress note dated 2/22/14, at 11:00 p.m. "Pt was found smoking 'pot' in his room. The nurse discussed the disadvantages of smoking in the room including fire hazard. The administrator was informed via text messaging and incident report filled out." A progress note dated 2/23/14, at 10:33 a.m., "Resident left with family member in a VAN for unknown destination at this time, hoping to return today. We will follow up with resident safe returned." A progress note dated 2/23/14, at 10:23 p.m., "Resident returned from visiting with a family. The nurse checked resident. No injury observed." A progress note dated 2/24/14, at 4:38 a.m., "Resident had been very confused and having difficulty to settled (sic) down in bed. judgment (sic) has been non-intact (sic) and appeared restless with a lot of tremor. He attested to this writer that when he goes LOA he smokes marijuana but never drink alcohol at all. He state (sic) "If I drink I will die". His platelet has been dangerously lower (sic) thus posing him at a risk for bleeding. Update on call doctor about resident change in condition, who then mandate this writer to send resident to the emergency room for thorough evaluation at this time. Meanwhile, writer had been trying to touch base with family members but unable. We will continue to follow up with his condition. " The resident was admitted to the hospital. A progress note dated on 2/24/14, at 3:32 p.m., " Writer called PCP and updated on his current use o

Based on observation, interview and document review, the facility failed to provide repositioning, comprehensively assess skin risk factors, assess and notify the physician of new pressure ulcer development in a timely manner and provide pressure redistributing devices in the wheelchair for 1 of 1 resident (R64) reviewed for pressure ulcers. R64 experienced actual harm due to development of two stage II pressure ulcers (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). Findings include: R64's current [DIAGNOSES REDACTED]. R64 was admitted on [DATE]. R64's annual Minimum Data Set ((MDS) dated [DATE], identified that a Brief Interview for Mental Status (BIMS-tool used to measure cognition) score was unable to be completed. R64's cognitive skills for daily decision making were severely impaired and R64 was rarely/never understood. R64's transfer ability was scored as a total dependence with a two person assist. R64 did not have any existing pressure ulcers recorded on the MDS. R64's Care Area Assessment (CAA) for pressure ulcers dated 2/11/14, revealed the resident was at risk for pressure ulcers due to pressure, needs special mattress or seat cushion to reduce or relieve pressure, immobility, altered mental status, cognitive loss, poor nutrition, incontinence, [DIAGNOSES REDACTED]. Care plan considerations included resident had no changes, will continue with the same care plan. R64's Skin Care Plan, dated 11/14/11, revealed R64 had no skin impairment. R64's Pressure Ulcer Care Plan, dated 11/14/11, revealed potential for pressure ulcers related to decreased sensory perception, incontinence, chairfast, immobility, at risk for shear and friction, cognitive impairment and requires assistance with activities of daily living (ADLs) pain, [MEDICAL CONDITION] drug use and aspirin therapy, [MEDICAL CONDITION], hypertension (HTN) and dementia. Goals included R64 would have intact skin, free of redness, blisters or discoloration through next review date. Interventions included weekly skin checks per facility policy, turning and repositioning every two hours and pressure redistributing device on bed and chair. R64's ADL Self-care Performance Care Plan, dated 11/14/11, identified R64 required assistance of two staff and an EZ-stand (a type of standing lift) for transfers and a Hoyer (full body lift) if the resident was weak or combative to be moved. Review of R64's electronic and hard copy clinical record dated 3/14/14, going back three months, lacked wound documentation or any progress notes indicating the presence of open areas on the scrotum. There were no documentation notes that the open areas had been reported to a physician or family. In addition, the chart lacked assessment documentation to define risk factors for development of pressure ulcers and the rationale for the current repositioning schedule. The facility nursing assistant (NA) worksheet for the south hallway, undated, indicated R64 should be checked and changed every two hours and PRN (as needed). Additionally, the worksheet indicated R64 was an EZ-stand with assistance of two staff, OK to use Hoyer lift if resistive; wheelchair, non-ambulatory. On 3/13/14, at 7:56 a.m. R64 was observed to have been assisted with cares by nursing assistant (NA)-D. The surveyor observed two open areas on the bottom of R64's scrotum. NA-D stated during the observation that he had told the nurse about the openings. After the surveyor inquired about the open areas, NA-D applied Remedy [MEDICATION NAME] (a type of antifungal barrier cream) to the sites. NA-D applied a clean incontinent brief. NA-D proceeded to dress R64's lower extremities and left the room briefly to obtain assistance to transfer R64 into their wheelchair. On 3/13/14 at 8:19 a.m., R64 was observed to be assisted by NA-D and NA-B into their wheelchair, which was observed to have a thin cloth covering over a mesh-webbing type seat. NA-D and NA-B used a standing lift to complete the transfer. No pressure redistribution cushion was present in R64's wheelchair. Continuous observations of the resident from the time of the transfer into their wheelchair at 8:19 a.m. through 11:00 a.m. on 3/13/14, revealed that R64 was not repositioned by facility staff. During interview with licensed practical nurse (LPN)-D on 3/13/14, at 8:55 a.m., LPN-D reported that any skin conditions should be documented on the wound flow sheets and stated LPN-A had those documents. At 9:11 a.m. LPN-A was interviewed and stated that R64's bath was scheduled yesterday and that there should have been a skin audit done. At that time, LPN-A began flipping through a three-ring binder with the skin audit sheets, and commented to LPN-D (also present) that she needed to complete her documentation on the skin conditions. Several skin audit sheets were observed with LPN-D's signature but no documentation of the skin condition was recorded on the forms. A skin audit sheet dated 3/14/14 by LPN-C, (LPN-A stated this should have been dated 3/12/14), indicated R64's skin to the coccyx and perineum was intact. LPN-A said any areas other than pressure ulcers would be documented in the progress notes on the electronic chart. On 3/13/14, at 11:00 a.m. LPN-B was observed to ask two nursing assistants, NA-C and NA-B, to reposition R64. At 11:05 a.m., two hours and 46 minutes after R64 had last been transferred into his chair, NA-C and NA-B attempted to assist R64 into bed utilizing the standing lift. R64 was unable to hold onto the lift handles and pulled his hands away from the lift. LPN-B entered the room and attempted to assist, however staff were unsuccessful as R64 could not hang onto the standing lift handles. R64 remained in the wheelchair. During an additional observation, at 1:25 p.m. on 3/13/14 NA-A and NA-D again attempted to transfer R64 into bed using the standing lift. R64 initially had difficulty holding onto the lift handles and then began to hold onto the lift frame long enough for R64 to be moved from the wheelchair into bed. R64 was noted to have two open areas on the scrotum. NA-D told the surveyor he had seen the open areas and informed a nurse of the areas, stating this had happened a week ago. NA-D further said the usual facility practice was not to reposition R64 every two hours, but that R64 was usually laid down after lunch. At 1:32 p.m., the surveyor informed LPN-D of the open areas on R64's scrotum. LPN-D went with the surveyor to observe the areas, and said she thought they were from incontinence of bladder. Two distinct irregularly shaped, elongated open areas with a pinkish-red wound base were observed. There was a superficial loss of skin over the areas. On 3/14/14, at 7:22 a.m. licensed practical nurse (LPN)-A was observed to measure the open areas on R64's scrotum. LPN-A identified them as a single 4 centimeter (cm) x 2 cm superficial area, LPN-A said they were two areas that looked like they had merged into one large area. LPN-A felt they were related to incontinence or potentially from sitting on the area and getting pinched. LPN-A was observed to apply Remedy [MEDICATION NAME] (a type of antifungal barrier ointment) around the open areas. A skin audit sheet documented by LPN-C dated 3/14/14, (which LPN-A indicated should have been dated 3/12/14), indicated R64's skin on the coccyx and perineum was intact. LPN-A said any areas other than pressure ulcers would be documented in the progress notes on the electronic chart. Review of R64's progress note documentation identified a lack of wound documentation or any progress notes indicating the presence of open areas on the scrotum. A progress note entered by LPN-A dated 3/14/14, at 8:06 a.m. revealed R64's hospice agency had been informed of the open areas to R64's scrotum to inquire into treatment. Nursing progress notes by LPN-D dated 3/14/14, at 8:47 a.m. revealed an order was received for a physical therapy evaluation and treatment for [REDACTED]. On 3/14/14, at 10:34 a.m. the director of nursing (DON) observed R64's open areas with the surveyor. The DON stated the open areas appeared to be pressure related, and might be aggravated by incontinence. The DON stated she would classify the sites as two separate stage II pressure ulcers (a type of pressure ulcer characterized by partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough - may also present as an intact or open/ruptured serum-filled or serosanguineous filled blister). The DON stated the measurement of the first area was 2.5 cm x 1 cm with clearly defined borders that were irregular in shape. The second area had measurements of 1.5 cm x 2.4 cm. The wound bases were noted to be whitish in color, a change from the previous observation that morning. Hospice LPN-F was also present at that time and concurred with the DON's impression. LPN-F confirmed that R64's brief was soiled with urine, and registered nurse (RN)-D who was also in the room, stated the resident had not been repositioned since before breakfast. RN-D confirmed that R64 typically does not lie down until after lunch and stayed in the wheelchair until then. The DON asked hospice LPN-F about the resident's wheelchair cushion, indicating it felt "pretty firm." LPN-F said she thought the chair was pressure redistributing, but would check on the literature from the manufacturer. The DON said R64 needed to be repositioned at a minimum now of hourly and new assessments needed to be started. The hospice agency medical supplier's information on the wheelchair, entitled Benefits of the "Judy" Chair, undated, indicated the wheelchair provided superior pressure mapping to that of similar wheelchairs, however did not specify the seat of the chair in and of itself constituted a pressure redistribution device. The facility policy entitled Skin Integrity Management, dated 5/12, directed skin integrity risk assessments should be completed on admission and at least quarterly. The policy further directed that the director of nursing services (DNS) was responsible to ensure a valid skin at risk tool is used (Braden Scale or Norton Plus Pressure Scale is required). The policy further identified the goal of any skin integrity process is to provide safe and effective care to prevent and/or treat pressure sores or skin issues, maintain function and improve quality of life.

Based on interview and document review, the facility failed to develop interventions for 1 of 3 residents (R123) identified with pressure ulcers at the time of admission to the facility. Findings include: R123's Hospital Nursing Progress Note dated [DATE], indicated R123 had three pressure ulcers which were connected to continuous [DEVICE] (vac) suction and the dressings were intact. The pressure ulcers locations and stages were not identified. R123 was admitted to the facility on [DATE], and deceased on [DATE]. R123's [DIAGNOSES REDACTED]. Admission Nursing assessment dated [DATE], indicated a full skin assessment had been completed and a right hip pressure ulcer area with measurements 6.5 centimeters (cm) length (L) x 3 cm width (W) x 2.2 cm depth (D) and 2.5 cm tunnel at 6 o'clock position, right buttock with measurements 4.6 cm (L) x 2.0 cm (W) X 0.0 cm (D) cm and right heel area measured 1.2 cm (L) x 1.0 cm (W) x 2.0 cm (D) had all been identified. The form did not indicate if the areas were pressure related nor were the areas staged. Progress Notes dated [DATE], indicated a full skin assessment had been completed with measurements as noted on the Admission Nursing assessment dated [DATE]. On the right hip area a wet to dry dressing had been removed and wound bed consisted of moist yellow, pink, red tissue with moderate amount of yellow, red odorless drainage were observed and the surrounding wound tissue had no redness, warmth, or tenderness noted and wound vac dressing had been applied. On the right buttock foam dressing had been removed from with wound bed consisting of dry pink and red tissue, no drainage, no redness, warmth, or tenderness noted to the tissue surrounding the wound and non-adherent dressing applied. On right heel foam dressing had been removed ulcer observed with wound bed consisting of moist red and yellow tissue with scabbing, large amount of odorless drainage noted, no redness or warmth noted to the tissue surrounding the wound and non-adherent dressing was applied. The Progress Note did not also indicate if the areas neither were pressure related nor were the areas staged. A physician's orders [REDACTED]." The facility Initial/Temporary Care Plan dated [DATE], identified R123 had pressure areas marked and indicated with wound vac. However, the medical record lacked evidence of any other interventions being put into place to prevent and/or minimize potential further skin breakdown such as turning and repositioning, wound care, and pressure relieving mattress. During document review it was revealed a Braden Scale-For Predicting Pressure Sore Risk dated [DATE], indicated R123 had a score of 11 which indicated R123 was at high risk and the Comprehensive Evaluation of Skin Risk Factors dated [DATE], identified the risk factors but lacked immediate interventions to minimize further potential skin breakdown. R123's admission Minimum Data Set ((MDS) dated [DATE], indicated R123 required limited to extensive assist of one to two with activities of daily living (ADL's) including bed mobility and transfers; had impairment on one side on the lower extremity with limited range of motion (ROM) and had one Stage 1 (a Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching) and two Stage 2 pressure ulcers (a Stage 2 is partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). The MDS noted R123 was not on a turning and repositioning schedule and did not have wound care treatments that were completed in the last seven days. When interviewed on [DATE], at 9:58 a.m. registered nurse (RN)-C MDS coordinator verified the temporary care plan had been developed but there without interventions to minimize further potential skin breakdown. RN-C further indicated "I believe there should have been more interventions listed than just the wound vac as resident had already pressure ulcers." On [DATE], director of nursing was unavailable for interview. The facility policy entitled Skin Integrity Management, dated ,[DATE], directed director of nursing services (DNS) or designee and the interdisciplinary team (IDT) were responsible to ensure the development and implementation of a comprehensive plan of care including prevention and wound treatments as indicated. The policy further identified the goal of any skin integrity process is to provide safe and effective care to prevent and/or treat pressure sores or skin issues, maintain function and improve quality of life.

Based on observation, interview, document review, the facility failed to ensure supervision, assessments, and appropriate interventions were in place to minimize injuries and accidents for 3 of 4 residents (R107, R72, and R76). This resulted in an immediate jeopardy situation. The accepted removal plan reduced the scope and severity to actual harm but no longer an immediate jeopardy. The lack of assessment, supervision, and education for safety while leaving the facility had resulted in a fracture of the shoulder and an assault by a boyfriend for R107. This had the potential to result in repeated serious harm for 1 of 1 resident (R107) as R107 continued to leave the facility unsupervised. An immediate jeopardy (IJ) was determined at 3:10 p.m. on 3/16/12, and the administrator and director of nursing (DON) were notified at 3:12 p.m. The systemic failure to assess residents before unsupervised leaves into the community had the potential to affect most of the 84 residents in the facility. The IJ had begun on 3/16/12, was removed at 3:00 p.m. on 3/19/12, when the facility had reassessed all the residents in the facility and determined that 19 of the 84 residents were safe to be unsupervised in the community. The removal plan was verified through observations of the facility implementing the plan. The plan was verified through interviews of the staff that worked on various shifts in the facility, and through reviewing the staff education that had taken place by the DON and administrator. The remaining residents had begun to obtain physician's orders [REDACTED]. R72 had serious harm during the elopement of 2/26/12, the facility had failed to ensure supervision, to prevent injuries while out in the community. This resulted in harm when R72 was admitted to an acute care hospital related to physical assault. R72 was not at immediate jeopardy because R72 remained at the hospital. R76 had an potential for harm due to an adverse outcome (fall with injury) while out on pass and did not have an assessment of the safety risks prior to having community passes. Findings include: R107 received short term care as a result of an ankle fracture and she also had [DIAGNOSES REDACTED]. R107 had resided at the facility since admit on 12/9/11. The routine standing orders for admission signed on 12/9/11, noted. "Resident may leave the nursing home on daytime or overnight passes with all medications but may not exceed 72 hours without a specific order." R107 had several adverse events (shoulder fracture, bruises to the legs, smelling of alcohol, leave without medications, Detox evaluations) that happened on the leave of absences (LOA) from the facility. The facility did not reassess R107, did not notify the doctor, there was no change in the orders, or interventions care planned to prevent future incidents. During an observation at 7:00 p.m. on 3/12/12, the surveyor asked the assistant director of nursing (ADON) as she left R107's room if R107 would be available for an interview. The ADON stated R107 was resting because she had been drinking and the next day would be better time for an interview. The progress notes documented: - On 12/15/11, R107 left on LOA without letting the day shift staff know or signing out. She did not have medications sent with her. She did not return until 12/16/11, on the afternoon shift. - On 12/28/11, she informed staff she would be going on an overnight pass for one night. She did not return until 12/31/11, at 5:00 p.m. and would not have had medications for 12/30/11 or 12/31/11. - On 1/5/12, the resident was on LOA, was brought to Detox by the police and held until 1/6/12, when she returned at 6:18 p.m. - On 1/25/12, the resident reported to nursing that she had injured her shoulder when she fell out of a car while with her fiancee. It was alleged the boyfriend had pushed her out of the vehicle. Occupational therapy (OT) had noted decreased range of motion and pain to the shoulder on 1/25/12. A magnetic resonance imaging (MRI) of the shoulder obtained 1/30/12, indicated a non-displaced greater tuberosity (upper arm bone) fracture. - On 2/2/12, there was a vulnerable adult report completed when R107 returned from a LOA at 5:24 a.m. and smelled of alcohol, and refused vital signs. She had been dropped off at the front door and reported she had been in a fight with her boyfriend and he prevented her from returning to the facility and had taken her wheelchair. She pointed to her forehead and stated she had a blow there from the boyfriend. At 3:30 p.m. on 2/2/12, the social worker documented R107 reported she was often the one that started the fights and did not want to press charges. The social worker documented she expressed concern about R107's safety while on passes but there were no changes in the pass orders. The doctor was not notified because R107 was her own person. - On 3/2/12, R107 was on a LOA and called at 5:00 a.m. and stated she was not returning, on 3/3/12, she called and stated she would return 3/4/12. There was no documentation of medications sent with her or her condition on return. - On 3/11/12, she left at 9:00 a.m. there was no record of her return until 3/12/12, at 6:00 p.m. when she returned from pass and an alcohol odor was detected. At that time she reported an injury to her legs from a fall and R107 received a narcotic pain medication without notifying the physician the detection of alcohol. On 3/13/11, she reported the injuries to her legs had been from her boyfriend striking her with a cane. A vulnerable adult report was filed and the police were not notified. - On 3/12/12, at 6:14 p.m. R107 had returned to the facility and stated she had a fall and had sustained an injury to her lower leg, and reported the boyfriend "beats her up". At that time it was documented that R107 had a strong smell of alcohol on her breath and person. There were no vital signs taken at the time. - On 3/14/12, R107 had again been on LOA with her fiancee/boyfriend and returned an odor of alcohol. - On 3/16/12, R107 had left the facility and a vulnerable adult investigation had begun for elopement. The resident was at Detox until she returned to the facility on [DATE]. The initial Vulnerable Adult (VA) Assessment was completed by the social worker on 12/20/11, and identified R107 had a history of [REDACTED]. The assessment noted R107 had physical limitations from the ankle fracture and was not following the doctor's order for non-weight bearing to the leg. The cognitive deficits noted R107 did not always use good judgement with decisions relating to alcohol abuse, and behaviors identified were that R107 was verbally abusive at times. The assessment also noted R107 had left the facility and not signed out or let staff know she was leaving. The current care plan dated 12/28/11, identified R107 as a VA related to physical limitations (ankle fracture), schizophrenia, and anxiety. The plan was to complete the VA assessment and assist in case of emergency. There were no interventions to address the identified areas of vulnerabilities from the assessment on the current care plan dated 12/28/11. There had been no changes to the plan of care to reflect the vulnerabilities identified on 12/20/11, and/or when there had been adverse events while on LOA, and/or additional VA investigations. The DON was interviewed at 8:10 a.m. on 3/14/12, and stated R107 had left on pass several times and was free to come and go, because she was her own decision maker. She stated that was the facility policy and she had no specific concerns for R107 leaving the facility. She was aware R107 had left the facility without staff being notified, but did not know how often she would have been without medications or if she received medications to go on pass. The DON stated R107 made her own decisions about passes and had a standing doctor order for passes. She stated it was not possible to keep track of R107 because she would leave and not tell staff. She noted she had missed several doctor's appointments because she was on LOA. She stated she was aware that R107 had used alcohol on passes, and she could not stop residents from using alcohol. She further stated the facility did not notify the physician when R107 was intoxicated or going on LOA (without notifying the staff). She stated she had not talked to any of the family members of R107, and there was no county case manager or a commitment filed with adult protection, During an interview at 9:25 a.m. on 3/14/12, with the DON she stated there was no policy for LOA's for the facility, however, there was a policy for elopement. R107 would not have been considered an elopement because she had standing orders for LOA. There also were no incident reports filed for the times R107 was on an LOA and did not receive medications, and when she returned smelling of alcohol. The DON stated there was no assessment completed to determine the ability to be safe while on LOA. During an interview with the administrator at 10:00 a.m. on 3/14/12, he stated the facility was not a jail and residents that made their own decisions could come and go as they pleased. He did not have knowledge of a system for the VA assessment to be considered in that decision, he was not aware of how the social worker should integrate that assessment into the plan of care. During an interview with licensed practical nurse (LPN)-B at 2:30 p.m. on 3/14/12, regarding R107 taking LOA from the facility. She stated R107 would leave and not notify the staff. She stated R107 would usually leave in the evenings and did not make arrangements for the LOA. LPN-B stated the facility staff did not know who would transport R107 when leaving the facility, and the location of her friend's homes. R107 would report to LPN-B that she had money taken from her while out on LOA. LPN-B stated she had tried to talk to R107 about abuse situations and resources to contact for assistance. LPN-B stated R107 did not use good judgment about decisions and could be verbally abusive. She gave an example of not following recommendations for non-weight bearing to heal the ankle fracture. LPN-B did not know if there had been education with R107 about the risks of her behavior but she stated she would remind her to follow restrictions. The DON commented at 3:30 p.m. on 3/14/12, R107 may leave the facility for LOA and not come back. She stated the absence was not considered an incident and would not be tracked. She the facility had no incident reports for being sent to Detox while on LOA, and there were no incident reports for the missed medications. She stated, "We are not doing anything for her at this time for her except waiting for the housing opening." During an interview with the medical director (and primary physician) at 10:00 a.m. on 3/15/12, he stated he was aware of that the LOA order was on the standing orders and had approved. He was not aware of any assessments that would be completed to determine if residents would be safe on LOA in the community unsupervised. He stated he would expect to be notified if they did not return as planned and did not have medications. He was not aware that R107 had been smelling of alcohol on return from LOA and would want to know if consuming alcohol had occurred. He stated that he was not always the person to be called "on call", and would get that information on the next visit at the facility or at the clinic. During an interview with the DON at 4:00 p.m. on 3/15/12, she stated the resident could receive medications on return from LOA, she stated it was not a problem for R107 to receive a narcotic pain reliever because the staff not was able to tell if R107 had been drinking, had spilled alcohol on herself, or been in contact with someone that had been drinking- when R107 smelled of alcohol to the staff. On 3/12/12, R107 returned at 6:00 p.m. and smelled of alcohol did not know of an amount of alcohol, and would not change giving the medications. She further stated if the resident was their own person for decision making the assessment for the ability to self administer medication would not apply to them taking medications outside the facility on LOA. She also stated that there was no system in place for staff to check in with a resident when they returned from a LOA to assess if they had taken medications, or the general well being of the resident after the LOA. R72 had sustained injuries related to a physical assault while out on leave from the facility without adequate re-assessment of causal factors and the implementation of possible alternative and appropriate interventions related to identified failures of current interventions. R72 was admitted to the facility in 11/1/11. R72 had [DIAGNOSES REDACTED]. R72 left the faciity on [DATE] and 2/26/12, without signing out. On 2/26/12, R72 ended up in an acute care hospital unconscious. R72 refused to comply with the LOA from the facility and there was no care plan for refusals. The medical record lacked evidence that the facility re-assessed the reasons for the refusals, and lacked evidence that the facility tried to intervene/notify R72 of the risks versus benefits of the refusals of leaving the facility. The medical record also lacked evidence that the facility re-assessed the medically needed social services for R72. R72's plan of care dated 11/17/11, indicated R72 had a Wanderguard in place. The plan of care did not indicate R72 was at risk for refusal to wear the Wanderguard nor did the plan of care indicate that R72 was at risk for leaving the facility. The care plan dated 12/26/11, for "need for opportunity to express feelings/concerns re: placement indicated the social worker would visit monthly and as needed, provide a pocket talker for resident if he does not have his during visits due to hard of hearing, and encourage resident to focus on positives in life. The VA assessment dated [DATE], revealed R72 had a history of [REDACTED]. R72 "had difficulty of staying on task." R72 would become fixated on an idea and sought out immediate gratification of his requests. The assessment also revealed R72 was hard of hearing and had a pocket talker in which he utilized so he could hear. The assessment did not reveal R72 refused care nor did the assessment indicate the resident left facility without signing out. The assessment also lacked any referral to outside services. The quarterly minimum (MDS) data set [DATE], indicated R72 Brief Interview for Mental Status (BIMS) score was 10 (a score of eight to ten indicates moderately cognitive impaired). The Quarterly Assessment Packet dated 2/2/12 to 2/8/12, and revised 2/24/12, noted R72 wore a Wanderguard to "Help promote resident's safety while militarizing independence." The Assessment further noted R72 had a history of [REDACTED]. The assessment did not indicate that R72 had a history of [REDACTED]. The progress notes for R72 were reviewed from admission going forward. At 2:30 p.m. on 2/13/12, R72 was noted not to be in the facility. The facility administrator and DON were notified of the missing resident at 10:00 p.m. (7.5 hours later). The progress noted R72 did not sign out when R72 left the facility. A Resident Accident/Incident Report was completed at 10:00 p.m. on 2/13/12. The report revealed R72 had eloped from the facility. The note indicated the physician/nurse practitioner were notified but there was no name, phone number or time as to when that took place. The progress note in the medical record lacked evidence that the primary physician had been called. The progress note dated 2/14/12, noted the resident was in the facility at 2:59 p.m. The progress note indicated a Wanderguard was applied. The progress note lacked evidence that the facility assessed the reason for the resident's leaving the facility, and lacked evidence that the facility educated the resident the consequences of leaving the facility without notifying staff. The progress note also read, "Wanderguard applied." It could not be determined if the Wanderguard was in place before R72 left the faciity on [DATE], (as the plan of care dated 11/17/11, noted he already had it in place and needed the Wanderguard as an intervention for R72's cognitive limitations). The progress note dated 2/15/12, revealed R72 becomes easily confused and the facility provided R72 with a 1:1 escort. R72's behavior escalated 2:02 p.m. on 2/15/12, when R72 demand that the Hennepin County Medical Center be called for the latest laboratory work-up that had been. He stated that if did not get the results he would call the Federal Bureau of Investigation (FBI) and the Secret Service. Staff tried to intervene and inform him that the test results were normal. At 12:47 p.m. on 2/16/12, the resident requested to have the FBI and the Secret Service called again because he had a headache. Staff wrote, "Resident was also talking and making no sense and jumping to subject to subject. Resident sitting at the front door and unwilling to move. Resident also trying to leave when the door opens from other people coming and going." The second time he tried to leave was right after the care conference was held at 4:35 p.m. R72 tried to leave the facility one other time on 2/16/12. R72 tried to leave the facility at 3:27 a.m. on 2/17/12, and staff intervened by calling the on-call physician. an order for [REDACTED]. At 4:43 a.m. on 2/17/12, R72 tried to leave the facility and tried to push staff away from the door. Staff intervened by calling 911. On 2/17/12, the resident was admitted to the crisis unit. R72 returned to the facility on [DATE]. The medical record lacked evidence that social services were in place to assist R72 in arranging provision of needed counseling. The medical record lacked evidence that social services comprehensively re-assessed R72, identified R72's needs, and sought to support his individual needs for his behavior. At 11:08 a.m. on 2/22/12, R72 returned from the crisis unit. At 11:43 a.m. R72 refused any type of an evaluation or re-assessment after R72 was readmitted back to the facility. R72 also refused to have staff apply the Wanderguard. The social worker then explained to R72, "We do not recommend that he leaves unsupervised." R72 left the facility at 1:21 p.m. and the social worker gave the resident a business card with the address and phone number. The resident returned to the facility on [DATE], at 4:48 p.m. At 10:57 p.m. a Wanderguard was placed on R72. On 2/24/12, R72 cut off the Wanderguard and the facility tried to replace it on 2/24/12, 2/25/12, and 2/26/12. On 2/22/12, R72 was discharged from the Hennepin County Crisis Unit and was readmitted back to the facility. The discharge information dated 2/22/12, indicated R72 was hospitalized due to paranoia and agitation. The instructions in activity, bathing diet, medicine, call health provider if needed, and appointments. The discharge also included a section on "After Care Plan" which directed R72 to take medications as ordered. The section of "Signs of relapse" directed R72 to be aware of thoughts of self-harm, increased depression, feelings of helplessness or hopelessness, unable to enjoy or complete usual activities, take prescribed medication as scheduled, keep follow-up appointments, talk to others about your concerns, get regular exercise, eat healthy diet, use community resources and stay sober. The hospital Interdisciplinary Care Plan dated 2/17/12, (that was sent to the facility on [DATE]) revealed the hospital was working with R72 to try to understand the thought process alteration by having R72 verbalize the impact on present/future lifestyle, health status, and functional performance. Another area the hospital was working was to reverse/prevent/modify R72's psychotic symptoms and mood stabilization. That was done by having verbally state once a shift that the psychotic symptoms are less or at an acceptable level for him. The hospital also worked on the prevention and management of chemical dependency. That included maintaining sobriety after discharge, a chemical health assessment, attending a mental illness chemical dependency group, and participating in the development of of a sobriety plan for use after discharge. R72's plan of care dated 12/26/11, noted there were no changes to the R72's vulnerable adult re-assessment and the safety risk re-assessment. The Admission Nursing assessment dated [DATE], revealed R72 had altered mental status and was able to remove oneself from unsafe situations. At 9:00 a.m. on 2/26/12, R72 left the facility. The medical record lacked evidence the facility tried to re-assess the reasons for leaving, re-assess the refusals and educate the resident of the consequences of leaving the facility. At 11:12 a.m. on 2/29/12, a progress note indicated R72 was admitted to the acute care hospital due to physical assault. The security camera at a nearby fast food establishment noted R72 to be punched in the face and then be thrown out of a moving car per the hospital discharge summary dated 3/6/12. The hospital note dated 3/3/12, noted R72 urine toxicity screen came back positive for opiates. The administrator was interviewed at 4:30 p.m. on 3/15/12. The administrator indicated the social worker went over it all with R72 regarding the risks versus benefits of not leaving the facility. When documentation was requested the facility could not provide the documentation. The administrator was interviewed at 12:15 p.m. on 3/16/12. He acknowledged the residents have the right to go freely if no dementia or court commitment. He also a verified, "I don't explain the risks and benefits of everyone who leaves the building." The County Case Manager (CCM) was interviewed at 10:40 a.m. on 3/19/12, and stated he was unsure how much R72 comprehended about his care. The CCM also indicated R72 was an elopement risk from the time of admission and recently the facility was looking for a locked unit for placement. The social worker was interviewed at 2:19 p.m. on 3/19/12. She indicated at first R72 did not show any signs of leaving but started to show signs a couple of months ago. When asked if R72 had any social service programs set-up she indicated she would not set them up unless the resident requested the service. When asked about the VA assessment she indicated it was done yearly and if needed. When asked if R72 should have been re-assessed for the vulnerabilities she did not know the answer. The VA Assessment Policy undated, was to ensure protection for each VA and to minimize the risk of abuse. The assessment would include physical limitations, mental limitations and emotional limitations. After the VA was assessed, "The plan shall include area of vulnerability, goal to minimize or prevent abuse and approaches by which the goal can be accomplished. A referral agency, which can provide services out of facilities scope of services to prevent or minimize, abuse will be entered into a total plan of care. The plan shall be reviewed and revised yearly and as deemed necessary." The VA assessment plan for R107 and R72 was not reviewed and or revised when changes occurred in their psychosocial well-being. R76 had a fall while on a LOA from the facility and did not have an assessment of the safety risks to reduce the risk of falls for R76. R76 was interviewed at 6:39 p.m. on 3/12/12, and reported she had a fall last week while on an LOA. She stated she was crossing the street late at night and fell . R72 was observed to have several facial abrasions and a large hematoma over the left eye. The medical record included a standing order for LOA from the facility with medications up to 72 hours, dated 6/1/10, and also 3/6/12. The care plan dated 10/28/11, noted that R76 had confusion due to dementia and needed consistent routine to decrease the confusion. The care plan dated 10/28/11, noted that R72 was at risk for falls due to medical conditions and that should keep the environment free of hazards and maintain adequate lighting at night. The care plan also noted R76 had visual alterations due to glaucoma and cataracts and needed glasses. The MDS dated [DATE], assessed that R76 had modified cognitive patterns for daily decisions. There was no assessment of the safety for the resident in the community. The incident report for R72 dated 3/7/12, documented that she returned from LOA at 2:00 a.m. and was noted to have an injury to her left eye and facial abrasions and was sent to the emergency room . The review of the fall noted that it was an isolated event with no previous falls, and she slipped on LOA. The report did not note if R76 had been wearing her glasses. There were no changes made to the care plan or a reassessment of the resident's safety in the community. During an interview with LPN-A at 7:40 a.m. on 3/15/12, he stated R76 had often gone out on pass and returned okay. LPN-A further remarked R76 would not always speak with him when coming back. The night of her injury he had noticed she was injured initially and had to "talk her into" getting treatment at the hospital. He stated he had not received specific instructions from the facility on assessing residents when returning from pass, but he knew from his nurse's training he had to check on the resident. The MDS nurse was interviewed at 8:20 a.m. on 3/16/12, and stated she was not aware of any care plan updates for R76 after the fall, she stated she had not seen her or assessed the injuries or the events of the fall. The DON at that time stated there were no new doctor orders for skin care or updated to the care plan since the injury happened on a pass, the facility would not know the risk factors that contributed to the fall. The facility Vulnerable Adult Policy and Procedures dated 2010, directed staff to report injuries which were unexplained to the state agency. The employee that noted the injury was to immediately report to the person in charge. The administrator and state agency would then be notified and the investigation would be completed by the administrator, DON, and/or the social worker would complete the investigations. The Vulnerable Adult Policy and Procedures policy dated 2010, also noted in Appendix B of the policy to give examples of physical maltreatment (abuse). The examples included staff to resident, resident to resident and visitor, relative or community person to residents. The policy further defined the visitor, relative or community person to resident as "Physical acts by these individuals to a resident that cause pain, suffering, injury, or hurt while on facility premises or in the community. Knowledge of physical maltreatment or excessive chemical restraints while the resident was on Leave-of-Absence (LOA), extended visit, or home visit in the community. Other: Any physical injury sustained by a resident which is not reasonably explained may be treated as if maltreatment may have come into play."