Every finding on record at Villas at Bryn Mawr LLC

Based on interview and document review, the facility failed to immediately report incidents of potential resident-to-resident abuse to the state agency (SA) within two hours, as required for 2 of 2 residents (R64, R116) reviewed for abuse. In addition, the facility failed to ensure allegations of potential abuse were reported to the state agency (SA), within 2 hours, for an injury of unknown cause resulting in a fracture for 1 of 1 residents (R80) whose allegations were reviewed. Further, the facility failed to ensure timely reporting of self-neglect for a missing resident for 1 of 1 resident (R7) reviewed who left the building and did not return and whose whereabouts were unknown. Findings include: R64 R64's quarterly Minimum Data Set (MDS) dated [DATE], indicated R64 had intact cognition, was diagnosed with depression and bipolar disorder, and was independent with all activities of daily living (ADLs). R64's email communication to the administrator dated [DATE] at 1:22 p.m., indicated R64 wrote to the administrator and the substance use disorder services director (SD) that R116 had come up to his unit and was telling other residents that he (R116) intended to fight him (R64). R64 then wrote that given the physical threats made against him, he was increasingly concerned about his safety. The administrator responded at 1:27 p.m. and indicated they would call the nurse back and let them know what was happening. At 2:19 p.m., the administrator advised R64 to stay on his current unit and not go to the substance use disorder unit and let staff at his current unit know if he had any issues. R64's medical record was reviewed and lacked an indication that R64's allegations of resident-to-resident abuse was reported to the SA. R116's admission MDS dated [DATE], indicated R116 had intact cognition, was diagnosed with depression, and was independent with transferring and walking. R116's progress note dated [DATE] at 4:50 p.m., indicated R116 was on 15-minute safety checks related to a verbal altercation with another resident. R116's medical record was reviewed and lacked an indication that R64's allegation of abuse involving R116 was reported to the SA. During an interview on [DATE] at 2:43 p.m., R64 stated that he had a verbal altercation with R116 last Friday. R64 stated that R116 had threatened him and called him vulgar names, but he did not believe any staff had seen the incident. R64 stated that on Friday he had also moved from the substance use disorder unit to a different unit. R64 stated he had then heard that R116 intended to fight him, so he had emailed the administrator because he feared for his safety. R64 stated that although other residents had talked with R116 over the weekend, he had not seen R116 since Friday. During an interview on [DATE] at 3:24 p.m., the administrator stated that the allegation that R64 had emailed her on [DATE] had not been reported as R64 was very grandiose, but she had put interventions in place to ensure his safety. During an interview on [DATE] at 10:35 a.m., licensed practical nurse (LPN)-C stated that he had been working the substance use disorder unit, that R64 had previously resided in and R116 currently resided in, this Saturday. LPN-C stated R64 was moved off the substance use disorder unit when R64 had been the aggressor in a resident-to-resident verbal altercation. LPN-C stated that as a precaution after the incident, facility staff were to assure R64 and R116 stayed on their respective units. LPN-C stated that if the resident reported abuse or he witnessed it, he would report this to the director of nursing (DON), administrator, or the manager on duty, and they would be in charge of reporting it. LPN-C stated that the administrator had been aware of this altercation between R64 and R116. R80 A submitted SA incident report, dated [DATE] at 6:30 a.m., identified an allegation of unexplained injury and self-neglect was being submitted for R80. An incident dated [DATE] at 7:00 a.m. was listed, which identified resident was in pain and sent out to the hospital and returned with fracture. Further in the report, it identified R80 called 911 himself on [DATE] complaining of pain and was sent to the hospital about 1 p.m. R80's admission Minimum Data Set (MDS) assessment dated [DATE], identified R80 had intact cognition with no hallucinations or delusion, and was dependent on staff for all activities of daily living (ADLs) including bed mobility and transfers. R80's care plan, printed [DATE], identified R80 transferred with assist of full lift (Hoyer lift-mechanical lift used for people who cannot bear weight) and assist of 2 staff. In addition, R80 was identified as a vulnerable adult while residing at the nursing facility and at risk for decreased cognitive and physical ability related to diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis and muscle weakness affecting the left side of the body following a stroke-blood clod in the brain) and aphasia (impairs ability to speak, write and understand both spoken and written language). R80's progress notes, [DATE] to [DATE], were reviewed and identified the following. -[DATE] at 1:34 p.m.: R80 called 911 due to leg pain and requested transportation to hospital -[DATE] at 7:01 a.m.: R80 was sent to the hospital on [DATE]. The note included a diagnosis of closed fracture of proximal end of the left fibula, unspecified fractur morphology and the fibular head is noted to have a fracture. R80 was to wear immobilizer for 6-8 weeks with recommended follow up with ortho in 2 weeks. -[DATE] at 7:02 a.m.: addendum to the note above: R80 returned from the hospital on [DATE] at 7:00 p.m. -[DATE] at 2:24 p.m.: R80 returned with documentation that reported a fracture. R80 denied any recent fall, injury or abuse. R80 reported pain to his left leg but denies any injury. Administrator notified. The progress notes lacked an entry of when R80 returned from the hospital and who was notified upon return. During an interview on [DATE] at 12:50 p.m., registered nurse (RN)-F stated they had been working the day after R80 returned from hospital ([DATE]) and had questioned the paperwork the facility had received when he returned from the hospital. RN-F stated she called the hospital to get additional information and was sent the x-ray results. RN-F stated the paperwork from the hospital had been reviewed upon from the hospital as it had passed on in report. Surveyor attempted to reach licensed practical nurse (LPN)-E on called [DATE] at 8:28 a.m. but unable to reach to follow up if they had notified management of fracture of unknown origin upon R80 returning from the hospital. Did not return call. During an interview on [DATE] at 9:12 a.m., licensed practical nurse (LPN)-D stated if a resident returned from the hospital with a fracture with unknown cause would be something that should be reported to the supervisor right away. LPN-D stated they would have to investigate what happened and report it to the state. On [DATE] at 10:18 a.m., director of nursing (DON) stated fractures of unknown causes would be reportable to the state agency. During an interview on [DATE] at 11:12 a.m., administrator reviewed the timelines of the incident and the report. Administrator verified she should have reported the incident to the SA within 2 hours. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy, dated 11/25/, identified the following: -Incidents to be Reported; section e. Injuries of unknown source - an injury should be classified as an injury of unknown source. When both of the following conditions are met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is in an area not generally vulnerable to trauma), or the number of injuries observed at one point in time or the incidence of injuries overtime. Furthermore, the policy indicated: How and when to report to the Minnesota Department of Health ([NAME])/ Office of Health Facility Complaints (OHFC) 1. Suspected Abuse shall be reported to OHFC online reporting process not later than 2 hours after forming the suspicion of abuse. 2. Suspicion of Neglect, Exploitation, or Misappropriation of resident property must be reported to OHFC online reporting process not later than 2 hours if the incident resulted in serious bodily injury. R7 R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R7 had intact cognition and had impaired on both upper and lower extremities on one side. The MDS indicated R7 was independent with eating, hygiene, dressing, toileting, and ambulated using a cane or wheelchair. The MDS indicated active discharge planning for return to community was not occurring, and R7 did not have a history of wandering. R7's Medical Diagnosis list reviewed [DATE], included stroke affecting the left side, schizophrenia, post-traumatic stress disorder, opioid abuse, depression, alcohol dependence, and difficulty swallowing. R7's care plan interventions dated [DATE], identified R7 needed 1 assist with toilet use for BM (bowel movement) and assist of 1 with ambulation with left side weakness. Interventions dated [DATE], included assist of 1 with grooming, bathing and dressing. In addition, a care plan focus dated [DATE], included R7 will have an appropriate discharge plan and R7 was working to move into an assisted living facility or group home. R7's [DATE] Medication/Treatment Administration Record indicated on [DATE] - [DATE], medications and treatments were marked with a 3 which indicated absent from home. MAR included orders for the following:-escitalopram (antidepressant) 10 milligrams (mg)-give 1 tablet by mouth in the morning for major depressive symptoms-nifedipine (medication used to treat high blood pressure) 90 mg tablet – give 1 tablet by mouth daily in the morning for hypertension (high blood pressure)-Eliquis (anticoagulant) 2.5 mg – give 2.5 mg by mouth two times a day related to hemiplegia and hemiparesis following cerebral infarction affecting dominate side-seroquel (antipsychotic medication) – give 25 mg by mouth tow times a day for schizophrenia-suboxone (buprenorphine-naloxone –2-part medication used to treat opioid use disorder) 4.1 mg sublingual film – give 1 film sublingually two times a day related to opioid abuse.-propranolol 10 mg – give 1 table by mouth three times a day for hypertension No medications were documented as administered during this time. R7's progress notes included: -[DATE] at 9:32 p.m.: resident not seen in the facility at the start of this shift. Writer called resident's phone number not in service. Writer called resident's mom and left a voice message.-[DATE] at 1:58 p.m.: writer filed missing person report for resident.-[DATE] at 4:17 p.m.: writer called resident's phone number to see when resident's plan on returning to facility. Resident's phone number was not working. Writer called family who did not answer. Writer left voicemail.-[DATE] at 9:12 a.m.: res' 18-day bed hold is up and res' bed was released.-[DATE] at 10:08 a.m.: SSD filled out a MAARC report The progress notes showed many entries for LOA (leave of absence) and absent from home throughout the time frame that were coded under default PN type for eMAR. A Notice of Resident/Patient Transfer or Discharge indicated the notice was mailed to R7 on [DATE] as R7's 18-day bed hold expired. The progress notes lacked indicated of a missing person report filed after 24 hours of no contact with resident. Furthermore, the progress notes indicated a MAARC report was not filed until [DATE] which was almost a month since last contact with R7. During an interview on [DATE] at 9:12 a.m., licensed practical nurse (LPN)-D stated when a resident doesn't return, they should then notify the supervisor or administrator after searching for the resident. LPN-D stated the local hospitals should be called, and all this was documented in the progress notes. During an interview on [DATE] at 9:28 a.m., social services designee (SS)-D stated if a resident was gone from the facility with no contact, then a missing person's report was filed. SS-D stated if a resident didn't return to the facility, they would hold the resident's bed for 18 days after last contact along with filing a Minnesota Adult Abuse Reporting Center (MAARC) report. SS-D stated R7 was in and out of the facility and sometimes went to his apartment. SS-D was unsure if R7 had signed out of the facility on [DATE]. SS-D stated social services was responsible for ensuring the MAARC report was filed for R7. Surveyor requested copy of sign out sheet for residents for [DATE] along with copy of the MAARC report. A MAARC report was provided for R7 and indicated it had been filed on [DATE] at 10:06 a.m. No copy of the resident sign-out sheet was provided. During an interview on [DATE] at 10:18 a.m., director of nursing (DON) stated if a resident didn't return when they indicated they would be back, the staff should be calling the resident/family and would be expected to put in progress notes regarding this. DON stated social services would follow up if the resident hadn't returned within 24 hours and nursing would provide information needed. During an interview on [DATE] at 11:09 a.m., administrator stated the report was filed late as it should have been filed 24 hours after resident didn't return. Administrator verified it appears the last contact facility had with R7 was on [DATE]. Administrator stated a MAARC report and a missing person report should have been filed so adult protection could get involved and verified that it had not been done until today [DATE]. A facility policy titled Leave of Absence and Discharging Against Medical Advice Process and Acknowledgement Form, updated 10/24, indicated under the leave of absence process:6. If you do not return to the facility within 24 hours from your expected time back and you fail to call the facility to let the staff know when you will be returning, a missing person report will be completed with the local law enforcement.7. If you call the facility and inform the staff that you will not be returning, you will be discharged Against Medical Advice (AMA). The facility protocol for discharges Against Medical Advice will be implemented including contacting adult protective services (MAARC).

Based on observation, interview and record review, the facility failed to maintain the resident room in a safe, clean, and comfortable condition for 2 of 2 residents (R30, R64) by failing to repair or otherwise seal a broken resident room window, leaving an opening to the outside environment that allowed pests to enter the facility. In addition, the facility failed to ensure condition of wall corner trim pieces and baseboards on the second-floor hallways were in a safe condition. Also, the facility further failed to ensure 2 of 2 residents (R10, R100) rooms were maintained in good repair by failing to address missing drawer fronts, missing mirrors, broken wallboard, hanging curtains off their hooks. Findings include: R30's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R30 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and was independent with activities of daily living (ADLs). R64's quarterly MDS assessment dated [DATE] indicated R64 was cognitively intact with a BIMS score of 15 and was independent with ADLs. During an interview and observation on 6/16/26 at 8:12 a.m., R64 stated he had moved into the room the previous week. R64 stated his roommate (R30) had told him the window had been broken for at least four months. Observation revealed an approximately a one-inch gap between the window frame and the windowsill that allowed bugs to enter the room and R64 reported seeing flies in the room over the previous several days. During an interview on 6/16/26 at 8:04 a.m., the Regional Maintenance Director confirmed the window was broken and there was a gap between the window and the frame. He stated the facility had identified an additional issue with the window the previous week and acknowledged there are methods to cover gaps such as this and they should have been implemented. He stated he would have the issue corrected immediately. During an interview on 6/16/26 at 12:06 p.m., the Director of Nursing (DON) agreed with the concern and stated the window should not have been open to the outside environment allowing pests or bugs to enter the facility. R10 R10's admissions Minimum Data Set (MDS) dated [DATE], identified R10 with intact cognition, moderately impaired vision with corrective lenses, impairment of one side of lower extremity, required substantial to maximal assistance with dressing and personal hygiene. In addition, R10 with diagnoses of anemia, viral hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and was on hospice. During observation and interview with R10 on 6/14/26 at 11:10 a.m., R10 was lying in bed. There was an empty drawer with a missing drawer front for R10 and a blank space on the wall above the dresser with a silhouette of a mirror. R10 stated she had been in current room since admission to the facility in April of 2026 and the room had always had a missing drawer front and no mirror on the wall. it bothers me and my room looks really bad. During interview with R10's family member (FM)-A on 6/15/26 at 4:14 p.m., in R10's room, FM-B stated, condition of the room is not what I expected. I want to move her. RM-B stated missing drawer fronts and cracked wallboard next to the head of her bed was bad and needed repair. I would never live in a place like this. During interview with R10's hospice nurse (RN)-B on 6/16/26 at 1:06 p.m., RN-B stated she visited R10 twice per week and stated, Condition of [R10's] room is filthy. Missing mirror and front drawer. RN-B stated, [R10] deserves better. R100 During observation and interview with R100 on 6/14/26 at 11:00 a.m., a hole in the wallboard was noted near head of bed which was placed twelve inches from the wall. Also, the entire wall had peeling paint with most of it near the head of his bed. R100 stated, [condition of room] looks awful but no one here does anything about it. During observation and interview with nursing assistant (NA)-A on 6/15/26 at 4:30 p.m., NA-A observed R100's window curtain hanging off the hooks on one corner, and missing drawer fronts to the dresser. I don't like the way those drawers look. I would like them fixed and looks like crap. NA-A stated expectation of staff to notify maintenance of repair requests by using the electronic work order (TELS) report. NA-A said she had not submitted a TELS report for maintenance repairs. At 4:32 p.m., NA-A walked into R10's room and pointed to missing drawer front and verified the drawer front was missing. Also, I do not like the condition of the curtains, walls and outlet there. Missing mirror or something (pointing to blank wall with silhouette of mirror). I would hate that in my house. During observation on 6/14/26 at 9:17 a.m., on the second floor of facility a wall corner trim outside elevator was cracked and missing a piece leaving sharp edges. A corner piece on the wall alcove outside the janitor closet across from the elevator and nursing desk was also cracked. A baseboard section across from nursing desk was missing and several cracks were observed. In addition, a broken corner piece of resident door was observed leaving wood visible behind it. During observation and interview with the regional maintenance director (RM)-D and the maintenance operation director (MO)-D on 6/15/26 at 5:26 p.m., MO-D stated expectation of staff to submit an TELS report for anything that is need of repair. Both RM-D and MO-D stated there were no records from staff to repair or replace drawer fronts, mirrors, curtains, holes in walls or corner trim pieces. RM-D and MO-D viewed R10 and R100's rooms and MO-D stated, Definitely not homelike here. MO-D viewed broken corner pieces and stated, it is not safe [for residents] walking by. During interview with licensed practical nurse (LPN)-B on 6/17/26 at 7:40 a.m., LPN-B stated expectation of staff to submit a TELS report for any maintenance issues or concerns. LPN-B stated she had not submitted any TELS reports in recent memory. During interview with trained medication aide (TMA)-A on 6/17/26 at 7:51 a.m., TMA-A stated, when you hear about or see anything that needs fixing or replacing, we have to let maintenance know by using TELS. TMA-A stated she had not submitted any TELS reports in recent memory. During interview with registered nurse (RN)-C on 6/17/26 at 9:13 a.m., RN-C stated expectation of all staff to submit a TELS report for any maintenance issues or concerns. During interview with director of nursing (DON) on 6/17/26 at 10:30 a.m., DON stated resident dresser drawers, mirrors, curtains, and holes in the wall are not appealing and should be in good repair. Facility policy on safe homelike environment was requested and not received.

Based on observation and interview, the facility failed to ensure handrails on the second floor were securely attached to the wall. This had the potential to affect all residents, staff, and visitors who had access to the handrails.Findings include: During observation on 6/14/26 at 9:17 a.m., second floor hallway handrails were loosely attached to wall across from the elevator, across from the dining room and nursing desk, between two resident rooms. In addition, one handrail was unattached at one end pulling away from the wall outside a resident room.During review of April, May, and June 2026 electronic work orders (TELS) reports, there was no report of loose handrails.During observation and interview on 6/15/26 at 5:26 p.m., the regional maintenance director (RM)-D and the maintenance operation director (MO)-D reviewed and verified the loose and unattached handrails on the second floor. MO-D stated expectation of staff to submit an electronic work order (TELS) report for anything that is need of repair or replacement including loose and unattached handrails. MO-D and RM-D stated they had reviewed TELS reports for January through June 2026 and they failed to identify any work order report for the loose and unattached handrails.During interview with trained medication aide (TMA)-A on 6/17/26 at 7:51 a.m., TMA-A stated, when you hear about or see anything that needs fixing or replacing, we have to let maintenance know by using TELS. TMA-A stated she had not submitted any TELS reports in recent memory.During interview with registered nurse (RN)-C on 6/17/26 at 9:13 a.m., RN-C stated unattached and loose handrails are a safety concern. RN-C stated expectation of all staff to submit a TELS report for any maintenance issues or concerns.During interview with director of nursing (DON) on 6/17/26 at 10:35 a.m., DON stated unattached and loose handrails, are not safe. DON stated expectation of all staff to submit a TELS report for any maintenance issues or concerns.Undated facility policy titled Safety stated the facility was to provide a safe environment by encouraging and empowering residents/employees to live and work in a manner that fosters personal safety.

Based on observation, interview and record review the facility failed to ensure timeliness of person-centered care conferences for 1 of 1 residents (R100) and to include periodic review and revision by an interdisciplinary team along with the resident in adjusting their care plan and making decisions about their care.Findings include:R100's quarterly MDS dated [DATE] identified R100 with intact cognition, substantial assistance needed for dressing, and toileting hygiene and had diagnoses of schizoaffective disorder, cancer, heart disease, diabetes, seizures, anxiety, depression, bipolar, and lung disease.Additional MDS assessments were completed as follows:7/15/25 Quarterly,8/5/25 Annual,10/22/25 Quarterly,1/15/26 QuarterlyR100's MHM IDT Care Conference Forms dated 10/6/25, and 3/26/26, indicated R100 had a guardian and family was involved in care, but did not include whether R100 was invited or attended.Review of R100 electronic medical record (EMR) revealed no other care conference forms to coincide with the MDS assessment schedule, including the most recent MDS dated [DATE].During interview on 6/15/26 at 4:57 p.m., R100 stated, I do not remember having a meeting to talk about my care here.During interview with social services designee (SS)-D on 6/17/26 at 8:24 a.m., SS-D stated she was responsible for scheduling and documenting care conferences in the EMR. SS-D stated the facility had originally scheduled and documented care conferences every three months regardless of the MDS cycle. SS-D reviewed R100's care conferences and MDS cycle and stated the care conferences were not done for the 7/15/25, 8/5/25, and 1/15/26 MDS cycle.During interview with registered nurse (RN)-C on 6/17/26 at 9:12 a.m., RN-C stated expectation of care conferences to be performed around the MDS schedule and the social services designee was responsible for scheduling and documenting them in the resident EMR.During interview with director of nursing (DON) on 6/17/26 at 10:30 a.m., DON stated expectation of care conferences to be completed with the MDS cycle by the SS-D. DON verified R100's MDS assessments were completed for 7/15/25, 8/5/25, and 1/15/26 and facility failed to conduct care conferences for R100 at those times.Facility policy on care conferences was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect vision status for 1 of 1 residents (R15) reviewed for MDS accuracy.Findings include: R15's Admissions Minimum Data Set (MDS) dated [DATE], identified R15 with adequate vision and no corrective lenses. In addition, R15 required assistance with hygiene and had an ostomy (abdominal opening for stool to drain out of). Also, diagnoses include encephalopathy (brain disorder which can lead to mental status issues, memory loss, personality changes and in some cases, coma), kidney disease, anxiety, depression, blood clots, and rhabdomyolysis (muscle breakdown). The Care Area Assessment (CAA) for Visual Function was not triggered. R15's Hospital DC Interagency Transfer form dated 4/1/26 identified R15 with uses glasses.R15's admission CONTRACT dated 3/19/26 with a form titled Personal Belongings Inventory identified R15 with eyeglasses.R15's care plan and kardex failed to indicate R15 wore eyeglasses.R15's Hearing/Vision Form assessment dated [DATE] completed by registered nurse (RN)-C identified R15 with adequate vision and no corrective lenses.During observation on 6/14/26 at 2:00 p.m., R15 sat in wheelchair out at dining room and was wearing eyeglasses.During interview with family member (FM)-B on 6/16/26 at 9:23 a.m., FM-B stated R15 wear[s] prescription eyeglasses.During interview with mental health technician (MH)-T on 6/17/26 at 8:34 a.m., MH-T stated he was the staff responsible for filling out the Personal Belongings Inventory section of the Admissions Packet. MH-T stated the admissions packet was electronic and he reviewed with resident and family the personal items that were brought in. This form was then filled out and imbedded into the admissions packet and downloaded into the electronic medical record (EMR).During interview with registered nurse (RN)-C on 6/17/26 at 9:28 a.m., RN-C verified she was the nurse manager on R15's unit and was familiar with R15. RN-C looked at the 4/1/26 Hospital DC Interagency Transfer form and verified it stated R15 had eyeglasses. RN-C then reviewed the Hearing/Vision Form assessment dated [DATE] completed by her and stated, I know he wears glasses and do not know why I documented that he did not wear them. RN-C reviewed R15's 4/7/26 MDS and verified it was coded incorrectly and the CAA did not trigger a care plan or kardex section regarding visual function.During interview with facility coordinator (M)-C on 6/17/26 at 9:59 a.m., M-C stated she was responsible for submitting the MDS information to Centers for Medicare and Medicaid (CMS) when the nurse managers complete the assessments. M-C stated, I think [R15] wears glasses and observed the EMR banner for R15 which had a photo of him wearing eyeglasses. M-C agreed R15's MDS was incorrectly filled out and the ball got dropped. M-C verified the CAA was not triggered which meant his care plan and kardex were not triggered. During interview with director of nursing (DON) on 6/17/26 at 10:30 a.m., DON stated expectation of MDS's to be completed accurately. DON stated R15 did wear eyeglasses and verified the EMR failed to have a care plan and kardex mentioning visual function. In addition, DON verified the 4/7/26 MDS did not trigger a CAA for visual function.Facility policy on MDS accuracy requested and not received.

Based on observation, interview and document review, the facility failed to ensure the emergency call system remained accessible and functional for 4 of 4 residents (R9, R30, R52, and R64) who used the shared bathroom by failing to ensure the bathroom emergency call light pull cord was long enough to be reached by a resident from the floor creating the potential for delayed staff response during an emergency.Findings include:R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R9 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was independent with personal hygiene and toileting, and had experienced one fall with minor injury.R52's quarterly MDS assessment dated [DATE] indicated R52 had severe cognitive impairment with a BIMS score of 4 and was independent with activities of daily living.R30's quarterly MDS assessment dated [DATE] indicated R30 was cognitively intact with a BIMS score of 15, was independent with activities of daily living, and had diagnoses that included unsteadiness on feet and unspecified dementia.R64's quarterly MDS assessment dated [DATE] indicated R64 was cognitively intact with a BIMS score of 15, was independent with activities of daily living, and had a diagnosis that included a history of falling.Observation on 6/14/26 at 9:48 a.m. revealed the emergency bathroom call light pull cord shared by R9, R30, R52, and R64 was broken off, leaving approximately one inch of cord hanging from the wall connection approximately half-way up the wall. The remaining cord was not long enough to be reached by a resident from the bathroom floor in the event of a fall, preventing residents from activating the emergency call system to summon assistance.During an interview on 6/16/26 at 12:06 p.m., the Director of Nursing (DON) confirmed the short emergency pull cord in the bathroom and stated the bathroom emergency pull cords should be long enough to be reached if a resident fell to the floor. The DON stated a maintenance work order would be submitted to repair the call light and add a longer chain to ensure the cord was reachable from the floor.A facility policy titled Call Light Policy, dated 5/16/23, indicated, A nurse call must be provided for each resident bathroom, facility bathroom (if the resident is able to access it), and in all areas used for resident bathing. If a pull cord is provided it must extend to within six inches above the floor, so it is accessible to a resident lying on the floor.

Based on observation, interview and document review, the facility failed to follow infection control standards of practice for cleaning a urinal for 1 of 1 resident (R2) reviewed for infection control. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated, R2 had severe cognitive impairment, didn't have delusions, didn't refuse cares, was continent of bladder, was independent with activities of daily living, was independent with transfers, and used a wheelchair for mobility. R2's MDS indicated diagnoses of anemia, coronary disease, heart failure, hypertension, and chronic lung disease. R2's care plan indicated he had a risk for alteration in elimination related to impaired mobility. Care plan indicated R2 was continent of bladder, and he kept a plastic urinal on his wheelchair. R2's care plan also indicated the staff had to clean or replace the urinal as needed. During observation and interview on 6/14/26 at 12:32 p.m., R2 was in his room, and on top of his bedside table there were two plastic urinals with black matter around the rims, numerous black spots inside the vessels, and 6-8 flies standing on the urinals. Additionally, there were little black insects flying throughout the room. R2 stated he used a urinal throughout the day and sometimes the staff emptied the urinals in the room's bathroom, but he also used the toilet in the spa room to empty his urinals. R2 said the staff never rinsed or washed his urinals, R2 said the staff had not replaced the urinals for a long time. During observation and interview on 6/15/26 at 3:57 p.m., trained medication aide (TMA)-B stated she emptied R2's urinal once to twice during her shift but has never washed or changed his urinals. During observation on 6/15/26 at 4:00 pm, R2's urinals were on top of his bedside table and within 20 centimeters there was a mug with water. The urinals were partially filled; one was closed with a lid, and the other had no lid. During interview on 6/15/26 at 4:04 p.m., TMA-B verified the urinals had black matter around the rims and black spots inside the vessel. TMA-B stated they were dirty, and she would replace them. During interview on 6/15/26 at 4:06 p.m., nurse manager/licensed practical nurse (LPN)-A observed the urinal on top of the bedside table and stated, They [urinals] should not be near food. They need to be emptied. They are dirty, this in an infection control issue. LPN-A also verified insects were standing in the urinals and flying in the room. During interview on 6/17/26 at 12:36 p.m., director of nursing (DON) stated she was informed about the urinals and said it was an infection control issue. Facility's policy titled Infection Prevention and Control Program dated 11/2024, indicated the primary mission of Monarch Healthcare Management is to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP is a facility wide effort involving all disciplines and is part of the quality assurance and performance improvement program.

Based on observation, interview, and document review, the facility failed to failed to ensure medications were stored in a secure manner when staff left a medication cart unattended and unlocked, resulting in unauthorized individuals having potential access to medications, including controlled substances. This had the potential to affect medications accessible in that cart by allowing unauthorized access and creating the potential for medication diversion or resident harm. Findings include:During continuous observation on 6/16/26 from 9:01 a.m. through 9:21 a.m., an unlocked medication cart remained unattended at the nurses' station while the assigned nurse was away from the cart. During the observation, four ambulatory residents walked past the medication cart, staff members came and went from behind the nurses' station, and the nurse manager also walked past the unattended cart. The cart was out of sight of staff intermittently throughout the observation. Because the medication cart remained unlocked, medications, including controlled substances stored within the cart, were no longer maintained in a double-locked manner.On 6/16/26 at 9:22 a.m., registered nurse (RN)-E acknowledged the medication cart had been left unlocked. RN-E stated, I always lock it, I should have. Someone was going on break and called me over and I left without locking it.During an interview on 6/17/26 at 11:35 a.m., the Director of Nursing (DON) stated staff were expected to lock the medication cart whenever they walked away from it for resident safety.A facility policy titled Medication Storage in the Facility, dated August 2019, indicated controlled substances were to remain double locked at all times.

Based on observation, interview, and document review, the facility failed to consistently and comprehensively assess a non-pressure skin condition to ensure skin condition changes could be adequately monitored and acted upon promptly to promote healing and reduce the risk of complications (i.e., infection, worsening) for 1 of 2 residents (R22) reviewed who had skin impairments. In addition the facility failed to ensure services were coordinated with the hospice agency of 1 of 1 residents (R10) reviewed who received hospice services. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R51 had moderately impaired cognition and was diagnosed with dementia and schizophrenia. The MDS indicated R22 was independent with toileting hygiene, required supervision or touching assistance with bathing/showering, and set up or clean up assistance for lower body dressing. R22's Weekly Skin Inspection dated 3/11/26, indicated R22 had ongoing red rashes on the perineal area, that a cream was applied per order, and included no further description such as if open areas were present on the skin. R22's provider note dated 3/16/26 at 12 a.m., indicated R22 had fungal dermatitis to her buttocks that was unresolved, open areas to her bottom, and the provider was ordering a new treatment. R22's Weekly Skin Inspection dated 3/18/26, indicated R22 had ongoing fungal rashes on the groin/ perineal area, that R22 was receiving an oral medication, and included no further description such as if open areas were present on the skin. R22's order summary dated 4/29/26, indicated R22 had an order dated 4/29/26 for Nystatin-Triamcinolone (a combination antifungal/steroid) cream twice a day to her bilateral legs, back, abdomen, and perineal area for skin condition. R22's care plan dated 5/1/26, indicated R22 had a risk for alteration in skin integrity related to dementia and schizophrenia. The care plan indicated R22 had a history of picking at skin and had a rash on the trunk/buttock/groin area with a goal of the rash resolving by the review date of 7/30/26. The care plan indicated staff were to monitor skin integrity daily during care, and the nurse was to complete weekly skin inspections. The care plan indicated nursing staff were to document on R22's skin condition and keep the provider informed of changes. R22's progress notes dated 5/15/26 to 6/14/26 were reviewed with the following referencing skin status: - 5/15/26 at 12 a.m., the provider note indicated that on exam of R22, the rash to her bottom continued to improve and was nearly healed with one small scab to her right buttock, no open areas noted, and mild redness to her bottom and groin. - Dated 6/12/26 at 12 a.m., the provider note indicated that on exam of R22's rash to bottom, it was stable with a few light scratch marks, no open areas, and mild redness to the groin and bottom. - No further progress notes indicating R22's skin status during this period were found. R22's Weekly Skin Inspection dated: - 5/20/26, indicated a cream was applied to R22's fungal rashes on her perineal area, abdomen, lower back, and bilateral legs. - 5/27/26, indicated a cream was applied to R22's fungal rashes on her perineal area, abdomen, buttocks, and bilateral upper legs. - 6/3/26, indicated a cream was applied to R22's fungal rashes on her perineal area, lower back, buttocks, and bilateral upper legs. - 6/10/26, indicated a cream was applied to R22's fungal rashes on her lower back and legs, perineal area, and buttocks. - The inspections did not include further description of the skin alteration, such as if open areas were present or what color the skin alteration was. During an observation and interview on 6/16/26 at 7:47 a.m., licensed practical nurse (LPN)-B was observed entering R22's room and escorting her to the bathroom. A small, thin (slightly thicker than a fingernail) scab that was about an inch long on her right buttock, with dark pink skin observed in the gluteal cleft expanding out to her bilateral buttocks. Slight redness was observed extending down a couple inches down the inner thighs. The skin was observed with no open areas. LPN-B stated that nursing staff were supposed to document on R22's skin alteration on her shower days in the weekly skin checks. LPN-B stated they were supposed to document whether the alteration was healing, moist or dried, if there was any odor or not, what the color of the wound was, and if it was open or closed. LPN-B was observed reviewing the 6/10/26 Weekly Skin Inspection and stated she did not see that nursing staff were including these things in their assessment, so she was unsure if the wound had changed since then or not based on this assessment. During an interview on 6/16/26 at 10:47 a.m., LPN-A, the nurse manager for the unit, stated that all residents had a weekly skin check after their shower to ensure their skin was intact. LPN-A stated that if the resident had a skin alteration, she would expect nursing staff to document a description of this alteration, including the color, if the area had any open areas or if it was closed, and if the wound was improving or not. LPN-A stated that R22 had a fungal rash that nursing staff applied a cream to as treatment. LPN-A stated she would expect assessments of this rash to be completed in the weekly skin checks. During an interview on 6/16/26 at 12:32 p.m., the director of nursing (DON) stated that nursing staff would complete weekly skin assessments that would be documented in the weekly skin assessment form. The DON stated she wouldn't expect staff to document if a rash was closed or its color, but would expect staff to document if the area had changed or if the rash had opened up. During an interview on 6/16/26 at 12:52 p.m., nurse practitioner (NP)-A stated R15 had a fungal rash since around February, and they had tried a variety of treatments, but the wound now seemed to be improving. NP-A stated there had been scabs from R22 itching the area in the past. NP-A stated she would expect nursing staff to document if there were any open areas or not, any worsening redness, or if the patient reported worsening symptoms. The facility's Skin Assessment and Wound Management policy dated 2/2025, indicated that staff would perform daily skin inspections with daily care, and a weekly skin inspection would be completed by licensed staff. The policy indicated if a significant alteration, that is When large, or multiple bruising, large skin tear, or other non-pressure related wounds such as diabetic, venous, or arterial ulcers occurred, staff would notify the provider and the resident representative, complete education, initiate skin and wound evaluation, notify the nurse manager/wound nurse, refer to dietary and therapies as appropriate, review and update the care plan and resident care lists, and update the care plan to identify risks for skin break down. R10's R10's admissions Minimum Data Set (MDS) dated [DATE], identified R10 with intact cognition, moderately impaired vision with corrective lenses, impairment of one side of lower extremity, required substantial to maximal assistance with dressing and personal hygiene. In addition, R10 with diagnoses of anemia, viral hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and was on hospice. During review and interview of R10's hospice binder at nursing desk on 6/14/26 at 1:14 p.m., with social services designee (SS)-D the binder contained no calendar of visits and no home health aide visit notes. SS-D stated, looks like we do not have [them] and missing information from the binder was necessary for all staff to provide needed care. During observation and interview with RN-A on 6/15/26 at 5:18 p.m., RN-A stated expectation of R10's hospice binder should have updated calendar for who is coming and when from hospice. If it is not in there then we will not know who is doing what and when for [R10]. RN-A pointed to R10's hospice binder at the nursing station and stated, it did not have a calendar in it before today so we could not find out when the aide comes. Communication is not ideal if we do not know who is coming and when. During interview with hospice nurse (RN)-B at 6/16/26 at 1:06 p.m., RN-B stated she was R10's case manager and visited twice per week. RN-B stated the hospice binder was supposed to have the visit monthly calendar and the written visit notes by each hospice service including home health aides, nursing, social worker, and chaplain. RN-B stated working with the facility has not been easy and communication is a problem. RN-B stated, I have had to replace that binder several times because [facility] keep losing it, although I do not know how. RN-B stated the facility did not have information needed to provide care for R10 with missing visit notes and calendars. In addition, RN-B stated facility did not reach out to her with concerns about missing calendars and visit notes. During interview with nursing assistant (NA)-A on 6/16/26 at 11:05 a.m., NA-A stated expectation of facility staff to review R10's hospice binder to receive needed information which included visit notes from all services. if no calendar or visit notes [then] we do not know who is coming out and when and what happened. During interview with staffing coordinator (S)-C on 6/16/26 at 11:09 a.m., S-C stated she also filled in as nursing assistant and trained medication aide when staffing is needed. S-C stated expectation of facility staff to review R10's hospice binder to determine when hospice staff were visiting and what happened at each visit. It is important to have a streamlined system in place to have us, hospice and family on the same page. During interview with family member (FM)-A on 6/15/26 at 4:14 p.m., FM-A stated she was primary emergency contact and daughter for R10. FM-A stated the hospice provider communicated frequently with changes and updates, however communication and updates from the facility were lacking and was not happy with facility. During interview with registered nurse (RN)-C on 6/17/26 at 9:13 a.m., RN-C stated expectation of facility staff to review R10's hospice binder to determine when hospice staff were visiting and what happened at each visit. RN-C stated she was unaware of facility reaching out to R10's hospice provider to communicate or collaborate on visits and updates. RN-C stated, there is a failure to communicate with us and hospice. If the calendar and visit notes are missing then we are unable to know what is going on and when. The process [here] is not therapeutic at this time for [R10]. During interview with director of nursing (DON) on 6/17/26 at 10:36 a.m., DON stated expectation to provide quality care to R10 is for facility staff to review R10's hospice binder to determine when hospice staff were visiting and what happened at each visit. DON stated, [There] should be better collaboration [with hospice] schedules and visit notes for everyone. Policy on communicating and collaborating with outside providers was requested and not received.

Based on interview and document review, the facility failed to provide a written bed hold (BH) for 3 of 3 residents (R9, R15, R100) reviewed for hospitalization. Findings Include: R15 R15's admissions MDS dated [DATE] identified R15 with inability to determine cognition, adequate vision with no corrective lenses, impaired function of one side of upper extremity, utilized a wheelchair for mobility, required substantial assistance with dressing and personal hygiene. In addition, R15 had diagnoses of Encephalopathy (malfunction in the brain causing mental status changes), blood clots, ischemic colitis requiring colostomy (bag outside body to collect stool), kidney disease, anxiety, depression, and rhabdomyolysis (breakdown of muscle causing kidney damage). R15's progress notes for 3/19/26 and 3/20/26 identified R15 with admission to facility on 3/19/26 and suffered a fall with head strike on 3/20/26 with return to the hospital. R15's progress note dated 4/1/26, stated R15 had readmitted to the facility. Also, R15's progress note dated 5/23/26 identified hospitalization and subsequent return on that date. R15's Care Conference form dated 4/8/26 identified R15 had admitted to facility on 3/19/26 and had a fall with a head strike and was admitted to the hospital. Also, R15 was readmitted to facility on 4/1/26. R15's Hospital Transfer form dated 5/23/26 documented by registered nurse (RN)-A identified R15 had another fall with a head strike and was sent to the hospital. The assessment form failed to mark section of 7. Bed hold form with indication of sending a signed bedhold form with R15 to the hospital. Form stated daughter, family member (FM)-B was notified. During interview with R15's FM-B on 6/16/26 at 9:23 a.m., FM-B stated she and the rest of R15's family were never notified or informed regarding a bedhold or transfer form with both hospitalizations on 3/19/26 and 5/23/26. FM-B stated she called the facility on 3/19/26 to follow up on R15's hospitalization because the hospital contacted her and not the facility. During interview with social services designee (SS)-D on 6/14/26 at 1:14 p.m., SS-D stated R15 was competent to make his own decision and reviewed R15's electronic medical record (EMR) and verified hospitalizations on 3/20/26 with return to facility on 4/1/26, and 5/23/26. SS-D stated nursing was responsible for ensuring a written and signed bedhold form was completed and scanned into the EMR. If form was not signed then a progress note would have to be done in the EMR and social services would have to follow up. SS-D stated this was not done for R15 for both his hospitalizations on 3/19/26 and 5/23/26. R100 R100's quarterly MDS dated [DATE] identified R100 with intact cognition, substantial assistance needed for dressing, and toileting hygiene and had diagnoses of schizoaffective disorder, cancer, heart disease, diabetes, seizures, anxiety, depression, bipolar, and lung disease. R100's EMR identified hospitalizations on 1/28/26, 2/25/26, 3/15/26, 5/19/26, 5/22/26, and 6/11/26 from the Hospital Transfer form assessments. All assessments failed to identify a signed bedhold form was offered and signed. During interview on 6/14/26 at 3:14 p.m., R100 stated he had never been asked to sign a bedhold form prior to any of his hospitalizations. Review of Ombudsman notices from facility to the Office of the State Long-Term Care Ombudsman for January to May 2026 failed to identify R4, R15, and R100's hospital transfers. During interview with social services director (S)-D on 6/17/26 at 11:15 a.m., S-D stated there was staff turnover and verified notices to the Office of the State Long-Term Care Ombudsman failed to include residents who transferred to the hospital and that bedholds were not documented in the EMR and should be. During interview with RN-A on 6/15/26 at 5:18 p.m., RN-A stated expectation of staff to start a Hospital Transfer form in the EMR for every incident of transferring a resident to the hospital. RN-A verified he documented R15's 5/23/26 Hospital Transfer form and also R100's 1/28/26, 2/25/26, 3/15/26, 5/19/26 ,5/22/26,and 6/11/26 Hospital Transfer forms. RN-A stated, I do not know anything about a bedhold form. I have never been told that I have to have a resident sign [that]. I only fill out the hospital transfer form in the EMR and mark the sections that I complete. During interview with licensed practical nurse (LPN)-B on 6/17/26 at 7:40 a.m., LPN-B stated expectation of nursing staff to document bed hold conversations in the Hospital Transfer form when sending resident to the hospital. Also, staff were supposed to document whether they obtained the signed form or not and to inform social services to follow up if form was not signed. During interview with RN-C on 6/17/26 at 9:05 a.m., RN-C stated expectation of nursing staff to create a document in the EMR titled Hospital Transfer form for each episode of transferring a resident to the hospital. RN-C stated the form identified what paperwork needed to accompany resident to the hospital and a signed bedhold form was included. RN-C reviewed R15's EMR and verified he was admitted to hospital on [DATE] with no Hospital Transfer form documented and no indication or scanned bed hold in the EMR. She also verified R15 was sent to the hospital on 5/23/26 and the EMR identified a Hospital Transfer form but no bed hold was offered or signed. RN-C reviewed R100's EMR and verified hospitalizations on 1/28/26, 2/25/26, 3/15/26, 5/19/26, 5/22/26, and 6/11/26. RN-C also verified bedhold were never offered and signed. RN-C stated, the EMR does not have bedholds uploaded and not done, it should be. During interview with director of nursing (DON) on 6/17/26 at 10:30 a.m., DON stated expectation of nursing staff to create a Hospital Transfer form in the EMR for each resident sent to the hospital. DON also stated expectation of staff to offer and have resident or guardian sign the form and if they were unable to, then document that in the EMR and have social services follow up. DON verified the process was not being done and it is on the radar to educate [staff] further for the bedhold process. R9's quarterly Minimum Data Set (MDS) dated [DATE] indicated R9 was cognitively intact, had no delusions, and did not refuse personal cares. R9's MDS indicated diagnoses of hypertension, diabetes, bipolar disorder, anxiety disorder, and chronic pulmonary disease. R9's progress notes indicated he was hospitalized on [DATE] and 1/30/26. R9's progress notes lacked evidence of a BH being discussed with the resident or representative at time of transfer for the 1/7/26 or the 1/30/26 hospitalizations or during either hospitalization. Facility's forms titled Hospital Transfer forms dated 1/7/26 and 1/30/26 lacked documentation about the BH. During review of R9's entire electronic medical record (EMR) lacked documentation whether a written BH form was sent to the hospital during R9's hospital stays on 1/7/26 and/or 1/30/26. During interview on 6/14/26 at 12:04 p.m., R9 stated he was very sick and was hospitalized twice in January. R9 said he was very sick with pneumonia at the beginning of January and later in the same month he returned to the hospital due to increase weakness in his right arm. During interview on 6/15/26 at 4:11 p.m., registered nurse (RN)-D stated when a resident was sick the nurse assessed the resident, updated the primary doctor, and the doctor decided if a sick resident needed to be sent to the hospital. RN-D stated the nurse sent a copy of the resident's face sheet, POLST (code status) form, medication record, treatment record, and hospital transfer form. When asked about the BH form, RN-D stated, sometimes the residents could sign the BH form before they are transferred to the hospital. RN-D stated there was a section on the Hospital Transfer form where the nurse would check if a BH form was sent with the resident or not. RN-D added they also wrote a progress note indicating what forms were sent to the hospital and whether a resident wanted to hold their bed or not. RN-D stated if a resident was unable to sign the BH before leaving the facility or the family/guardian could not be contacted, then the nurse working the following shift needed to follow up. RN-D verified there were no BH forms in R9's EMR for his two hospitalizations in the month of January. During interview on 6/16/26 at 10:45 a.m., the medical records manager (MRM) verified R9's EMR did not contain any BH forms. MRM stated the BHs were scanned into the miscellaneous section, and if they were not scanned, the forms were never completed or signed. Facility's policy titled Bed-Holds and Returns dated 2/2026, indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy also indicated: Prior to the transfer, written information will be given to the residents and the residents' representatives that explains in detail: The rights and limitations of the resident regarding bed holds. The reserve bed payment policy as indicated by the state plan (Medicaid residents). The facility per diem rate requires to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and The details of the transfer (per the Notice of Transfer).

Based on interview and document review, the facility failed to ensure ongoing, adequate monitoring for side effects with psychotropic medication use to promote continuity of care for 1 of 5 residents (R15) reviewed for unnecessary medication use. In addition, the facility failed to ensure psychotropic medication had identified target behaviors/symptoms, and therefore failed to monitor for target behavior/symptoms for 1 of 5 residents (R15) reviewed for unnecessary medication use.Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], indicated R15 had some difficulty making decisions regarding tasks in daily life in new situations and demonstrated no delusional thinking during the review period. The MDS indicated R15 used antidepressant medication and was diagnosed with depression and anxiety. R15's care plan dated 5/20/26, indicated R15 had an alteration in mood and behavior related to anxiety, depression, ADHD (attention deficit/ hyperactivity disorder), and mild cognitive impairment and was enrolled in mental health services per recommendation. The care plan did not include target behaviors or side effect monitoring for duloxetine. R15's order summary dated 6/13/26, included an order dated 5/22/26 for 60 milligrams (mg) of duloxetine (an antidepressant medication) daily for depression. R15's medical record, including the treatment administration record, was reviewed and did not indicate that duloxetine target behaviors were identified or being monitored. Side effect monitoring for duloxetine use was also not found after reviewing R15's medical record. During an interview on 6/17/26 at 9:11 a.m., licensed practical nurse (LPN)-C stated R15 received duloxetine for depression. LPN-C stated that usually target behavior monitoring and side effect monitoring were added to the treatment administration record (TAR), but he did not see that it had been added. LPN-C stated he was unsure what target behaviors related to his duloxetine but did not think R15 had been having any side effects from the medication. During an interview on 6/17/26 at 9:17 a.m., LPN-A, the nurse manager for the unit, confirmed she had reviewed R15's medical record and stated that she did not see that target behaviors were identified or monitoring was in place for his duloxetine. LPN-A stated that she also did not see that side effect monitoring for the duloxetine was in place and would have to add it. During an interview on 6/17/26 at 9:22 a.m. with the director of nursing (DON) and regional nurse consultant (RNC)-A (a registered nurse), RNC-A stated that residents taking psychotropic medications should have target behavior monitoring and side effect monitoring in place. The DON stated this monitoring would be documented in the TAR. The facility's Psychotropic Medication Use policy dated 5/2025, indicated that identified target behaviors would be monitored along with individualized interventions as well as supporting documentation in the clinical record. The policy indicated that ongoing documentation must include behavioral indicators or symptoms, monitoring for effectiveness, and potential for adverse consequences.

During observation, interview and record review, the facility failed to ensure protection of resident property for 2 of 2 residents (R10, R15) reviewed for missing items.Findings include:R10 R10's admissions Minimum Data Set (MDS) dated [DATE], identified R10 with intact cognition, moderately impaired vision with corrective lenses, impairment of one side of lower extremity, required substantial to maximal assistance with dressing and personal hygiene. In addition, R10 with diagnoses of anemia, vital hepatitis, arthritis, osteoporosis, hip fracture, anxiety, depression, chronic lung disease, respiratory failure, cataracts, and was on hospice.R10's admissions Care Area Assessment (CAA) with assessment review date (ARD) of 4/28/26 identified vision problems indicated by Moderately impaired and ability to see in adequate light (with glasses or other visual appliances).R10's MN admission packet dated 4/22/26, identified a Personal Belongings Inventory form with and X marked next to Glasses. The form failed to identify any clothing that was brought in by resident or family at admission.During observation and interview with R10 on 6/14/26 at 11:10 a.m., R10 was lying in bed wearing a nightgown. R10 stated she was missing several nightgowns and a pair of eyeglasses. R10 stated the facility was aware of the missing items and had not investigated.During interview with R10's family member (FM)-A on 6/15/26 at 4:10 p.m., FM-A stated she visited R10 daily and R10 was now missing five nightgowns which were labeled and [R10] is on her third pair of glasses. FM-A stated facility staff were aware but no one from the facility investigated.During interview with hospice nurse (RN)-B on 6/16/26 at 1:06 p.m., RN-B stated she visited R10 twice per week and experienced difficulty working with facility. RN-B stated R10's eyeglasses were missing and had notified facility but nothing was done. RN-B stated R10's nightgowns were missing, Literally everything is missing from [R10's] room. R15 R15's admissions MDS dated [DATE] identified R15 with inability to determine cognition, adequate vision with no corrective lenses, impaired function of one side of upper extremity, utilized a wheelchair for mobility, required substantial assistance with dressing and personal hygiene. In addition, R15 with Encephalopathy (malfunction in the brain causing mental status changes), blood clots, kidney disease, anxiety, depression, and rhabdomyolysis (breakdown of muscle causing kidney damage).R15's MN admission Packet dated 3/19/26 identified a Personal Belongings Inventory form with an X next to Glasses.R15's admissions CAA with assessment review date (ARD) of 4/7/26 identified 03. Visual Function as Not Triggered.R15's orders, care plan and kardex failed to identify visual impairment.R15's Admissions Data Collection assessment dated [DATE] identified R15 as having no to Corrective lenses (contacts, glasses, or magnifying glass)R15's Hearing/Vision Assessment Form dated 3/20/26 and 4/2/26, the forms identified R15 with adequate vision. No corrective lenses.During record review of R15's Hospital DC interagency transfer form dated 4/1/26, identified R15 with uses glasses when prompted regarding any visual impairments.During interview with R15's FM-B on 6/16/26 at 9:23 a.m., FM-B stated R15 wore prescription eyeglasses and when she visited him on 4/9/26 they were bent and dirty and were tucked away in his bedside table. She stated R15 was supposed to have them on. FM-B stated he was missing them entirely on two subsequent visits and staff were unable to locate them. FM-B stated no one from the facility contacted her about the missing eyeglasses. FM-B stated she had to replace R15's eyeglasses.Facility Grievance logs with dates from 1/21/26 to 6/14/26 failed to identify missing items for R10 and R15.During interview with nursing assistant (NA)-A on 6/15/26 at 4:32 p.m., NA-A stated expectation of staff to fill out a grievance form for reported missing items. NA-A stated she was aware of R10's missing eyeglasses and nightgowns yet did not file a grievance because she thought someone else did.During interview with RN-A on 6/15/26 at 5:18 p.m., RN-A stated expectation of all staff to fill out a grievance form for reported missing items and the social services department would conduct a formal investigation.During interview with licensed practical nurse (LPN)-B on 6/17/26 at 7:40 a.m., LPN-B stated resident belongings were documented on a personal inventory form which was attached to the admission packet. LPN-B was unaware of who documented it and where it would be located in the electronic medical record (EMR). LPN-B stated social services department was responsible for investigating missing items once staff identify and fill out a grievance form.During interview with trained medication aide (TMA)-A on 6/17/26 at 7:51 a.m., TMA-A stated the facility had a personal inventory form to identify all belonging that are brought in by the resident at admissions but was unaware of where to locate the document or determine if there was one completed for R10 and R15.During interview with social services designee (SS)-D on 6/17/26 at 8:33 a.m., SS-D stated she was responsible for investigating missing items once the staff fill out a grievance form. SS-D stated she was unaware of R10 and R15's missing items. SS-D reviewed the grievance logs and verified they were not reported missing. SS-D stated she believed the mental health technician (MH)-T was responsible for documenting personal inventory of all residents upon admission to the facility. SS-D was unable to locate the form in the EMR for both R10 and R15.During interview with MH-T on 6/17/26 at 8:34 a.m., MH-T stated he was assigned to review personal inventory for all residents upon admission. MH-T stated his role was to complete the personal belonging inventory form electronically which was attached to the admission forms. MH-T verified both R10 and R15 were located in their EMRs with their admissions packets with eyeglasses documented as present on admission.During interview with RN-C on 6/17/26 at 9:31 a.m., RN-C verified she had completed the 3/20/26 Hearing/Vision Assessment form for R15. RN-C stated, I know he wears glasses and do not know why I documented that he did not wear them. RN-C verified the incorrect information she documented failed to trigger a Care Area Assessment (CAA) R15's admissions MDS which failed to create a care plan and kardex for R15 with regard to eyeglasses.During interview with the facility's MDS Coordinator (M)-C on 6/17/26 at 9:59 a.m., M-C stated she was responsible for submitting all MDS information to Centers of Medicare and Medicaid. M-C reviewed the vision section of R15's admissions MDS and stated it was not filled out correctly. I think he wears eyeglasses. M-C stated R15's inaccurate MDS resulted in the CAA section to not be triggered for vision therefore causing R15's care plan and kardex to not include his prescription eyeglasses. M-C stated, the ball got dropped.During interview with director of nursing (DON) on 6/17/26 at 10:30 a.m., DON stated expectation of staff to fill out a personal inventory form for anything that the resident brought with them upon admission. DON was unaware of who was assigned to complete the form and download it in the EMR. For missing items, the DON stated expectation of staff to fill out a grievance form and social services department could then investigate. DON verified the grievance logs failed to identify missing eyeglasses for R10 and R15. DON stated the staff had failed to document and follow up on missing items.Facility policy on missing items was requested and not received.

Based on interview and document review, the facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to 1 of 3 residents (R39) reviewed for beneficiary notices.Findings include: R39's admission Minimum Data Set (MDS) dated [DATE], indicated R39 had intact cognition. R39's SNF Beneficiary Protection Notification Review form dated 5/28/26, indicated R39's last covered day of Medicare Part A service was on 5/28/26, and the termination was provider-initiated when Part A benefit days were not exhausted. R39's NOMNC form dated 5/28/26, indicated R39's last covered day of Medicare Part A service was on 5/28/26 and was signed by the resident on 5/27/26. R39's medical record was reviewed, and no indication that facility staff had attempted to give R39 the NOMNC form before 5/27/26 was found. During an interview with the administrator on 6/17/26 at 8:12 a.m., the administrator confirmed that she could not find an indication that the NOMNC form was given to R39 before 5/27/26 in R39's medical record. The administrator stated she would have expected this form to be given at least 48 hours before the service end date. The facility's NOMNC policy dated 2/20/23 indicated the NOMNC must be delivered at least two days before Medicare-covered services end.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 3 of 3 residents (R11, R40, R53 ) who were seated at the dining room table with other residents who were served meals without being served meals themselves resulting in them waiting for their meals while tablemates dined.Findings include:R11's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R11 had intact cognition and required set up or clean-up assistance from staff for eating.R40's annual MDS assessment dated [DATE], identified R40's short term and long term memory appeared OK and a Brief Interview for Mental Status (BIMS) was not completed indicating R40 was rarely/never understood. Further, the assessment identified R40 was independent with eating.R53's significant change MDS assessment dated [DATE], identified R53 had moderately impaired cognition and required set up or clean-up assistance from staff for eating.On 6/14/26 at 12:09 p.m., the lunch meal service was observed on 2nd floor main dining room. There were residents in the dining room waiting for lunch. The meal cart came up to the floor at 12:13 p.m., and the food was transferred to the steam table. It was observed that R11 and R20 were seated next to each other at the same table on opposite side of the dining room than the steam table along with two other unidentified residents. At 12:30 p.m., R11 was observed to be eating his lunch. At 12:35 p.m., R11 expressed frustration as R11 was still waiting for his lunch. R11 stated it pisses me off as happens all the time [referring to tablemates being served before him]. It was observed that the 2 unidentified residents had finished eating and left the table and R20 was almost done with lunch. At 12:48 p.m. R11 was served lunch (18 minutes after tablemates had been observed eating). At 12:52 p.m., staff delivered desserts to some residents while other residents had not yet been served lunch.On 6/16/26 at 8:14 a.m., the breakfast meal service was observed on the 2nd floor main dining room. There was a table with 2 residents (R82 and R40). At 8:18 a.m., R82 was served a bowl of cold cereal and milk. At 8:30 a.m., R40 was served breakfast (12 minutes after tablemate was served breakfast and eating).During the same observation during the breakfast meal service, another table had 4 residents seated and R53 was seated at the end of the table. Other residents had been served cold cereal in front of them at the start of the observation at 8:14 a.m. At 8:22 a.m., R53 was observed to request oatmeal for breakfast as he did not have any food in front of him despite tablemates having been served. At 8:35 a.m., R53 requested, again, to have some oatmeal which was then provided at 8:37 a.m. (23 minutes after tablemates had been served)During an interview on 6/16/26 at 8:51 a.m., R53 stated he had to wait for breakfast this morning after asking couple of times for oatmeal. During an interview on 6/16/26 at 8:58 am., R40 stated that it happens all the time and stated she frequently had to wait for meals after others at the table are served and added I am used to it.During an interview on 6/16/26 at 10:26 a.m., nursing assistant (NA)-A stated they assist serving residents in the dining room. NA-A stated they served residents as they came into the dining room. NA-A stated if the residents were already in the dining room, they served them as the trays were prepared. NA-A stated they did not serve residents by table. During an interview on 6/17/26 at 9:04 a.m., NA-B stated residents were served by how the trays were prepared and that was determined by the order of the meal tickets. NA-B stated residents were served on a first come first served basis and not by table.During an interview on 6/17/26 at 10:18 a.m., director of nursing (DON) stated that every unit's process for serving food was a little different. DON stated meals should be served table by table. During an interview on 6/17/26 at 11:12 a.m., administrator stated the process for the order of serving residents in the dining room was as the tickets came up from dietary, the residents are served. Administrator verified residents seated at the same table should be served at the same time.A facility policy on dignified dining was requested but not received.

Based on interview and document review the facility failed to assess, develop, implement interventions and provide supervision for 1 of resident (R1) reviewed for tube feeding. The facility was aware R1 had food seeking behaviors and was on a NPO (nothing by mouth) diet restriction. This resulted in R1 being sent to the emergency department. Once in the emergency department, R1 required intubation and resuscitation by cardio pulmonary resuscitation (CPR) due to cardiac arrest. The immediate jeopardy began on 3/08/26, when the facility failed to assess, develop, implement interventions and provide supervision to R1 when R1 was known to have food seeking behaviors and was on a NPO diet restriction. R1 was sent to the emergency department (ED) on 3/08/26, with decreased responsiveness, temperature of 105 degrees Fahrenheit and was found to have large portions of food materials in R1's oropharynx (upper airway). The immediate jeopardy was removed on 3/13/26, but noncompliance remained at the lower scope and severity level D (isolated, scope and severity level) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's diagnoses included malnutrition, anxiety disorder and depression. R1 was severely cognitively impaired, usually understood with unclear speech and had no behaviors. The MDS further indicated R1 required set up to partial assistance with activities of daily living (ADL)'s, occasionally incontinent with urine and frequently incontinent with bowel, and was independent with mobility. In addition, the MDS indicated it was unknown if R1 had weight gain or loss but received nutrition via tube feeding (G-tube) with a weight of 165 pounds (lbs.)R1's care plan dated 2/19/26, indicated R1 self seeks food and fluids while NPO (nothing by mouth), risk versus benefits completed on 2/19/26, required reminders and redirection related to poor cognition.R1's Risk versus Benefit form dated 2/19/26, indicated resident is currently NPO status with tube feeding meeting 100% of nutrition and hydration related to dysphagia (difficulty swallowing) and history of silent aspiration. Therapy staff report resident has been self-seeking food and fluids for ingestion. The form further indicated the risks related to non-compliance would be consuming oral food or fluids could result in aspirating food or fluid into lungs, cause lung infection/pneumonia, loss of airway and inability to breath, return to hospitalization and possible death. The form indicated the provider was updated on 2/19/26 and working with SLP (speech language pathology). SLP planned to assist R1 with improving swallow function and there was a video swallow test to be scheduled for further assessment of R1's swallow ability. A registered dietician (RD) progress note on 2/19/26, indicated R1 was NPO, related to dysphasia with a history of silent aspiration. R1 was self-seeking food and fluids per staff reports. R1 had impaired cognition and required redirection and reminders of diet order. RD reviewed risk versus benefit with R1 related to NPO status. It was difficult to assess R1's understanding, R1 shrugged shoulders and made some facial expressions during education but was unable to repeat back to writer (RD) risks of consuming oral intake.On 2/24/26, record of email exchanges with IDT (interdisciplinary team) related to R1's low slums (St. Louis University Mental Status examination), indicated R1 had a score of (6/30) which indicated dementia. R1's wandering and the need for a memory care bed was discussed. No memory care bed was available. The team determined they would continue to monitor R1 with no new intervention established.A hospital History of Present Illness (H&P) dated 3/08/26, indicated R1 arrived at the emergency department (ED) and was found with acute hypoxic (lack of sufficient oxygen supply to body tissues) and hypercarbic respiratory failure (low oxygen levels with high carbon dioxide), intubation was complicated by tracheal stenosis (tightening of the trachea) immediately beyond the vocal cords with delayed ETT placement (Endotracheal Tube through the mouth/nose into the trachea to manage the airway) and a brief in-hospital cardiac arrest requiring CPR and was a concern for aspiration at the time of intubation as large food material was suctioned from the oropharynx (the middle part of the throat behind the mouth, comprising the soft palate, base of the tongue, tonsils, and side/back walls, which acts as a passage for air, food, and fluids, assisting in swallowing and speech). The H&P further indicated R1 had been G-tube dependent since January and was not supposed to be taking food or fluid orally. Nurse practitioner (NP) visit note on 2/25/26, indicated R1 was seen and had aspiration, coughing, resident continues strict NPO with staff reports she continues to seek out food and fluids. Resident reports she has been eating and coughs with swallowing. And a chest Xray was ordered to rule out aspiration pneumonia.R1's medical record indicated Chest Xray results dated 2/27/26, indicated no fluid/massed noted.On 2/27/26, a progress note indicated facility contacted R1's daughter to discuss guardianship due to extreme confusion, daughter agreed to discuss.NP visit note on 3/4/2026 indicated R1 presented with silent aspiration, cough, coarse lung sounds, R1 continued to report food and fluid intake by mouth despite strict NPO. Order placed for another chest x-ray. Results were read on 3/5/2026 with no negative results.A progress note dated 3/09/26 at 1:45 a.m., indicated resident sent to hospital unresponsive pulse 151 all other vitals were stable. 911 arrived O2 (oxygen) sats declined family notified.Email dated 3/11/26, related to the ongoing concerns with R1, interim Administrator indicated, When IDT was made aware resident was food seeking, IDT met and implemented intervention of monitoring order that entered on 02/19/2026.During interview on 3/09/2026 at 4:35 p.m., paramedic who responded to the call on 3/8/26 stated, the call came in at 12:40 a.m., and paramedics arrived at 1:00 a.m. R1 had heavy breathing and was unresponsive. R1's temp was 105 degrees Fahrenheit, BS (blood sugar) was in the 200s. When R1 arrived at the hospital, R1 was found to in acute hypoxic and hypercarbic respiratory failure. Intubation in the ER was complicated by large food particles from the oropharynx and a diagnosis of aspiration pneumonia. R1 had a brief cardiac arrest, requiring CPR and was admitted to the ICU with placement on a mechanical ventilation.During interview on 3/11/26 at 11:49 a.m., NP stated she was informed by the staff of R1's food seeking behaviors on 2/19/26, and when she saw R1 on 2/25/26, R1 nodded her head yes when she asked R1 if she was eating or drinking food. NP ordered chest xray, results were normal. In addition, the NP stated she saw R1 on 3/4/26, NP ordered another chest xray over concerns of her eating and the results were normal. During interview on 3/11/26 at 2:06 p.m., RD stated she was informed on 2/19/26, R1 was seeking food and was found drinking soda. RD stated on 2/19/26, she completed the risk vs. benefits form with R1 although her cognition was not good and was unable to repeat back her understanding, she felt education needed to be completed and R1 was her own person. In addition, an order was added to R1's treatment administration record (TAR), to observe for self-seeking food and fluids as needed and provide re-education as needed due to poor cognition. During interview and document review on 3/11/26 at 3:58 p.m., employee (E)-A stated two weeks ago she had observed R1 eating a gummy jolly rancher that another resident on R1's floor had given to R1. E-A stated she informed a registered nurse and was told he [E-A] could not give R1 candy due to her NPO status. In addition, E-A stated within the past couple of weeks, she had observed R1 wandering into other residents' rooms and had to stop her twice before she would try to eat food on the left-over room trays. (E)-A also stated she had seen R1 wandering all over the unit and had seen her in the dining room during and after meals. Review of R1's record lacked evidence of any action taken in response to these events.During interview on 3/11/26 at 4:08 p.m., facility SLP-A stated R1 had severe cognitive deficits, and wandered all around the unit. SLP-A stated R1 did not understand what NPO meant. SLP-A stated if R1 were to eat regular food or fluids, she was at high risk for aspiration which her swallow evaluation at the hospital indicated on 2/09/2026. R1's video swallow, completed at the hospital, indicated R1 had silent aspiration with thin liquids and deep penetration with all other trials and was recommended NPO.During interview on 3/11/26 at 8:15 a.m., licensed practical nurse (LPN)-A stated he worked the night shift on 3/07/26 to 3/08/26, and shift started at 10:30 p.m. LPN-A received report from the evening shift, R1 was now receiving bolus (large, intermittent doses) tube feedings. LPN-A stated he did his rounds at the start of the shift checking on his residents and R1 was sleeping. LPN-A then stated at 12:00 a.m., he was notified by nursing assistant (NA)-B resident was unresponsive. LPN-A called the charge nurse, registered nurse (RN)-A, to come to his floor while he checked R1's POLST (Physician Orders for Life-Sustaining Treatment) and R1 was full code (all necessary measure taken to sustain life) status. LPN-A stated, NA-A took R1's vital signs and was unaware R1's vitals indicated a temperature of 97.8 degrees Fahrenheit and the arriving paramedics received a temperature of 105 degrees Fahrenheit. During interview on 3/12/26 at 3:50 p.m., employee (E)-B stated she had seen R1 wandering all over the unit and had seen her in the dining room during and after meals. On 3/12/26 at 8:30 a.m., NP stated she was never informed R1 had eaten jolly rancher gummies and would expect to be immediately notified so a chest x-ray could be ordered and increased monitoring of R1's respiratory status, especially with the risk of eating food could cause aspiration and choking. During interview on 3/12/26 at 3:30 p.m., regional nurse consultant stated after 2/19/26, there had been no documentation of resident food seeking or wandering into rooms for food. Also, interviews with residents and staff show that no one had seen her attempting to get food or have food. Therefore, there was no need for the facility to implement stricter interventions since she wasn't demonstrating any further food seeking behaviors after the first intervention was implemented.Interview on 3/12/26 at 3:43 p.m., with medical doctor (MD)-A stated he is currently responsible for the care of [R1] and in reading [R1's] hospital note on 3/08/26, if she would have had food lodged in her oropharyngeal for a long period of time she would have been coughing constantly at all times and it would have been noticed, and her fever upon arrival at the emergency department of 105 is consistent with acute aspiration.The immediate jeopardy that began on 3/08/26, was removed on 3/13/26, when the facility completed a full house audit with residents who had modified diets. They audited care plans for those with modified diets and provided training to staff on modified diets and any changes made to care plans.

Based on interview and document review the facility failed to assess and develop a plan to ensure tube feeding needs were met for 1 of 1 resident (R1) reviewed who had a behavior of disconnecting her feeding and sustained over 13 pounds (lbs.) of weight loss in less than 30 days as a result. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's diagnoses included malnutrition, anxiety disorder and depression and was severely cognitively impaired, usually understood with unclear speech and had no behaviors. The MDS further indicated she required set up to partial assistance with activities of daily living (ADL)'s and was independent with mobility. In addition, the MDS indicated it was unknown if R1 had a weight gain or loss but received a tube feeding with a weight of 165 pounds (lbs.).R1's care plan (CP) dated 2/19/26, indicated R1 self seeks food and fluids while NPO (nothing by mouth), risk versus (vs) benefits completed on 2/19/26, and required reminders and redirection related to poor cognition. The CP further indicated she had actual alteration in nutrition and had weight loss over 30 days related to inadequate caloric intake as evidenced by disconnects feeding prior to end time. Risk vs benefit form completed on 3/02/26. R1's Risk vs. Benefits form dated 3/02/26, completed by the facility's registered dietician (RD) indicated resident was NPO status with tube feeding meeting 100% of R1's nutrition and hydration need. The risks related included: it was important that you [R1] keep your tube connected to the pump during this time to allow your body to obtain the adequate calories and protein and fluids/nutrients your body needs to stay healthy and maintain weight. Disconnecting your feeding tube prior to 9:00 a.m. could result in continued weight loss, malnutrition, dehydration, return to hospitalization or possible death. The form indicated the RD placed a call to primary family member (FM)-A to update and review. FM-A was in agreement with attempting bolus feeding (gravity used to slowly give the tube feedings over a 15-to-20-minute time period). Dietary progress note dated 3/02/26 at 4:41 p.m., indicated R1, exhibits significant weight loss over <30days [less than 30 days] weight series: 2/16/26 168lbs. to 3/2/26 155lbs. and confirmed with reweight. Down 13lbs/7.7%/<30days. Staff report res. [R1] often disconnects feeding prior to end time in morning thus resulting in inadequate calories via tube to support stable weight. Staff report res. often has high movement in bed, moving back and forth and tube at risk of being tugged or pulled on. Res. may tolerate and be more compliant w/ [with] bolus tube feeding regimen during day by gravity. Reviewed risk vs. benefits w/ res. Res. w/ poor cognition and difficult to assess understanding. Call placed to res. primary contact [family member (FM)-A]. Reviewed weight loss and risk vs. benefits. [FM-A] in agreement w/ bolus schedule. Re-estimated needs d/t [due to] wt [weight] loss: 155lbs actual wt 25-35cal/kg [calories per kilogram], 1-1.3g [grams] pro/kg [substance per kilogram], 30cc [cubic centimeters] fluid/kg: 1760-2450cal/day, 70-91g pro/day and 2100 cc fluid/day. I would recommend Osmolite (a therapeutic, fiber-free, ready-to-use enteral formula suitable for bolus feeding)1.5 bolus 1.5 cartons or 355cc QID (four times a day) via gravity. Flush 125 ml (milliliters) before and after each bolus feeding QID. New regimen would offer total of 2130cals, 89g pro/day and 2086cc fluid/day. Cont. w/ ok for ice chips per order, however not a significant source of fluids. Provider notified of wt loss r/t inadequate calories r/t res. Ill compliance to feeding regimen. Requested bolus schedule change and awaiting reply. RD to follow up as needed w/any changes to meal intakes or weights. Provider updated re: risk vs benefits education. RD to follow up as needed. Awaiting orders. An additional note on 3/03/26, completed by RD indicated, provider rec. [recommends] start bolus tube feeding schedule. New orders for Osmolite 1.5 355ml (1 and a half cartons) QID bolus by gravity w/ 125ml water pre and post bolus. Rec. weekly weights for observation of weight trends. RD to follow up as needed. R1's weights listed in point click care (PCC) (facilities computerized documentation system) indicated the following weights since admission on [DATE]:-2/16/2026- weight was 168.0 lbs.-2/18/2026- weight was 165.0 lbs.-2/28/26- a weight was documented as 166.8 lbs. (although the RD struck out the weight on 3/02/26 and wrote Incorrect Documentation.)-3/01/26- a weight was documented as 155.5 lbs.-3/02/26- weight was documented as 155.0 lbs.-3/07/26- weight was documented as 155.0 lbs. During interview on 3/10/26 at 5:32 p.m., family member (FM)-A stated she visited R1 on 2/27/26 noticed a brown colored substance on her bed sheets. When FM-A asked the staff, she was informed it was due to R1 disconnecting her tube feeding. FM-A stated the RD informed her of the weight loss on 3/02/26, when her feedings were changed to bolus feedings. During interview on 3/11/26 at 6:40 a.m., licensed practical nurse (LPN)-C stated he had been informed R1 was disconnecting her tube feeding but was unsure how long this occurred before she switched to bolus feedings on 3/02/36. During interview on 3/11/26 at 2:06 p.m., RD stated on 3/02/26, she discovered R1's weight loss and did strike out the weight listed on 2/28/26 in PCC since she knew it was an error after getting a second weight on 3/02/26 which showed R1's weight to be 155.0 lbs. RD found out, from talking to staff, R1 was disconnecting her tube feeding. RD stated R1 was on weekly weights due to being a new admission and had a new tube feeding. RD stated she then completed with Risk vs Benefit for disconnecting the tube feeding and received an order to start bolus feeding from R1's physician to decrease the amount of time the tube feeding is running. RD stated the order was changed to bolus feeding four times a day. During an additional interview on 3/13/26 at 12:44 p.m., RD indicated she was unsure when R1 started to disconnect her tube feeding. RD was made aware R1 was disconnecting the tube feeding, prior to the end time, the same day as the progress note (3/2/26). RD stated she did not talk to registered nurse (RN)-C about the incorrect weight and staff were not re-educated on incorrect weights and what they should do. During interview on 3/13/26 at 2:03 p.m., nursing assistant (NA)-C stated she has never seen R1 disconnect her tube feedings when she worked with her. Weight Policy dated 10/2012, indicated it is the policy of Monarch Healthcare Management to obtain accurate weights and provide monitoring to ensure each residents nutrition parameters are maintained within acceptable parameters to prevent avoidable decline in nutritional status, unless their clinical condition demonstrates that this is not possible. The policy indicated at the discretion of the interdisciplinary team and/or physician residents at high risk maybe continued more frequents weight monitoring.

Based on interview and document review, the facility failed to ensure newly developed areas of skin breakdown were promptly assessed to determine interventions needed to promote healing, ensure recommendations and orders for pressure ulcer care were acted upon timely to facilitate healing and reduce the risk of continued worsening for 1 of 4 residents (R4) reviewed. R4 developed skin breakdown on 12/6/25, that was not addressed until several days later and when R4 was seen by a wound care provider for the developed pressure injuries then the recommendations for care were not implemented until weeks later causing harm to R4 when he developed more pressure ulcers and his existing ones worsened. The facility took corrective action prior to the onsite survey, and these findings are being issued at past non-compliance. Findings include: R4's Monarch Healthcare Management (MHM) Weekly Skin Inspection, dated 11/30/25, identified R4 had a shower and listed a section to record his skin condition. The evaluation identified R4 allowed the skin inspection with findings recorded, Skin clean [,] dry and intact. R4's significant change Minimum Data Set (MDS), dated [DATE], identified R4 had moderate cognitive impairment, required moderate assistance with bed mobility (side-to-side rolling), and had no current unhealed pressure ulcer or injuries. R4's progress note, dated 12/3/25, identified R4's MDS was changed to a significant change in status (SCSA) MDS as R4 sustained a fall with a wrist fracture and was needing more assistance with cares transfers since returning from the hospital (on 12/2/25). R4's Braden Evaluation, dated 12/3/25, identified R4 had slightly limited sensory perception, had rare moisture exposure, and walked occasionally. This Braden evaluation scored R4 with a score, 19.0 [low risk]. R4's MHM Weekly Skin Inspection, dated 12/6/25, identified R4 had a shower and listed the same section to record R4's skin condition. This identified R4 allowed the skin examination to be completed and recorded, Ongoing open area on left buttock, other skin clean dry and intact. The evaluation lacked any measurements or wound characteristics of the area; no recorded dictation on what, if any, treatment was done for the area. R4's corresponding Pressure Ulcer/Injury Care Area Assessment (CAA), signed 12/11/25, identified R4 had frequent bowel and bladder incontinence, and required assistance with bed mobility and transfers causing the CAA to trigger for completion. The CAA outlined R4 had multiple medical conditions including a recent fall with a wrist fracture, dementia, diabetes mellitus, and stage III kidney disease. The CAA recorded, He does not have any pressure ulcers. The CAA identified R4 was at risk for skin breakdown and outlined the care plan focus would be to minimize his risk for them. R4's MHM Weekly Skin Inspection, dated 12/11/25, identified R4 had a bed bath and allowed a skin check to be done. The skin examination recorded, Noted redness and wound to his scrotum. The evaluation lacked dictation if this was the same area identified on 12/6/25, or if that prior area had healed or remained. The completed evaluation lacked any recorded treatments being done to the site(s). R4's SW - Skin Issues note, dated 12/12/25, identified R4 had a new skin issue acquired in-house on the sacrococcygeal area. This was recorded as moisture-associated skin damage (MASD) and measured 4.42 (L) X 3.19 (W) X 0.1 (D), with a total area of 10.1 (cm). There was no tunneling or undermining present. R4 had another skin issue on his left gluteus recorded as MASD. This was also acquired in-house and measured 1.92 (L) X 1.31 (W) X 0.1 (D), with a total area of 2.03 (cm). There was no tunneling or undermining present. A subsequent note, dated 12/12/25, identified R4 as having MASD to his scrotum and left buttocks. Barrier cream would be applied. R4's MHM Weekly Skin Inspection, dated 12/13/25, identified R4 had a shower and a skin check completed. The examination recorded R4's skin condition with, Ongoing wound scrotum and left gluteus areas. Other skin areas clean, dry, and intact. The completed evaluation lacked any recorded treatments being done to the site(s). R4's SW - Skin Issues note, dated 12/16/25, identified one wound was present on R4's sacrococcygeal area. It was recorded as MASD and listed as, Improving, with measurements listed 2.33 (L) X 6.35 (W) X 0.1 (D) and having a total area of 7.6 (cm2). There was no undermining or tunneling present. R4's IWC (Integrated Wound Care) Initial Progress Note, dated 12/16/25, identified R4 was seen by physician assistant (PA)-A who recorded R4 as being over [AGE] years old with a past medical history of stroke, delusional disorder, kidney disease, diabetes and severe calorie malnutrition. The note identified R4 had been followed by the facility registered dietician (RD) and had not been re-evaluated since developing skin breakdown. R4 was followed by the facility wound team for moisture-associated skin damage (MASD) and R4 remained incontinent of bowel and bladder and was unable to reposition himself. R4 . [has] scattered areas of erosions over right buttock and sacrum. Will recommend fastidious pericares, Triad paste to be applied BID and PRN [as needed], repositioning per facility Braden protocol and initiation of an APM [alternating pressure mattress]. Will ask dietitian to review current diet, supplement, and protein orders considering new skin breakdown. Will ask primary team to evaluate whether any changes to his care plan are indicated. The note recorded R4's only wound as: - #1 MASD Buttock/Sacrum (Right) measuring 2.3 (L) X 6.4 (W) X 0.1 (D) and having an area of 14.72 (cm). The wound had light serosanguinous drainage, and the tissue was recorded as, 100% Dermis. R4's Aeris History & Physical, dated 12/17/25, identified R4 was seen by the medical nurse practitioner (NP)-A to follow up on recently drawn labs. A physical exam indicated R4 had no acute distress and did not mention or review his skin condition or areas of breakdown. The NP wrote orders for more laboratory monitoring and to increase his scheduled insulin dose. R4's SW - Skin Issues note, dated 12/23/25, identified R4 had multiple skin issues present. These were recorded as: - #001 Sacrococcygeal area; pressure ulcer/injury; deteriorating progress. The staging recorded as, Unstageable pressure ulcer/injury . due to slough and / or eschar. The wound measured 4.59 (L) X 4.1 (W) X 0.1 (D) with a total area of 11.5 (cm2). There was no undermining or tunneling present and it had light drainage. - #002 Rear left thigh; MASD; stable condition. The wound was acquired in-house and was stable. The wound measured 0.7 (L) X 0.46 (W) X 0.1 (D) with a total area of .026 (cm2). R4's IWC Follow-Up Progress Note, dated 12/23/25, identified R4 was seen by physician assistant (PA)-A who recorded R4 as now being unable to reposition himself in bed. R4's sacral wound progressed to an unstageable pressure ulcer with moist necrotic tissue in the base. PA-A recorded, [I] expect that this will evolve to have significant depth. The requested APM was not in place but requested a second time. R4's blood glucose levels remained elevated and medication adjustments were ongoing. The note added, Does not appear that dietitian has updated evaluation of nutritional needs now since development of wound, will continue to request. Will start documenting the left glute wound separate from the sacrum, however this is not a new wound. The wounds were recorded as follows: - #1 Pressure ulcer Buttock/Sacrum (right), measuring 4.6 (L) X 4.1 (W) X 0.1 with a total surface area of 18.86 (cm). The wound had light drainage and no odor present, with a wound bed of 50% dermis and 50% eschar. - #2 MASD Buttocks; measuring 0.7 (L) X 0.5 (W) X 0.1 (D) with a total surface area of 0.35 (cm). The wound had light drainage present and a wound bed of 100% dermis. The note recorded a treatment for each wound with the pressure ulcer treatment listed as, Clean with WC or bath wipe, apply Triad Paste, BID & PRN. **Start APM and ensure Q2 hours repositioning orders are in place. Further, PA-A asked to have the RD evaluate and consider adding would healing supplement and protein supplement. R4's care plan, last reviewed 12/26/25, identified R4 had bowel and bladder incontinence and directed staff to check and change him every 2-3 hours and as needed. The care plan identified R4 was at risk for an alteration in skin integrity due to his past stroke history and cognitive impairments. R4 had a history of pressure ulcer(s) to his buttocks. A goal was listed for skin breakdown to be resolved by the next review period along with interventions including: - Staff to remind patient to offload and offer assistance to nap after each meal (resolved 12/16/25). - Monitor skin integrity during cares and weekly inspection by the nurse. - Assist of two with turning and repositioning (initiated 4/23/23). - Low air loss air bed, pressure redistribution (initiated 12/24/25). - Weekly measurements and assessment of wound (initiated 12/24/25). - Monitor for skin breakdown and signs of infection. Report to MD (initiated 12/24/25) - Followed by wound care (initiated 12/24/25). R4's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 12/2025, identified R4's medication administrations and treatments with staff initials to show them as completed. This identified the following orders: - MASD Buttock / Sacrum . Clean with WC or bath wipe, apply Triad Paste, BID [twice daily] & PRN, started on 12/17/25 and discontinued on 12/24/25. This was recorded as completed twice a day until 12/23/25. - Pressure Injury / Sacrum . Cleaned with WC or bath wipe, apply Triad Paste, BID & PRN, started on 12/24/25 and discontinued on 12/31/25. This was recorded as completed for each administration. - Air mattress - Monitor for working order and replace as needed, started on 12/29/25. This was first recorded as completed on 12/29/25 (PM shift). There were no recorded PRN treatments in these areas. The treatment on the TAR started on 12/17/25 (Triad Paste) was the first recorded treatment being done for R4's developed skin breakdown despite it being recorded by the staff on 12/6/25. There was no intervention recorded to demonstrate the barrier cream application (see 12/12/25 progress note) was being done or had been consistently completed. R4's Aeris History & Physical, dated 12/30/25, identified R4 was seen by NP-A for a regulatory visit. A physical exam recorded R4 as in no acute distress and did not mention or review his skin condition or areas of breakdown. The NP identified R4 had no concerns and that his blood sugars remained elevated. NP-A wrote orders for laboratory monitoring and to increase his scheduled insulin dose. R4's SW - Skin Issues note, dated 12/30/35, identified R4 had multiple skin issues present with more new areas recorded. These included: - #001 Sacrum; Pressure ulcer/Injury; deteriorating status. The staging was recorded as unstageable and wound measured 8.9 (L) X 5.8 (W) X 0.3 (D) with no undermining or tunneling present. - #002 Rear left thigh; MASD; unknown status. The area measured 0.9 (L) X 0.9 (W) X 0.1 (D) and was without undermining or tunneling. - #003 Scrotum; MASD; new wound acquired. The area measured 3.29 (L) X 3.24 (W) X 0.1 (D) with a total surface area of 6.79 (cm2). There was no undermining or tunneling noted. - #004 Buttocks; Pressure ulcer/Injury; new wound acquired. The staging recorded as unstageable and wound measured 6.46 (L) X 7.61 (W) X 0.3 (D) with no undermining or tunneling present. The wound bed had 10% granulation tissue and 90% eschar. R4's IWC Follow-Up Progress Note, dated 12/30/25, identified R4 was seen for wound care by an NP who recorded, Patient resting in bed. Having discomfort with position change. Multiple new areas noted today, found when completing routine rounds. Needs air mattress and Foot Boots. Has new area of MASD to scrotum, new diabetic wounds to bilateral feet, left lateral foot and unstageable PU [pressure ulcer] to the right gluteus. The NP recorded R4's pressure ulcer injury as: - #1 Pressure ulcer Buttock / Sacrum (right) measuring 8.9 (L) X 5.8 (W) X 0.3 (D) with a total surface area now of 51.62 (cm). The wound now had moderate drainage with a wound bed recorded as 80% granulation, 10% slough, and 10% DTI (deep tissue injury). The treatment was listed to clean the site with wash cloth, pat dry, apply a calcium alginate cut to fit the wound, then apply skin prep to the peri-wound and cover with an absorbent dressing, change every day. - #4 Pressure ulcer Buttock (Right) with no measurements recorded. This wound was recorded with 90% eschar and 10% granulation tissue present in the wound bed. The treatment was listed to be cleaned with a cloth and dried, skin prep applied to the peri-wound, and a hydrocolloid dressing be placed. That was also to be changed daily. R4's SW - Braden Scale, dated 12/30/25, was recorded as a late entry and identified R4 had no sensory perception impairment, having occasional moisture exposure, and being chairfast. This Braden evaluation scored R4 with a score, 16.0 [low risk]. R4's progress note, dated 1/2/26, identified R4 was short of breath and lethargic and was sent to the hospital via EMS. R4 did not return. R4's Pressure Injury Root Cause Analysis, dated 1/7/26, identified an interdisciplinary team (IDT) review of R4's developed unstageable pressure ulcer on his buttocks. The date of injury was 12/30/25. The form contained various items to be discussed and reviewed including Braden score(s), care plan interventions, nutritional risk and interventions, and floor staff interviews about their condition. R4's care plan was updated and the physician consulted about the wound. A section labeled, Actions Taken, identified R4's care plan was changed. R4's medical record was reviewed and lacked evidence R4 was comprehensively assessed by the IDT after the wound on his buttocks was identified on 12/6/25 to determine what interventions were needed to promote healing or reduce the risk for new ulcers; nor after the initial area continued to progress from MASD to a developed pressure ulcer. The record supported treatments were being done to these areas after 12/16/25 when R4 was seen by the PA/NP from IWC. None of their recommendations of dietary evaluation or an APM were acted upon until weeks later and just before R4 was hospitalized . The care plan lacked evidence of new skin interventions until 12/24/25 when the wound had been present for weeks prior. When interviewed on 2/26/26 at 12:24 p.m. nursing assistant (NA)-A stated they recalled working with R4 and explained he had been walking with assist of one until he fell from bed and broke his wrist (on 12/2/25). R4 then needed more help with mobility upon returning from the hospital. NA-A stated they recalled him having a little bit of skin breakdown on his buttocks but expressed it was managed by the nurses mostly. Barrier cream being applied to the area at times but was unsure of the timeline when that started or stopped. NA-A stated they felt staff were repositioning him every few hours during the shift, but this was not recorded in the record. When interviewed on 2/26/26 at 12:52 p.m. registered nurse (RN)-A stated R4 needed more help when he returned from the hospital with a wrist fracture. R4 was typically incontinent of bowel and bladder, and staff had to help him manage that. R4 had some MASD areas and did not know what happened with R4's skin issue. They thought he had always used a regular mattress while at the facility and did not recall an APM ever being placed on the bed. RN-A stated the director of nursing (DON) and assistant director of nursing (ADON) knew more information about R4. When interviewed on 2/26/26 at 1:12 p.m., the ADON and DON stated R4 returned from the hospital on [DATE] with a new wrist fracture and declined in status needing more help with cares. ADON stated R4 developed the pressure ulcer on 12/12/25 and it was not concerning at the time, then progressed and got bad several weeks later. DON verified the record lacked evidence that the RD had ever re-evaluated R4 despite the ongoing recommendations from PA-A. DON explained when a new skin issue or ulcer develops, the IDT review is completed using the paper form titled Pressure Injury Root Cause Analysis. This was to be completed with each new ulcer, but it was not done until after R4 had been hospitalized on [DATE] because the nurse manager and ADON were unaware it had to be done. DON stated education had since been completed with them to ensure these wounds were not missed again. ADON and DON reviewed R4's TAR and verified the first documented evidence of an APM being applied was on 12/29/25; and DON stated their Technical Environmental Life Safety (TELS) system supported that same date as when it was asked to be installed by maintenance. DON verified an APM was readily available at the campus to be installed within a day or two of being ordered or recommended. ADON stated they were unsure why they had updated R4's care plan to reflect the air mattress before it had been installed. At 1:33 p.m., RD-A joined the interview. RD-A stated they had not been notified until late December 2025 about R4's wounds needing to be evaluated for nutrition. RD-A stated the nurse managers or ADON should update them when the wound providers are making recommendations for nutritional review, and they would have recorded the review in the record. RD-A stated if they were told about R4 timely, they would have evaluated his calorie needs and started a supplement for him since he was not on one prior. DON and ADON acknowledged the lack of assessment from the IDT of the developed ulcers being done until after he had been hospitalized (nearly a month later) but both reiterated the re-education was provided after they discovered the missed care. When interviewed on 2/26/26 at 1:50 p.m., NP-A stated they were involved with R4's care while he was at the nursing home. NP-A stated R4 had diabetes, and they were actively trying to adjust his insulin several times to better control his blood sugars. R4 needed a mechanical lift for transfers towards the end of his stay at the center but did not have details of his skin condition. NP-A stated if skin issues were identified, they usually would tell the nurses to update the IWC so they could follow them and address it adding a specific referral was not needed for that. NP-A could not identify if R4's pressure ulcers were avoidable or not but stated if interventions and recommendations were acted upon timely then the wounds could have likely been less severe. During an interview on 2/27/26 at 10:02 a.m., PA-A stated R4 needing extensive assistance with bed mobility and transfers. R4 identified as high risk for skin breakdown which is why the recommendations for the IDT to review R4's needs and for RD to evaluate R4 were made. R4's MASD and evolution to a pressure ulcer was multi-factorial. PA-A stated the care center was expected to act on their recommendations for repositioning and wound care, having an APM installed at the start of the wound would have helped slow down the wound progression. PA-A stated it was hard to say whether the wounds were avoidable or not because the recommendations were not followed. A facility Skin Assessment & Wound Management policy, dated 2/2025, identified guidelines for assessing and managing wounds. This included completion of a Braden Scale, implementation of appropriate skin measures, completion of the skin evaluation and risk factors forms, and routine ongoing skin monitoring by the staff. The policy identified a section labeled, Pressure Wounds, which directed steps when a new ulcer was found. This included notifying the provider, completing education with the residents and family, initiating a skin and wound evaluation, referring them to dietary if needed, reviewing and updating the care plan interventions. The past noncompliance harm-level finding was corrected prior to the onsite survey exited on 2/27/26. The facility implemented multiple actions to address the noncompliance which included education provided to the nurse leadership team on expectations with a developed pressure wound, the nurse leadership team on MDS completion, and the nurse leadership on care planning and skin interventions. In addition, a sample of current residents with pressure ulcers were reviewed and identified no additional concerns with the care provided.

Based on interview and document review, the facility neglected to provide care and services to a resident with mental health needs who refused assessments and interventions since admission on [DATE], R1 was not transferred to a higher level of care despite facility and provider awareness for 1 of 3 residents (R1) who were reviewed for neglect of care when R1 contacted emergency medical services (EMS) because she felt dizzy, was vomiting, and could not move her lower extremities. When EMS arrived R1 was adhered to her mattress and covered in urine and feces. R1 admitted to the hospital malnourished, with maggots around her groin, bra hook embedded down to the muscle layer, reddened folds to right flank, pressure ulcers from stage one to stage four covered her entire back, open areas to coccyx, and bilateral gluteus, and skin tears along her posterior thighs. The immediate jeopardy began on 9/21/25, when facility failed to send R1 to a higher level of care when they were unable to provide hygiene, assess her skin, identify the cause of the unpleasant smell and suspected foot wound, for a bedridden resident and identified on 9/25/25. The administrator, regional director of operations, and director of nursing (DON) were notified of the immediate jeopardy at 5:10 p.m. on 9/25/25. The immediate jeopardy was removed on 9/25/25, but noncompliance remained at the lower scope and severity level 2 D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Hospital Discharge summary dated [DATE], indicated R1 was treated for back pain, and they found an abnormal lesion on her spine. During the hospitalization she had fixed delusions and refused medical care. She was placed on a court hold related to unwillingness to care for spine lesions and refused to have the surgical screw removed from her shoulder. R1's admission data assessment dated [DATE], indicated she refused to let staff examine her skin.R1's 48-hour care plan dated 7/8/25, indicated she had a self-care deficit related to back pain and schizophrenia. Her mobility was altered. She was continent of bowel and bladder and required help from one staff member to toilet. She was at risk for skin breakdown. Interventions included staff would complete weekly skin assessments and report any breakdown to the provider, turning every 2 hours, pressure relieving mattress, and wheelchair cushion.R1's care plan focus dated 7/8/25, indicated she had a risk for skin impairment related to incontinence and refusal of care. She preferred to lay in bed all the time and did not want staff to wake her up. Implemented turn and reposition every 2-3 hours. Monitor skin integrity daily during cares, placed pressure redistribution mattress and wheelchair cushion, and report concerns to the provider. R1's care plan focus dated 7/9/25, indicated she was at risk for malnutrition. Interventions included offer food and fluids, and alternative meals as requested. Offer ice cream, yogurt, and pudding and encourage her to eat meals. She received a supplement. R1's provider note dated 7/9/25, indicated R1 had an odor of unknown etiology, the room had a malodorous smell, concerned of a foot wound, R1 was very private about her body. R1 refused to answer question if she had any open skin areas. R1's clinical nutrition evaluation dated 7/9/25, indicated her weight was 180.5 pounds (lbs.) R1's admission Minimum Data Set (MDS) dated [DATE], indicated she had normal cognition, mild depression, delusions, and rejection of cares. She used a wheelchair for mobility, needed the assistance of one with toileting, shower, dressing, and transfer. Needed set up assistance for hygiene needs, and staff set up her meals. She was continent of bladder and had frequent stool incontinence. She had depression, Schizophrenia, and back pain. She did not have a risk for pressure ulcers, or any skin injuries. She took antipsychotic and seizure medications. R1's care plan focus dated 7/14/25, indicated her behaviors were related to trauma when she was hit by a car and sustained life-threatening injuries. Interventions included applying Associated Clinic of Psychology (ACP) recommendations. Use a trauma informed approach to care, work at her pace, and build trust. Staff would update the provider regarding any behavior changes. R1's Risk verse Benefits document dated 7/14/25, indicated she had refused care and vaccinations. She was at risk for health, hospitalization and or death. R1's weekly skin assessment dated [DATE], 7/22/25, 8/6/25, 8/12/25, 8/19/25, 8/26/25, 9/2/25, 9/9/25, 9/12/25, and 9/16/25, indicated she refused a bath and her skin checked by staff. R1's provider note dated 7/16/25 indicated R1 had mild anemia with a hemoglobin of 11.5, her basic metabolic panel was unremarkable. Staff stated R1 has been intermittently refusing cares and medications. R1 refuses treatment for lytic lesions.R1's provider note dated 7/18/25 indicated she was seen for pain management and rehabilitation recommendation. R1 did not appear to be in distress, no breakdown in hands or heels, moves all extremities, R1 had decreased endurance, activity of daily living impairment, muscle weakness, deep vein thrombosis risk, constipation risk, and skin breakdown risk due to decreased mobility. R1's Associated Clinic of Psychology (ACP) note date 7/21/25, indicated services were established.R1's facility doctor notes dated 7/22/25, indicated R1 refused a skin check, no distress, and R1 only permitted him to listen to her heart and lungs. No sign of infection, R1 denied any pain. R1 continued to have malodorous smell, and he was concerned she had a wound on her foot. R1's ACP note dated 8/1/25, indicated R1's chief complaint medication management. The ACP provider indicated R1 was malodorous and smelled of urine and fecal matter. R1 discussed her previous hospital stay, continues to have back pain and that is why she can not walk, but is working with physical therapy to get better as they check on her every once in a while. R1 was on a civil commitment with a [NAME] Order, with limited insight into her condition. A Psychotropic medication was increased. R1's ACP note dated 8/4/25 indicated R1 was wrapped in a blanket on an unmade mattress, less malodorous than prior visit, continues with delusional thinking, has poor insight and judgement. R1 does not appear to be ready to accept showers.R1's provider note dated 8/19/25 indicated she was seen in her room laying on her bed, paranoia and delusions noted during exam.R1's care conference dated 8/19/25, indicated no issues with pain, changes in her condition, or skin integrity. She was a full code. She needed the assistance from one staff to toilet. Staff would check and provide peri care every 2 to 3 hours. Resident stated she had bleeding from her gums. She indicated the reason she did not shower was a lack of privacy. They discussed her refusal of care, and it was emphasized if she were unwilling to comply with cares, the consequences would be a prolonged stay at the facility and poor prognosis. Dietary indicated her weight was 181.0 lbs. on 8/13/25, and she only ate ice cream, pudding, and yogurt. R1's ACP noted dated 9/5/25, indicated R1 was malodorous and lying in bed. Her insight and judgement are limited, reports being depressed, slightly more distressed. A medication for depression was prescribed.R1's ACP noted dated 9/8/25, indicated staff report concerns for mood, poor appetite, low intake, continuing to self-isolate, remaining in bed all of time, and will sometimes use provider towel to clean herself up, but is not showering. R1 is unkempt, wrapped in blanket lying on unmade mattress, poor oral hygiene and malodorous.R1's weight dated 9/10/25 by wheelchair at 9:00 p.m. was 180 lbs.R1's ACP note dated 9/15/25, indicated staff report ongoing concern for mood, low intake, continuing self-isolate in room. R1 remains in bed all the time. A county assessor visited to assess relocation services.R1 hospital note dated 9/21/25, indicated she was admitted to the hospital after she called EMS. She arrived with the mattress adhered to her. Her bra and a pill were stuck to her back. Urine, stool, and wounds were found along with maggots on her groin. Records indicated R1 weighed 152 lbs. upon admission. R1's care plan intervention dated 9/22/25 for a focus of refusing cares and fixed delusions, indicated she was private about her body and refused help to bathe and complete skin checks. She refused to answer the provider when asked if she had any open wounds. Interview with the physician assistant (PA)-A on 9/24/25 at 9:11 a.m., stated R1 had to be decontaminated before surgery, her entire back was a pressure ulcer, and her bra strap hooks broke down the skin into the muscle in her back. R1's INR was so high related to malnutrition that the surgery had to be performed in two episodes. Interview on 9/24/25 at 11:15 a.m., registered nurse (RN)-A stated every time she attempted to help R1, she would yell no and get out. She was unable to touch the resident during her stay, she told the manager and provider regarding the refusal of care. They would bring her linen, and bathing supplies to help her clean up. They would stand outside the room with the door cracked to encourage her, but the resident refused. The room smelled, and when a new resident was assigned to the same room, they ended up walking out the door and family stated it was because of the smell in the room.Interview on 9/24/25 at 2:27 p.m., social worker (SW)-A indicated they did not report to the state concerns regarding rejection of care. R1 was visited by ACP weekly and a psychiatrist monthly. They were trying to build trust with her. Every time she saw R1, she would always be in bed with 2 to 3 blankets covering her. Interview on 9/24/25 at 2:48 p.m., the DON indicated she did not know the severity of R1's condition. She did not feel R1 was trying to harm herself. They had ACP and the psychiatrist assessing her regularly. The facility medical doctor saw her on 9/13/25, and did not bring any concerns regarding a need to transfer to the hospital. They were trying to balance R1's refusals while maintaining her right to refuse care. They had no indication what was happening to the resident under the covers. Interview on 9/25/25 at 9:10 a.m., the administrator stated when a resident refused care the process included, updating the provider, complete a risk verse benefit assessment, educate, and update the care plan. She did not feel the situation rose to the level of self-harm, but more self-neglect on R1's part. She did not have a change in condition or indicated a need for hospitalization. Since R1 left the facility, they did an investigation and taught their staff to find a way to negotiate the residence compliance with care. Interview on 9/25/25 at 9:50 a.m., medical director (MD-A) stated a higher level of care would be the skilled nursing facility or a hospital. He was unable to say if R1 had self-injuring behaviors. He wished the hospital would have pursued a guardianship for her so they would have had more help to manage her behaviors.Interview on 9/25/25 at 2:16 p.m., Paramedic (P)-A stated R1 called EMS because she lost feeling in both of her legs. He found her lying directly on the vinyl mattress top. She had a urine and feces-soaked towel between her legs, and a basin with bloody emesis next to the bed. They were unable to roll her in bed because her body was adhered to the mattress. They cut the top layer of the mattress off to transport her. She looked sick, dehydrated, and the room smelled like infection, urine, and stool. Staff told him R1 refused to let them care for her. His emotions got the best of him, and he was unable to engage with the staff anymore. He just focused on transporting R1 to the hospital. The immediate jeopardy that began on 9/21/25, was removed on 9/25/25, when the facility completed a full house skin check audit. If a resident had refused, a skin check was done. They audited all care plans for refusing skin checks. Updated target behavior orders to include a section regarding refusal of cares, showers, and skin checks. Clinical team would attend weekly ACP meetings to discuss concerning behaviors and update care plans. Morning meeting agenda now includes a section for refusal of care. In case of refusal staff would update the individual department team (IDT) meetings, schedule care conference, do a behavior contract or other individual specific interventions.

Based on interview and record review, the facility failed to follow R1's Physician Orders for Life-Sustaining Treatment (POLST) do not attempt resuscitation (DNR), do not intubate (DNI), and to allow natural death for one of three residents (R1) reviewed for cardiopulmonary resuscitation (CPR). R1 was found unconscious in his room in his wheelchair and registered nurse (RN)-A and licensed practical nurse (LPN)-B initiated CPR when R1 requested DNR/DNI, allowing for natural death, potentially complicating R1's rights by unnecessary life-saving measures. The past noncompliance immediate jeopardy began on [DATE] when RN-A and LPN-B initiated CPR on R1, who's wishes were DNR/DNI. RN-G and Administrator-A were notified of the immediate jeopardy at 9:44 a.m. on [DATE]. The immediate jeopardy was removed, and the deficient practice was corrected on [DATE], after the facility implemented a systemic plan to correct the deficient practice prior to the start of the survey, therefore, the IJ was issued at past non-compliance.Findings include: R1's admission record obtained on [DATE] indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia. R1's additional diagnoses included chest pain, alcohol abuse, dependence on supplemental oxygen, and hypoxemia. R1's care plan dated [DATE] indicated staff would follow POLST guidelines. R1's POLST dated [DATE] indicated R1 was to receive resuscitation/CPR. R1 was to receive full treatment using intubation, advanced airway interventions, and mechanical ventilation as indicated. R1 was to be transferred to the hospital and/or intensive care unit if indicated. The treatment plan would include full treatment including life support measures in the intensive care unit. R1's POLST dated [DATE] indicated R1 was to not be resuscitated and to allow natural death. R1 was to have his pain and suffering controlled using any medication by any route, positioning, wound care, and other measures. R1 could receive oxygen, suction and manual treatment of airway obstruction as needed for comfort. R1 preferred no transfers to the hospital for life-sustaining treatments. R1's progress note dated [DATE] indicated RN-A saw R1 slumped in his wheelchair while doing 2:00 a.m. rounds, called R1's name but no response was given. RN-A checked R1's pulse, called a code blue, and emergency medical services (EMS) was called. CPR was initiated while waiting for paramedics. EMS arrived and requested R1's POLST which was dated [DATE] indicating full code treatment. RN-A then found R1's most recent POLST status and EMS stopped all CPR. During an interview on [DATE] at 11:11 a.m., RN-F stated she was alerted by NA-B that RN-A needed help in R1's room. RN-F went to R1's room and saw R1 slumped in his wheelchair and RN-A standing in the room. The crash cart and automated external defibrillator (AED). RN-A and RN-F lowered R1 to the floor. RN-F attempted to place the AED pads on R1, but they did not stick to him, so she went to get another set of AED pads. During this time, RN-F saw that EMS had arrived and RN-F directed them to R1's room. LPN-B was performing CPR when EMS arrived to R1's room. RN-A came back to RN-F and stated EMS was wanting to know R1's code status. RN-F checked the code status on the computer, and it stated DNR, but EMS stated they wanted a hard copy of the DNR. RN-F brought EMS the hard copy of the DNR/DNI order and EMS stopped CPR. RN-F stated she had assumed RN-A had already known R1's code status because she was R1's primary nurse. During an interview on [DATE] at 1:09 p.m., RN-A stated she went in R1's room to do her 2:00 a.m. rounds when she saw R1 in his room slumped in his wheelchair. RN-A checked R1's pulse and he had no pulse. RN-A called NA-B for help and instructed her to get RN-F and LPN-B. Once RN-F arrived, RN-A and RN-F got R1 off his wheelchair and onto the floor. RN-F applied the AED pad, but they were not sticky enough to use. NA-B called EMS. LPN-B arrived and initiated CPR. LPN-B became fatigued, and RN-A took over CPR. RN-F left to get a different set of AED pads and noted EMS had arrived. RN-F directed EMS to R1's room where LPN-B was performing CPR. EMS took over CPR. EMS asked for R1's current POLST. RN-A found a POLST from [DATE] which indicated R1 was to receive full code. EMS stated R1 was in the hospital recently and asked if his code status changed while in the hospital. RN-F looked on the computer system and noted that R1 was to receive DNR/DNI. RN-F told EMS that R1 was a DNR/DNI and EMS had stopped CPR and allowed natural death. RN-A stated she freaked out during the incident and she should have checked the code status prior to initiating CPR. During an interview on [DATE] at 1:36 p.m., RN-G stated she would expect that a nurse would check a resident's code status prior to initiating CPR. After RN-A and LPN-B completed CPR on R1, RN-G stated administrator-A and herself suspended RN-A and LPN-B pending the facility's investigation. Both RN-A and LPN-B received a final warning for not following a resident's care plan. RN-G stated administrator-A completed an audit on all resident's POLST's to ensure they matched what was in the resident's care plan and computer system. During an interview on [DATE] at 1:44 p.m., administrator-A stated after RN-A and LPN-B initiated CPR on R1 despite his DNR/DNI orders, the facility started an investigation. Administrator-A initiated education for all licensed nurses that included the definition of a code blue, what to do if a staff member round a resident unresponsive, how to page a code blue, how to respond to a code blue, what types of items need to be brought to a code blue, how to check a resident's POLST in the computer system, who can provide CPR, communication during and after a code blue, the crash cart, and CPR certification. The education was followed up by a quiz. This education was completed by 17 of 19 licensed nurses. The facility also completed an audit to ensure all licensed nurses had current basic life support (BLS) certifications. The facility completed a full audit to check resident's code statuses to ensure what they had in paper matched what was on the resident's care plan and the resident's profile in the computer system. The facility reviewed their CPR policy. The facility had completed CPR drills and code blue drills on all staff on all shifts. RN-A and LPN-B was provided a corrective action plan and further education about CPR and the process of a code blue. Administration completed full mock codes with RN-A and LPN-B. RN-A and LPN-B were suspended during this investigation. During an interview on [DATE] at 9:08 a.m., LPN-B stated she heard RN-A yelling for help. When she went to R1's room, RN-A and RN-F were in the room. RN-F had placed the AED pads. LPN-B stated she assumed RN-A or RN-F had already checked R1's code status. LPN-B stated she initiated CPR. Once EMS arrived, EMS took over performing CPR. LPN-B stated she did not check R1's code status because she thought RN-A and RN-F had already confirmed the code status. The facility's Cardiopulmonary Resuscitation policy revised on 12/2024 indicated CPR would not be initiated if the resident had a valid do not resuscitated order in place. The past non-compliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice was corrected by [DATE], after the facility implemented a systemic plan that included education for all licensed nurses that included the definition of a code blue, what to do if a staff member round a resident unresponsive, how to page a code blue, how to respond to a code blue, what types of items need to be brought to a code blue, how to check a resident's POLST in the computer system, who can provide CPR, communication during and after a code blue, the crash cart, and CPR certification. The education was followed up by a quiz. The facility also completed an audit to ensure all licensed nurses had current basic life support (BLS) certifications. The facility completed a full audit to check resident's code statuses to ensure what they had in paper matched what was on the resident's care plan and the resident's profile in the computer system. The facility reviewed their CPR policy. The facility had completed CPR drills and code blue drills on all staff on all shifts. RN-A and LPN-B were provided a corrective action plan and further education about CPR and the process of a code blue. Administration completed full mock codes with RN-A and LPN-B. RN-A and LPN-B were suspended during this investigation.

Based on observation, interview, and document review the facility failed to provide adequate levels of supervision to prevent elopement for 1 of 1 residents (R1) who required 24/7 supervision, resided on a locked unit and left the facility without their knowledge. This resulted in an Immediate Jeopardy (IJ) situation for R1. The IJ began on 6/10/25, when R1 was not provided with adequate supervision during an outside activity which resulted in R1 leaving the facility at approximately 1:23 p.m., he was found by police at approximately 1:46 p.m. on a busy street about a half mile away from the facility. The administrator, director of nursing and regional nurse consultant (RNC)-A were notified of the immediate jeopardy on 6/24/25, at 11:42 a.m. The facility implemented immediate corrective action on 6/10/25 to prevent recurrence, so the IJ was issued at past non-compliance. Findings include: R1's Hospital discharge summary provider note dated 3/14/25, identified R1 had orders to reside in a locked unit due to profound cognitive impairment due to severe Traumatic Brain Injury (TBI) where the person has experienced a period of unconsciousness due to head trauma. Psych evaluated and agreed R1 lacked decision making ability and had a history of an elopement at the hospital in September 2024. Will need to continue to wear helmet on head when the head of bed is greater than 30 degrees until cranioplasty (repair the bone in the skull) is performed. Needs 24/7 supervision. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and was independent with activities of daily living. R1 had diagnoses of traumatic brain injury (a brain injury caused by an external force, blow to the head or a jolt), hemicraniotomy (a neurosurgical procedure where a portion of the skull is removed to relieve pressure on the brain), intracranial injury with loss of consciousness, nicotine dependence and metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the body). R1's Elopement Risk Evaluation dated 3/14/25, indicated R1 was at risk for elopement due to habit/history of wandering or attempts to leave the unit/building, was ambulatory or able to self-propel wheelchair, asking to go home or other specific destinations, cognitive deficit diagnosis and family had voiced concerns that resident may have a tendency to wander or elope. R1 scored a 5, which identified a score of 4 or greater indicated a potential for elopement. Goals of care identified R1 will not leave the building alone and will follow Leave of Absence (LOA) policy. Interventions identified wanderguard will be monitored for proper functioning, door alarms will be answered promptly, guardian will be kept informed and will be invited to activity of their choosing. R1's Care plan dated 3/14/25 identified a focus of at risk for elopement with corresponding goals R1 will not leave the building alone. Interventions included door alarms will be answered promptly, guardian will be kept informed and will be invited to activities of their choosing. R1's Care plan dated 6/11/25, identified focus of risk for elopement due to wandering, impaired cognition, statement of wanting to leave, and history of elopement with corresponding goals that included, the resident will not leave the building alone. Interventions included wanderguard in place, wanderguard will be monitored for proper functioning, door alarms will be answered promptly, guardian will be kept informed and will be invited to activities of their choosing. R1's facility Progress Notes noted the following: 6/10/25 at 2:09 p.m., R1 went downstairs in the front lobby with the activity director, took off, Minneapolis police was called, description of R1 was given, R1 was later brought back to the facility by officer, alert and oriented per resident baseline. 6/10/25 at 2:27 p.m., identified R1 did not return with white helmet. Writer asked R1 where his helmet was. R1 stated he threw the helmet away when he took off. 6/10/25 at 2:30 p.m., R1 was taken outside the facility to the parking lot to pet baby goats, At 1:23 p.m., R1 was noted missing by staff. Police were called. R1 was located, skin checks completed with no pain or discomfort noted. R1 was placed back on the secured unit, oriented to self, place, season and safe. 15-minute safety checks order initiated. 6/10/25 at 3:19 p.m., at around 12:50 p.m., R1 went down to see the baby goats that were in the front of the building with staff. Around 1:23 p.m., R1 was noted to be missing from the front parking lot. TR director immediately notified the administrator. Administrator immediately initiated elopement protocols. Administrator notified Minneapolis police. Minneapolis police sent several squad cars to patrol the area. At around 1:46 p.m., R1 returned to the facility with the police. R1 had no injuries. Skin check and vital signs completed by nurse. R1's guardian and primary care provider updated. Facility filed Office of Health Facility Complaints (OHFC) and started education and investigation. During an interview on 6/23/25 at 10:01 a.m., Director of therapy (DOT)-A indicated R1 had severe cognitive impairment due to his brain injury and would not be safe in the community unsupervised. R1 was quick and completely independent with mobility and would run. R1 was also very impulsive and does not have the insight to know if traffic lights are red or green he would run right through them. DOT-A stated the likelihood of R1 getting hurt unsupervised in the community was very high, when R1 eloped on 6/10/25, he had the risk of being mugged, going with a stranger, getting hit by a car in traffic, we are lucky he wasn't killed. During observation and interview on 6/23/25 at 10:33 a.m., R1 was lying in his bed in his room with his helmet off. R1 stated a couple weeks ago he was outside with the goats, and he took off because he was mad and wanted a cigarette. R1 further stated the police came for him and it was not fun. I was somewhere in Minneapolis, I did not know how to get back here, I was scared. During an interview on 6/23/25 at 11:11 a.m., Activity Director (AD)-A indicated on 6/10/25, she had brought three residents from the locked unit down to the goat activity and one of them was R1 around 1:05 p.m AD-A stated she went to bring another resident back up to the locked unit and asked the activity assistant (AA)-A to keep an eye on R1. When she got back around 1:10 p.m. R1 was gone. AD-A stated she immediately notified the administrator and started looking for R1 in our vehicles. AD-A further stated when she first brought R1 down another resident had given R1 a cigarette and the cigarette was removed which upset R1. The police did end up finding R1 about 4 blocks from the facility. During an interview on 6/23/25 at 1:54 p.m., AA-A stated R1 was outside on 6/10/25, when the baby goat petting activity was going on before lunch time. AA-A stated another resident had given R1 a cigarette and AD-A took it away from him and R1 was very upset and went to sit next to another resident. AA-A stated he had too many other residents to keep an eye on and was not aware R1 was going to take off like he did. AA-A stated AD-A came back down asked where R1 was and then we were all looking for him. During an interview on 6/23/25 at 10:59 a.m., nursing assistant (NA)-A stated she was working the secured unit where R1 resided the day he eloped. NA-A indicated R1 went to see the [NAME] goats outside and someone wasn't watching him, he was gone and he can run very fast. NA-A stated R1 was constantly asking to go outside, he was always looking to get out pacing up and down the halls to go for a walk trying to get out. During an interview on 6/23/25 at 10:41 a.m., licensed practical nurse (LPN)-A stated she was working the secured unit that R1 resided on the day he eloped. LPN-A indicated the activity director called her around lunch time and asked if R1 was on the unit and she told activity director he was not. LPN-A stated it was not safe for R1 to be outside unsupervised, if he was running trying to get away, he could have been killed in traffic. During an interview on 6/23/25 at 11:40 a.m., Receptionist (R)-A indicated she worked 6/10/25. AA-A asked her sometime before lunch if she had seen R1, she told him no. R-A stated she immediately went outside and started looking for him. The police found him about 4 blocks away from the facility. R-A further stated R1 resided on a locked unit and residents from the locked unit require supervision. During an interview on 6/23/25 at 2:13 p.m., LPN-B stated she was the unit manager for R1 and had worked the day R1 had eloped. LPN-B stated the root cause of R1's elopement was lack of supervision and R1 was someone who definitely needed supervision. LPN-B stated after the elopement all Interdisciplinary team (IDT) members met and went over the elopement policy and immediately started education to all staff that anyone residing on the locked unit needed 1:1 supervision when taken off the unit. LPN-B further stated R1 was also placed on 15-minute checks and a wanderguard was put on his left wrist. During an interview on 6/23/25 at 2:50 p.m., DON indicated he was notified R1 was missing via text message from the administrator. DON further indicated R1 was found 4 blocks away by police and brought back 20 minutes later to the facility unharmed. DON stated the root cause of the elopement was inadequate supervision, the person responsible for watching R1 that day was brushed onto someone else. DON further stated everyone residing on the locked unit required 1:1 supervision when outside the locked unit and are all at risk for elopement. During an interview on 6/23/25 at 3:17 p.m., administrator stated she was notified by AD-A at 1:23 p.m. that R1 was missing from the facility after an activity in the parking lot. Administrator indicated she shot out a group text message to all department heads to delegate directions and got in her car to search for R1. Administrator stated she flagged down the police in the road and gave them a picture of R1 and they assisted with the search of four squad cars. Administrator further stated R1 was found about 21 minutes later around 1:45 p.m., about a half mile from the facility, on the corner of [NAME] avenue and [NAME] avenue north by the police and was brought back unharmed without his helmet. Administrator stated the root cause of the elopement was lack of supervision from our staff. During an interview on 6/23/25 at 4:28 p.m., medical director (MD)-A indicated if the root cause of R1's elopement was lack of supervision and resided on a locked unit, an appropriate prevention intervention would be to provide 1:1 to supervision when taken off the unit. During an interview on 6/23/25 at 4:28 p.m., guardian (G)-A stated the facility notified her of R1's elopement from the facility on 6/10/25. G-A further stated she told the facility if R1 was unsupervised he would run, he was on a locked unit for a reason. G-A indicated she was grateful he was not lost and that he was back safe. Facility policy titled, Elopements policy revised 6/2023 .the facility will implement interventions to minimize these risks and hazards as appropriate. For residents at risk of elopement Missing Resident Event Documentation should include an admission assessment, which may indicate potential to wander or exit facility. Care plan that addresses potential to wander or exit facility and the measures taken to prevent wandering/elopement. All attempts to elope, efforts to locate, notification and results of efforts. Full observation/visualization after an elopement for any injuries or new symptoms or conditions which may have developed. Entries that are time specific to reflect the responsiveness and Timeliness of actions taken to locate and assess the resident. Bracelet alarm/device is in place and functioning (per TAR or other form of documentation), if applicable. The facility will implement the following plan for conducting internal and external searches to locate missing residents. If a resident is discovered missing or is suspected of having eloped, the charge nurse takes the following steps: The charge nurse will initiate a search of the unit upon which the resident resides, with all employees assigned to the unit. The charge nurse will notify the Administrator or nursing supervisor if the resident cannot be located on the assigned unit. The nursing supervisor will take over as the Search Coordinator in the absence of the Administrator. The past-noncompliance immediate jeopardy began on 6/10/25, and was removed on 6/10/25, when the facility implemented a systemic plan to ensure all residents were safe. On 6/10/25, a facility-wide elopement risk assessment was completed that day, and care plans were updated with individualized interventions. Staff received targeted education prior to their shifts on the elopement policy, and emphasizing the requirement for 1:1 supervision for residents from the secured unit when outside.

Based on interview and document review, the facility failed to have a system in place to train staff on the process for unlocking the main entrance doors for emergency medical services (EMS) personnel after hours when the doors were locked from 10:00 p.m. to 7:00 a.m R2 had difficulty breathing, 911 was call, and EMS personnel could not gain entrance to the building for ten minutes. This deficient practice placed all 81 residents residing in the facility at risk for serious harm, impairment or death (immediate jeopardy [IJ]) for delayed EMS response. The IJ began on 7/29/24 at 2:29 a.m. when R2 reported difficulty breathing, and staff phoned 911 at approximately 2:09 a.m. on 7/29/24. When EMS arrived at the facility, the doors were locked. A staff member attempted to open the doors and were unable. EMS was unable to enter the building for approximately 10 minutes. The administrator and director of nursing (DON) were notified of the IJ on 8/8/24 at 4:51 p.m. The IJ was removed on 8/9/24 at 11:46 a.m., but noncompliance remained at the lower scope and severity level of an F, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The Daily Census dated 8/5/24 and provided by the facility on 8/6/24 indicated the facility census was 81 residents. R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact, had no behaviors, and required assistance of two staff for transfers. R2's Diagnoses List undated, included kidney disease, diabetes, dialysis treatments, and left below the knee amputation. On 7/29/24 at 2:09 a.m., a progress note indicated R2 reported difficulty breathing and staff phoned 911, and emergency medical services (EMS) arrived at approximately 2:29 a.m. On 8/7/24 at 11:22 a.m., the administrator stated the front doors were locked at night, as some residents had a dealer dropping off drugs at night. The nurses had keys to the front doors at night. She was not aware there were issues unlocking the doors timely during the night. On 8/7/24 at 12:53 p.m., nursing assistant (NA)-A stated the nurse who was working on first floor on 7/29/24 night shift was an agency staff, and couldn't find the key to open the door. NA-B tried to open the door, but didn't know how. NA-A was able to open the door with the keys from the first floor nursing station's medication cart after NA-B tried, and then asked for help from other staff on second floor. There had been other times when staff could not open the door. She did not report the problem to administration because she thought the nurses would. There was usually one nurse on first floor, one on second floor, and 4-5 NAs in the building on night shift. On 8/7/24 at 2:07 p.m., during a subsequent interview, the administrator stated only the nurse on first floor station one [near the front door] had the key to unlock the door at night. Reception staff didn't work at night, and the NAs could get the key from the nurse to unlock the door as needed. Staff were trained about a year ago to open the door, but she could not provide proof of the education. The NAs could open the door if they got the key from the nurse, but would have to remove the key from the key ring as it was on the first floor medication cart key ring. An email sent by the administrator on 8/8/24 at 2:32 p.m., indicated since 7/1/24, 123 shifts were covered by agency staff, of that, 30 were night shift nurses. On 8/7/24 at 2:56 p.m., registered nurse (RN)-A stated agency staff did not know how to unlock the door after hours. Staff who can open the door must know which keys go to which doors. On 8/7/24 at 3:10 p.m., licensed practical nurse (LPN)-A stated the nurse who worked first floor was responsible to open the door for EMS staff, or they could give the keys to another nurse or NA to unlock the doors. The key to the front door was on the key ring to the first floor medication cart. On 8/7/24 at 3:22 p.m., RN-B, an agency staff, stated no one had ever shown her how to unlock the front door after hours when it was locked. On 8/7/24 at 3:53 p.m., paramedic (P)-A stated when EMS arrived at the facility, the doors were locked. The staff member who attempted to open the doors could not do so, and left. The staff person came back with a staff who had keys to unlock the door, which allowed EMS to enter the building. EMS were unable to enter the building for up to 10 minutes. P-A stated, A breathing problem is a high priority call and emergency. The fire department arrived at the facility prior to the ambulance team. It was unusual the fire team was still outside, as typically the fire team was already with the resident when the ambulance team arrived. But this time the fire captain was pounding on the door to get in. The fire department has previously had significant issues getting access to this facility during other incidents in the night hours. On 8/7/24 at 4:44 p.m., NA-B stated R2 stated she was short of breath, It's not gotten that bad before and I haven't seen her go to the hospital for something like that. There was one key for the front door, the nurse on first floor kept it at night, and he had not been taught how to open the door. He had tried to open the door twice that night, and when he could not, he went to second floor to ask staff for help. He didn't know how long that took. He had not reported the issue to administration because he thought NA-A did. On 8/8/24 at 8:59 a.m., fire captain (FC)-A stated the facility had a two-step system lock on the facility front door, and night staff did not know how to open the door for the emergency call for R2. One staff came to the door twice, couldn't unlock the door, and left without speaking to the fire or ambulance staff. The staff person then came back with another staff who was unable to unlock the door, and it took 10 minutes to get the door unlocked. In 10 minutes, the resident could have gone from having difficulty breathing to full arrest or death. The fire department had been to the facility 23 times since July 1, 2024, and had difficulty getting into the facility about every other call. If there is a fire, they won't be able to get people out. Everyone needs to know how to let us in. On 8/8/24 at 9:41 a.m., NA-C stated she had not been trained how to unlock the door, and she didn't know who had a key to unlock the door. Agency staff who were working on 7/29/24 night shift did not know how to open the door. She did not report it to administration because the night NA staff was gone before administration came for day shift, and she thought the nurses would report it. It took 10-15 minutes to get the door open. On 8/8/24 at 10:35 a.m., the DON stated she was responsible for staff training, but did not train staff how to unlock the door, and agency staff education did not include how to unlock the front doors. A 10-minute delay could cause the death to someone who needed assistance. The facility had not met with fire staff in the last four years, and did not know they were having access problems. She did not know why staff didn't tell her about it. Staff should wait at the door when 911 was called. The door was locked at night for night shift, and was unlocked in time for morning shift to enter. On 8/8/24 at 2:13 p.m., the administrator stated two nurses and four NAs work night shift. On 8/8/24 at 2:35 p.m., RN-A stated the doors were secured from entering the building and exiting the building. Agency staff usually did not know how to open the door, but should be taught by facility staff. On 8/8/24 at 2:50 p.m., P-B stated EMS staff had trouble getting in the facility during the night. On 8/8/24 at 2:54 p.m., a sign on the front door directed visitors to the back of the building if they were unable to get in, and to ring the bell to alert staff. Receptionist (R)-A stated the sign had been posted for a couple of months. On 8/8/24 at 3:24 p.m. the maintenance staff (M)-A stated there were no problems with locking the doors, and they only locked from the inside, and not the outside. The staff should know how to open it. A lock was installed during COVID, and he had not heard of anyone having access issues at night. Usually when visitors came, the nurses opened the door. Nurses should be at the door to let EMS in at night. The nurses lock the door anywhere between 8 p.m. to 10:30 p.m. The facility put the lock on because residents tried to leave at night. On 8/9/24 at 1:16 p.m., during a subsequent interview, P-B stated when his EMS crew came at night, it took up to 10 minutes for staff to let them in the door. This had occurred 3-4 times over the previous four weeks. He had commented about the delays to the staff each time, but had not contacted facility administration. The EMS crew pounded on the doors to get staff to let them in. A policy for locking the door was requested and not provided. The immediate jeopardy that began on 7/29/24 was removed on 8/9/24, after nursing staff was educated about the unlocking the doors timely for emergency personnel, with the expectation staff would meet emergency personnel at the front door, assist them to the elevator, and direct them to the resident who required emergency assistance. The facility provided education about how to unlock the front doors, and staff demonstrated they could open the front doors. The facility educated staff how to push the doors open with the emergency bar for emergency egress, posted instructions at each nursing station that had a key to the door, and provided instructions for who to call for maintenance including maintenance staff, the DON, and the administrator. The facility contacted the Minneapolis fire chief to ensure the fire department staff were aware of the building door codes. This was verified through observation, interview and document review.

Based on interview and document review, the facility failed to ensure resident protection from abuse when staff pinched a resident for 1 of 4 residents (R4) reviewed for abuse. The concierge assistant (CA) pinched R4 after R4 punched CA in the chest. R4 was immediately assessed and found to have a reddened area with pain at the location of the pinch. This resulted in immediate jeopardy (IJ). The IJ began on 7/18/22, at approximately 8:00 p.m. when R4 was heard yelling that she was pinched while being wheeled towards the nursing station by the concierge assistant (CA) and was found to have redness and pain rated 9/10 to her right scapular (shoulder blade) area. The administrator and director of nursing (DON) were notified of the IJ on 7/22/22, at 11:57 a.m. The IJ was removed on 7/23/22, at 10:45 a.m. but non-compliance remained at a lower scope and severity of D - isolated scope and severity which indicated no actual harm with the potential for more than minimal harm, that is not IJ. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], noted R4 had severely impaired cognition and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Vulnerable Adult Maltreatment Report dated 7/18/22, filed by the facility to the State Agency (SA) noted R4 was heard yelling at the CA that she pinched her, when Registered Nurse (RN)-A asked the CA why she pinched the resident, the CA replied she hit me in the chest. A progress note dated 7/18/22, at 8:18 p.m. indicated R4 was pinched around 8:00 p.m. on her shoulder. R4 was heard yelling, complaining you pinched me, you pinched me. When RN-A asked the CA why she pinched her, the CA stated R4 hit her in her chest. The CA left the facility soon after the incident. RN-B's skin assessment form dated 7/18/22, noted R4 had redness noted to her right scapular area. RN-B's pain assessment form dated 7/18/22, noted R4 complained of pain to her right scapular area and rated it 9/10. A facility interview/statement record dated 7/19/22, at 10:50 a.m. indicated R4 was interviewed in her room about the incident on 7/18/22. The document indicated R4 reported she wanted to go out to smoke, and was told smoking time was over. R4 punched the CA in the chest. The document indicated the CA did not say anything but pinched her on her right shoulder. R4 thought the CA did this with intention and that she feels safe at the facility but not around the CA. A facility resident interview dated 7/19/22 at 10:30 a.m. noted a resident was present for the interaction on 7/18/22, between R4 and the CA. The statement noted she observed R4 coming out to the smoking patio as it was about to close, the CA brought R4 back in the building and every time she was brought back in, R4 would wheel herself back out, the resident did not see anything else. A facility undated written statement from the CA noted she reported to RN-A that R4 came screaming and attacking her, she wheeled over the CA's foot multiple times, smeared feces on the elevator door, and this was the fifth time the CA had reported R4's behaviors to the nurse. The statement noted that R4 had been known to kick and scratch the CA, she always stayed calm and lets the nurse on duty know. A facility undated written statement from RN-A noted R4 was heard yelling, complaining you pinched me. When RN-A asked the CA why she pinched her, the CA stated she hit me in the chest. The CA left the facility soon after the incident. A facility interview on 7/19/22, at 10:10 a.m. R5 stated he was present for the interaction that occurred on 7/18/22. R5 stated he did not observe the incident because he was in front of R4 and the CA but stated he did hear R4 say you pinched me. During an interview on 7/21/22, at 10:38 a.m. RN-A stated on the evening of 7/18/22, she was at the first-floor nursing station and heard yelling. The CA was pushing R4 in her wheelchair towards the nursing station. RN-A stated R4 was saying she pinched me, she pinched me, and when RN-A asked CA why she pinched R4 the CA said, because she punched me in my chest. RN-A stated she then told the CA that what she did was wrong and was abuse, the CA walked away, locked the patio, left the keys and left for the night. During an interview on 7/21/22, at 10:47 a.m. the CA stated that on 7/18/22, she was performing her duties on the outside smoking patio. The CA had began her shift at 8:00 a.m. and was working until 8:00 p.m. to help out. The CA stated as she was getting ready to close the door to the smoking patio for the night, R4 came out, she told R4 that she had to close the door and it was one minute until 8:00 p.m. when R4 began to punch her in the chest (CA demonstrated the movement by R4, punching both fists forward). The CA stated she immediately reported the incident to the nurse at the first-floor nursing station, she could not recall if she had pushed R4 towards the nursing station since R4 was able to self-propel her wheelchair. The CA stated after she reported the incident, she locked the patio door and left for the night, it was the end of her shift. The CA stated she had not had much interaction with R4 prior to that evening and was not aware if R4 had demonstrated physically abusive behavior to staff in the past. The CA stated she was not suspended, did not have to do education prior to her return to work, and there was no disciplinary action taken with this incident, she worked her regular schedule the week of the incident. During an interview on 7/21/22, at 11:09 a.m. RN-B stated he was working on the second-floor nursing station and received a call from RN-A. RN-B stated RN-A told him that a staff member pinched R4 because R4 punched her in the chest. RN-B stated he performed a skin assessment and noted redness to R4's right shoulder and that R4 also rated her pain 9/10 to that area. RN-B stated R4 was able to tell him where she was pinched and that the smoking lady pinched her. During a review of the outside smoking patio camera footage on 7/21/22, at 12:01 p.m. the camera footage is missing video from 7:37 p.m. to 9:11 p.m. R4 is not visible on the footage due to the incident occurring around 8:00 p.m. During an interview on 7/21/22, at 1:05 p.m. the Nurse Manager (NM) stated she was on call the night of the incident and received a call from RN-B stating a resident said a staff member pinched her. The NM arrived at the building and stated there were no direct witnesses. The NM stated RN-A informed her that she was at the nursing station and heard screaming, went to check on the resident, the resident reported CA pinched her and the CA replied she punched her in the chest and left right away when RN-A attempted to engage her. The NM stated she had the RN-A write a statement and then she filed the report with the SA based on the written statement, she added that the resident felt safe and denied pain. The NM stated she spoke with R4 and asked her what happened, she stated R4 reported the smoking person pinched her. The NM stated the residents story remained consistent and asked if this writer had spoken with R4 because she is able to report. The NM further stated she had worked with R4 and never had an issue like this before. The NM stated she only made the report to the SA, she did not do anything else for this incident and was also not aware of any disciplinary action taken with the CA. During an interview on 7/21/22, at 2:08 p.m. R5 stated he was present for the incident, he stated he did not see the incident because it had occurred behind him. R5 stated he was almost at the first floor nursing station when he heard R4 yelling she pinched me, she pinched me. During an interview on 7/21/22, at 2:38 p.m. the administrator stated she was notified of the incident by the NM by text the evening of the incident. The administrator stated the NM came to the facility and filed the report, residents and staff were interviewed and no one saw the incident, only heard what happened. The administrator stated on the evening of the incident, the smoking aide left at the end of her shift on 7/18/22. The administrator stated the facility called the CA to place her on suspension and informed her they needed a written statement, the CA was already scheduled to be off work on 7/19/22, and 7/20/22 and returned to work on 7/21/22. The administrator stated she did not have documentation of the phone call, and did not do a formal interview with the CA. The administrator noted the CA was educated on 7/21/22, around 9:30 a.m. and that she did provide smoking monitoring prior to that education. The administrator stated the education provided was instruction, when a resident becomes upset, staff should remove themselves and get another staff person to assist. The administrator stated she had not completed the investigation; she did not review the camera footage from the outside smoking patio nor the inside hallway. The administrator further stated that the investigation was inconclusive because there was no witness, no proof of injury and it was only what staff and residents said and she was unable to make a determination. The administrator stated she briefly reviewed the assessment documentation in the electronic medical record (EMR) and that the redness to R4's scapula area could have been from hitting and smearing feces though there were no witnesses that R4 was hitting or smearing feces and R4 did not have a history of physical aggression towards staff. During a review of the first-floor elevator camera footage on 7/21/22, at 4:27 p.m. R4 exited the elevator at 7:53 p.m. she was self-propelling in her wheelchair towards the nursing station and goes out of camera view, at 7:54 p.m. R4 is seen wheeling herself towards the smoking patio, at the 7:56 p.m. R4 is being pushed in her wheelchair by the CA, she has her arm crossed over her chest with her hand reaching towards her right shoulder, the CA is seen walking again towards the smoking patio at 7:56 p.m. at 7:58 p.m. RN-A is seen pushing R4 to the elevator, RN-B appears to the right and pushes R4 into the elevator at 7:59 p.m. the CA is seen walking toward the nursing station with keys and disappears from the camera view. A facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriate of Resident Property effective 11/28/17, noted the definition of physical abuse includes hitting, slapping, pinching and kicking, it noted the definition of immediately to mean as soon as possible but ought to not exceed 24 hours after the discovery of the incident. The policy noted the each resident will be free from abuse while residing at the facility and that no abuse or harm of any type will be tolerated. The immediate jeopardy that began on 7/18/22, was removed on 7/23/22, when the facility suspended the CA, interviewed residents that smoke to ensure they felt safe, provided education to all staff regarding abuse/neglect, and education related to responding to residents with behaviors without retaliation, but the noncompliance remained at the lower scope and severity level of D - isolated scope and severity which indicated no actual harm with the potential for more than minimal harm due to continued implementation and verification of a plan of correction.

Based on observation, interview, and document review, the facility failed to assess and implement care plan interventions to prevent unsafe smoking for 2 of 2 residents (R2, R4) who had a history of smoking in the facility. This constituted an immediate jeopardy (IJ) for R2 and R4. The IJ began on 1/10/22, at 2:36 p.m. when R2 was noted to be smoking in her room and the director of nursing (DON), the regional clinical director and administrator were notified of the IJ. The immediate jeopardy was removed on 1/11/22, at 5:48 p.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's diagnoses included acquired absence of left leg below knee, acquired absence of right leg above knee, anxiety disorder, asthma, unsteadiness on feet, generalized muscle weakness, lack of coordination and abnormalities of gait and mobility obtained from the admission Minimum Data Set (MDS) dated [DATE]. R2's care plan for smoking dated 12/8/21, identified resident was a smoker and had history of smoking in room and other unauthorized areas. The care plan directed staff to ensure smoking materials were secured by facility staff and staff was to notify charge nurse immediately if it was suspected resident had violated facility smoking policy. In addition, the staff was to instruct resident about the facility policy on smoking locations, times, safety concerns. R2's Smoking Risk Evaluation-V2 dated 12/7/21, indicated R2 was a unsafe smoker with score of 4, R2 smoked in unauthorized areas, and refused to follow the facility safe smoking policy. The assessment directed staff to follow the facility smoking policy. During review of the interdisciplinary notes the following was revealed: -12/7/21, social service note indicated nursing staff had reported that resident was caught smoking in her room. Social services then had met with resident and discussed the risk and benefits of smoking in her room and social service staff had removed all smoking material from residents room and R2 had reported that she will not smoke in her room any longer. -12/17/21, social service note indicated R2's room was searched that day for smoking materials as it was reported resident was smoking in unauthorized areas. During the search staff found drug paraphilia including burnt tin foil, coils, and rolled up burnt money. Staff gave R2 a risk and benefits, Associated Clinic of Psychology (ACP) was to see resident, physician was updated and R2 re-signed the drug and alcohol policy. In addition, orders initiated for every shift room searches and monitoring R2 for signs and symptoms of substance use. -1/10/22, behavior narrative indicated, Writer was alerted to the smell of cigarette smoke by MDH surveyor. Writer responded to this resident's room and noted cup with 3 cigarette butts in it. Resident willingly gave up pack of cigarettes and lighter. Nursing to redo smoking evaluation. Social services to review smoking policy with resident. Writer advised resident no smoking allowed indoors and advised of risks including residents using oxygen in the building. Resident expressed understanding. Nursing to update provider. During review of the Electronic Medication Administration Record (EMAR) for January 2022, it was revealed the nurses were directed to remove any lighters and were to sign off every shift doing room search for drugs and drug paraphernalia. During further review of the EMAR it was revealed there were shifts which room searches were not signed off as completed. In addition, the order did not direct to remove smoking materials from R2's room and secure the smoking materials at the nursing station despite R2's past incidences of smoking in the room. On 1/10/22, at 10:43 a.m. a haze and profound fresh odor of cigarette smoke was observed down Station 1 hallway by R2's room. As surveyor went down the hallway there were two staff, one in the room next to R2's room and housekeeping (HK)-A in the hallway. Surveyor then went and alerted the regional clinical director registered nurse (RN). -At 10:46 a.m. the regional clinical director was observed going room by room down the hallway and as surveyor was looking around and asking where the smell was coming from, HK-A stated and as she pointed to R2's room that she had smelt the smoke in there earlier. At this same time the activities assistant (AA) came out of room 116 and stated it was smelling like smoke as she went past R2's room. -At 10:48 a.m. after knocking at the door and going into R2's room, surveyor observed a profound fresh smell of cigarette smoke in the air. This surveyor summoned the regional clinical director into R2's room. As she entered the room the regional clinical director verified the cigarette smoke and asked R2 if she had been smoking and R2 stated Yes and willingly handed the regional clinical director a pack of red [NAME] Non-menthol with 8 cigarettes and lighter. During this observation on the floor under the bed was a 4 ounce plastic cup with small amount of liquid and inside there were three cigarette filters with ashes in the cup. R2 was at that time lying on the bed on her abdomen. In addition, during the observation, the two beds in R2's room were observed with mattresses and linen on them, the floors and the bed were cluttered with personal clothing all over the room and there was papers and magazines which were inflammable. -At 10:53 a.m. HK-A stated, I work on weekends mostly and residents here smoked in the rooms and the staff usually would talk to them but this is on going and normal thing here. During interview on 1/10/22, at 11:25 a.m. the social services designee (SSD) and RN-A unit manager both reviewed R2's recent smoking assessment dated [DATE], and verified that R2 had been identified with history of smoking in unauthorized areas and in the room. Both also reviewed R2's care plan and verified the care plan directed for staff to keep all smoking materials away. They both stated R2 had moved over the weekend to the current room from another unit upstairs and they were not aware R2 had moved to the room until this incident was brought to their attention. Both also stated R2 was capable of going out to the community to buy other smoking materials and it was difficult to know when to remove it from R2. They both acknowledged although R2's smoking materials were hard to track, the staff over the weekend had failed to remove the material from her possession to prevent R2 from smoking in her room. During interview on 1/10/22, at 12:22 p.m. R2 stated prior to this current room on first floor she resided on the second floor. R2 stated she had gone out to the community and bought more smoking material for herself because no staff had bothered taking the materials from her and so she had always kept them until she moved to the 1st floor. During interview on 1/10/22, at 12:33 p.m. nursing assistant (NA)-A stated when R2 resided at the unit, R2 had been caught smoking in her room or other resident rooms several times and that was why all the resident smoking materials were supposed to be kept at the nursing station. NA-A stated R2 was supposed to come and ask when she had to smoke at the designated times. NA-A then stated all of R2's materials for smoking were supposed to be kept by the nurse, and at times because it was difficult to know when they had obtained materials from the community the nurse manager and administrator would make staff search the rooms. During interview on 1/10/22, at 1:27 p.m. the DON stated she would expect the staff to follow the care plan interventions and all staff was to intervene right away when they observed or suspected a resident was smoking in unauthorized areas and in their rooms. The DON further stated if the care plan interventions in place were not effective, this was supposed to be discussed so other interventions can be tried. The DON acknowledged there was a high risk of fire due to the use of oxygen in the building by other residents. R4's diagnoses included seizures, muscle weakness (generalized), alcohol abuse, other abnormalities of gait and mobility, unsteadiness on feet, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left dominant side, and [CONDITION(S)] obtained from the quarterly MDS dated [DATE]. The MDS identified R4 had a functional limitation in range of motion on one side on the upper and lower extremities. In addition, the MDS identified R4 had short term memory problems. R4's care plan dated 4/19/21, indicated resident was a smoker and had history of sharing smoking materials with others. The care plan directed staff that residents smoking materials were to be secured by facility staff, staff was to periodically monitored R4 while engaging in leisure smoking on facility smoking patio. R4's Smoking Risk Evaluation - V 2 dated 12/29/21, identified R4 was potentially unsafe smoker and he smoked in unauthorized areas and inappropriately provided smoking materials to others. Although the facility had identified R4 was unsafe and care plan developed with interventions the facility was unable to provide evidence the interventions had been implemented to ensure R4 did not smoke nor share materials with other residents. During review of the interdisciplinary notes the following was revealed: -12/21/21, behavior narrative note indicated resident was smoking in room and and the writer went to room to stop him from smoking in room. Resident was aggressive when he was told not to smoke in room. He was also protective of his lighter and refused to turn it over. The writer took away his roommate's cigarette making machine due to both R4 and roommate smoking in room. Resident was angry why writer took his roommate's cigarette making machine. R4 came to the nursing station and was hitting the writer with his cane. R4 attempted to go in the medication room to grab his roommate's cigarette making machine and was stopped from entering the medication room. During review of the EMAR for January 2022, it was revealed the medical record lacked documentation of staff completing room searches as indicated. In addition, the interdisciplinary notes lacked documentation of implementing the care planned interventions to prevent R4 from sharing smoking materials with others and smoking in unauthorized places following the incident on 12/21/21. On 1/11/22, at 11:58 a.m. during a random observation a haze and profound fresh odor of cigarette smoke was observed down at the end of first floor Station 1 hallway where R4's room was located. As the surveyor stood outside R4's room, the profound fresh smell of smoke was observed in the room. As the surveyor entered the room two half smoked cigarettes with ashes were observed by the edge of the night stand which was next to the bed in R4's room. On the bed were other clothing items and linen and around the room there was a privacy curtain, magazines and furniture which were inflammable. -At 12:03 a.m. surveyor brought the facility administrator to R4's room and she verified that R4 had been smoking in the room. The administrator then took a napkin, wiped the ashes and cigarettes and put them in the garbage. She then stated she was going to follow up with R4 but thought it was R4's roommate who had been smoking. -At 12:10 p.m. the administrator and SSD approached surveyor and SSD stated they had searched R4's room that morning and had taken everything out and they were not sure what else they were supposed to do because they were following the facility policy. The administrator stated they were not sure how R4 had obtained the smoking materials and all the residents who smoked had been educated on 1/10/22, on not sharing smoking materials. During a meeting with the the regional director social services, the regional clinical director, the facility administrator and the vice president of operations on 1/11/22, at 12:55 p.m. surveyor informed management the current IJ removal plan with R2 would not be removed due to R4 smoking incident on 1/11/22, at 11:58 a.m. The staff was informed an updated removal plan which included R4 needed to be submitted to the State Agency (SA). The director of social services stated the facility had discussed involving Associated Clinic of Psychology (ACP) and including other providers at the facility to assist with resident individualized behavior/incentive/rewarding plans to help the residents who were having problems with smoking inappropriate areas to assist with addressing the smoking problem. During the meeting the administrator verified R4's medical record lacked documentation of the room search which had been completed that morning. The regional clinical director stated they were going to add room searches every shift for R4 to be documented. The facility policy and procedure for Safe Smoking dated reviewed 10/13/20, indicated upon admission residents were to be informed of the resident safe smoking policy. If a resident was deemed unsafe smoker based on our assessment, the facility will implement individualized interventions to prevent unsafe smoking practices. Smoking is a privilege here, it is not a right. Residents may smoke cigarettes and e-cigarettes only in the following designated smoking areas: 1. Outside: smoking patio is provided on first floor by the dining room 2. Indoor smoking room on station 3 for only the residents that reside on that station . In addition, the policy indicated residents were not allowed to smoke in the corridors or any other areas of the building and smoking indoors was prohibited at all times for residents and visitors. Residents who ignore the safe smoking policy by endangering themselves and others may receive the following consequences: verbal warning and then a written contract and persistent violation of the safe smoking policy may result in the resident losing smoking privileges or finding alternative living arrangements. The IJ's began on 1/10/22, at 10:43 a.m. and was removed on 1/11/22, at 5:48 p.m. after the facility had implemented an acceptable removal plan which consisted of the facility had removed R1's and R4's smoking materials from the rooms; all residents who smoked were re-educated on the facility smoking policy including smoking in appropriate place and times of smoking; all staff are and will be educated on the smoking policy and what to do if they see or suspect a resident smoking in unauthorized areas including their rooms, smoking assessments were completed for R1, R4 and care plans were updated. Staff was and will be educated on R2's interventions to include not being allowed to have smoking materials in the room, room searches will be completed every shift in R2 and R4's rooms and recorded in the treatment administration record, extra smoking detectors were installed in R2's room and bathroom, R4 was placed on a positive reinforcement plan. Additionally, all residents who have been identified as high risk based on history of smoking in unauthorized areas will be discussed with social services, nursing, and Associated Clinic of Psychology (ACP) on 1/14/22, to develop a positive reinforcement program as appropriate.

Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation when R88 was found with an absent pulse and respirations, CPR was not performed, and R88 died . The IJ began on [DATE], at approximately 11:30 a.m. when R88 was found without a pulse or respiration and CPR was not initiated. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 3:35 p.m. The IJ was removed on [DATE], at 5:00 p.m. but non-compliance remained at the lower scope and severity level of D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include R88's Admission Record dated [DATE], indicated R88's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R88's admission Minimum Data Set (MDS) dated [DATE], indicated R88 had intact cognition. R88 had no documented behaviors identified on the MDS. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A History and Physical (H&P) dated [DATE], indicated R88 was admitted from the facility to the hospital on [DATE], for [CONDITION(S)]. Hospital Discharge Orders dated [DATE], indicated R88 was ordered a full-code status (meaning CPR was to be performed) by the physician. A progress note dated [DATE], at 4:34 p.m. indicated registered nurse (RN)-A documented R88's code status was full-code. A progress note dated [DATE], at 9:22 a.m. indicated R88 died on [DATE]. Further, R88 told a nurse he was going to his room to take a nap at approximately 10:30 a.m. A laboratory technician went to R88's room between 11:30 and 11:45 a.m. and found R88 unresponsive. A nurse evaluated R88 and no pulse was detected. The progress note further indicated R88 was DNR. During an interview on [DATE], at 6:57 p.m. RN-A stated the last code status entered in R88's electronic medical record (EMR) was DNR and dated [DATE]. RN-A confirmed R88's Hospital Discharge Orders (dated [DATE]) indicated a full-code status was ordered for R88. Further, RN-A verified R88's code status was reviewed upon R88 returning from the hospital, however, was not reviewed with R88 nor updated in R88's medical record. During an interview on [DATE], at 8:23 p.m. RN-A stated he should had the physician review R88's code status upon return to the facility on [DATE]. During an interview on [DATE], at 9:28 a.m. family member (F)-H stated she spoke to R88 at approximately 11:00 a.m. on [DATE], and R88 stated he felt fine. F-H stated R88 had a positive outlook and if he was discharged from the hospital with full-code orders that was what he wanted. F-H stated R88 planned to discharge from the facility and went to see specialist to pursue a liver transplant. F-H stated she was notified by RN-A R88 died around 1:30 p.m. on [DATE]. During an interview on [DATE], at 10:00 nurse practitioner (NP)-A stated she was informed R88 died on [DATE], at 2:30 p.m. NP-A stated she was not aware R88 was a full-code and did not review R88's code status after R88 returned to the facility from the hospital. NP-A stated she expected staff to review R88's code status and orders upon return from the hospital and update the POLST, as needed. NP-A stated the facility was unable to continue a DNR order if R88 returned to the facility with an ordered full-code status. During an interview on [DATE], at 10:50 a.m. registered nurse (RN)-A stated he saw R88 obtain mail on the first floor of the facility earlier in the morning, on [DATE], and R88 appeared physically well. RN-A stated R88 was found unresponsive in bed by a laboratory technician and licensed practical nurse (LPN)-D was the first nurse to assess R88 after he was found unresponsive. RN-A stated he also observed R88 who was warm to touch and did not have rigor mortis (stiffening of the body muscles). RN-A confirmed he did not initiate CPR because R88 was DNR and he knew what R88 would had wanted contrary to his previous statement in which he stated R88 was a full-code. During an interview on [DATE], at 11:20 a.m. LPN-D stated on [DATE], she saw R88 during the morning at approximately 8:00 a.m. and he was smiling was he wheeled himself in a wheelchair. LPN-D stated she also observed R88 participating in a coloring activity around 10:00 a.m. and shortly after headed back to his room to lay in bed. LPN-D stated at approximately 11:30 a.m. a laboratory technician entered R88's room and exited shortly after to report R88 was unresponsive, but still breathing. LPN-D stated she obtained a vitals cart and called RN-A for help. LPN-D stated R88 was warm to touch, but did not have respirations. LPN-A confirmed she did not attempt CPR because R88's EMR indicated he had a DNR order. During an interview on [DATE], at 12:35 p.m. a hospital social worker, (SW)-C stated when R88 was hospitalized , his code status was reviewed and changed to full-code. SW-C stated on [DATE], she observed the discharging physician discuss code status with R88 and R88 requested a full-code status. SW-C stated she ensured R88's code status was accurate and updated the code status when R88 was in the hospital. During an interview on [DATE], at 12:40 p.m. the administrator confirmed R88's code status was not changed and remained DNR after R88 returned from the hospital on [DATE]. The administrator stated R88's code status should had been reviewed and updated upon return to the facility. The administrator stated CPR was not started on R88 because his code status was listed as DNR and the resident had pooling of blood in his back. The administrator stated she did not observe R88 on [DATE], and was unable to find documentation in R88's medical record which indicated he had pooling of blood in his back. The administrator stated she felt R88's code status was not reviewed or reconciled upon readmission from the hospital. Facility policy titled CPR-Cardiopulmonary Resuscitation dated [DATE], indicated the facility will provide basic life support when a resident requires emergency care during a witnessed or unwitnessed event, prior to the arrival of emergency medical services, subject to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The IJ that began on [DATE], at approximately 11:30 a.m. was removed on [DATE], at 5:00 p.m. when the facility developed and implemented a systemic plan which was verified through interview and document review. The plan included: - All resident code statuses were reviewed to ensure they were current and consistent with resident wishes. - Education was provided to nursing staff and social services, prior to their next scheduled shift, to review code statuses for accuracy during care conferences, quarterly, annual reviews, and upon admission/readmission. - The facility ensured all residents code statuses were accurately reflected throughout the medical record.

Based on interview and document review, the facility failed to allow 1 of 1 residents (R1) to return to the facility after a non-medically recommended leave of absence (LOA). When R1 returned to the facility, she was notified she was discharged , and had no safe discharge plan in place. This resulted in an immediate jeopardy (IJ) for R1 who was homeless, subsequently relapsed on substances, and was hospitalized on four separate occasions for intoxication, suicidal ideation, and mental health concerns. The IJ began on 7/27/21, at 2:00 p.m. when R1 was discharged without notice against medical advice (AMA) after she went on a leave of absence (LOA) that was determined by the facility to be AMA. R1's commitment case manager was not notified of R1's LOA or subsequent AMA discharge. R1 returned the following day (7/28/21) only to gather a few belongings. The administrator was informed of the IJ on 8/26/21, at 3:25 p.m. The immediate jeopardy was removed on 8/27/21, at 1:00 p.m. but non-compliance remained at the lower scope and severity of a D, isolated and potential for more than minimal harm. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order for Recommitment dated 11/5/20, indicated R1 was recommitted as a chemically dependent person to the Commissioner of Human Services until 11/13/21, unless revoked or extended. R1's terms of commitment included maintaining sobriety from all non-prescribed mood-altering substances of abuse, successful completion of treatment services, completion of urinalyses or breathalyzers as requested, taking medications as prescribed, and working with her case manager. Grounds for revocation of commitment included use of substances, harming, or threatening to harm self or others, and unsuccessful discharge from aftercare placement. R1's care plan dated 7/8/21, lacked information and/or interventions regarding R1's substance use disorder, mental health concerns, or chemical dependency commitment. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/21, at 11:28 p.m. a progress note indicated R1 went on an LOA at 2:00 p.m. and did not return to the facility. R1's physician was not contacted to authorize the LOA. R1's commitment case manager (CM)-A was not contacted by the facility regarding the LOA. On 7/28/21, at 3:15 a.m. and 11:13 a.m. progress notes indicated the facility had called 911 to report R1 missing. The facility was contacted by a local hospital at 2:30 a.m. to inform them R1 had been hospitalized for intoxication and suicidal ideation. At 9:00 a.m. R1 returned to the facility. Social Services was to complete a referral to chemical dependency (CD) program for R1. On 7/28/21, at 9:03 p.m. and 9:23 p.m. progress notes indicated R1 was found passed out in her room with six empty alcohol bottles. The physician was called and R1 was sent to the emergency room (ER). At 10:30 p.m. R1 returned from ER. R1 had no new orders or interventions put in place after this second hospitalization within 24 hours for substance use. On 7/31/21, at 1:56 p.m. R1's hospital extended care progress note indicated, Not recommending for patient to leave the facility but if patient insists on leaving, she should not go overnight rather a few hours and return to the facility for medication administration and monitoring. Nursing staff to notify primary provider the next work day on this call and current patient condition. On 7/31/21, at 2:40 p.m. a progress note indicated R1 requested to go on an LOA. Registered nurse (RN)-A contacted nurse practitioner (NP)-A to request an LOA order due to R1's recent LOA and substance use. NP-A indicated, No order for LOA. RN-A advised R1, If she leaves it's AMA. R1 stated she would be back tomorrow and left the facility. R1's medical record lacked any documentation she attempted to return to the facility and the facility would not let her in. On 8/25/21, at 9:43 a.m. R1's family member (FM)-A was interviewed and stated RN-A called to verify if R1 would be staying with them for a birthday party during LOA, which FM-A confirmed. FM-A stated they were not made aware by RN-A that if R1 left the facility she would be discharged and unable to return. FM-A stated he would not have taken R1 out if he would have known this. On 8/25/21, at 10:30 a.m. R1 was interviewed and stated she was informed she was leaving AMA by RN-A, however, the repercussions of this were not explained to her. R1 stated she had left before and returned and was not aware she would be kicked out. R1 stated when she returned to the facility on [DATE], she was informed by RN-B she could not return without a doctor's order. R1 stated her discharge from the facility contributed to her subsequent relapse on drugs and alcohol as she had the rug pulled out from under her and did not have a safe place to go. On 8/25/21, at 10:30 a.m. R1's primary nurse practitioner (NP)-B stated she was not in the loop on R1's AMA discharge, and was not informed until several days later. NP-B stated she expected the facility to notify the appropriate parties if a resident was being discharged AMA and were vulnerable, and R1's significant history with substance abuse was her biggest vulnerability. On 8/25/21, at 2:45 p.m. NP-A was interviewed and stated she was informed by the facility R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . NP-A stated if R1 insisted to go out, she should return to the facility for her evening medications and should not stay overnight. On 8/26/21, at 8:23 a.m. CM-A was interviewed and stated she had not been informed of R1's LOA, substance use, or discharge from the facility. CM-A stated it was imperative to be informed of R1's activity and relapses with substances as this would be reported to the court during R1's commitment hearing. CM-A further stated commitments can only be revoked during hospitalization s, and she may have sought additional treatment programs or services for R1 at that time. On 8/26/21, at 12:15 p.m. RN-A was interviewed and stated she did not know R1 was on commitment or had a case manager and had never notified the CM. RN-A verified there were no interventions in place for R1 regarding substance use. RN-A verified R1 refused to sign AMA papers and they were not co-signed by staff, R1 stated to RN-A she would be back tomorrow. RN-A stated R1 was then discharged , and when she returned to the facility on [DATE], around 10:00 a.m. RN-A was informed R1 could not come back by the administrator, but was allowed to retrieve a few belongings from her room. On 8/26/21, at 10:55 a.m. RN-B was interviewed and stated he did not know R1 was on commitment or had a case manager and had never notified the CM. RN-B verified there were no interventions in place for R1 regarding substance use. RN-B verified R1's 7/27, LOA did not require an order. RN-B stated R1 refused to sign AMA papers and they were not co-signed by staff. RN-B verified no formal risk and benefits document was completed with R1 re: AMA. RN-B stated R1 was discharged immediately on 7/31/21, AMA per administrator direction. RN-B verified R1 could not come back to the facility by administrator. On 8/26/21, at 11:13 a.m. social service worker (SS)-A was interviewed and stated she did not know R1 was on commitment, and had never been in contact with CM-A. SS-A verified CM-A should have been contacted re: R1's substance use and hospitalization s. SS-A verified the care plan lacked any interventions regarding R1's chemical dependency, nor that she had a commitment order. On 8/26/21, at 11:50 a.m. the administrator was interviewed and stated CM-A should have been notified of R1's substance use and hospitalization s. The administrator verified R1's care plan and orders lacked interventions regarding substance use, and there was no AMA or risk and benefits forms completed for R1 prior to being discharged AMA. The administrator verified she informed R1 of the AMA discharge and the inability to return to the facility. The administrator stated R1 asked how she could get her medications and told her she had no where to go. The administrator stated an AMA discharge was never safe, but it was R1's choice. The facility policy Transfer and Discharge Guideline dated 11/28/17, directed it is the practice of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is: 1. Necessary for the resident's welfare and the resident's needs cannot be met in the facility 2. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; 3. The resident requires immediate transfer or discharge based on the residents urgent medical need 4. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; 5. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; 6. The health of individuals in the facility would otherwise be endangered; 7. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or 8. The facility ceases to operate. The facility policy Policy for Alcohol and Unauthorized Drugs Villa Healthcare dated 7/27/21, directed if suspicions of drug or [CONDITION(S)] are suspected, the resident may be subject to the following: 1. If a resident is found with possession, use, or distribution of unauthorized drugs or alcohol it will be confiscated by facility staff. 2. The facility staff will conduct an initial room search and will continue to do random room searches if necessary. 3. The resident's physician will be notified and able to make medication changes as appropriate. 4. The facility may notify the police of the quantity or if there are concerns of personal harm or damage to property arising from the use of unauthorized drugs and/or alcohol. 5. If visitors/family members are found with distribution of unauthorized drugs and alcohol, they will be asked to leave the facility and police may be notified. 6. Residents who ignore the policy endangering themselves or others may be given to a discharge notice from facility at any time. The facility policy AMA- Against Medical Advice dated 8/4/21, directed prevention - attempt to understand, to the extent possible, the reason for the resident's desire or decision to leave AMA. Use any resources available to verbally intervene. This can include contacting: social workers, nurses, physicians, resident care coordinators, risk management professionals, resident relations coordinators, clergy members, behavioral health representatives, family members of the resident, or the resident's personal physician. Consult with the physician, resident and / or resident representative, Apply prevention strategies, Review and outline the benefits of staying and risks of leaving, Obtain signatures from the resident and / or resident representative on the AMA form, Should the resident and / or resident representative refuse, obtain a second staff as a witnessed signature, Consult Adult Protective Services to apply their discretionary judgment for requirement of welfare checks inside the community, Document and preserve the AMA form inside the medical record. The immediate jeopardy which began on 7/27/21, was removed on 8/27/21, when the facility identified and reviewed all residents on a commitment order for appropriate monitoring and ensured these residents had orders to contact social workers and case managers with any breach of commitment. In addition, education was provided to facility social work staff to update commitment case managers on any changes of condition or violations of commitment. Social workers and nurses were educated to update commitment case managers on leave of absences and discharges of committed residents. Nurses were educated on the facilities substance abuse protocol, updated transfer and discharge guidelines, updated leave of absence and AMA policies which were updated on 8/11/21. This was verified by observation, interview and document review by the surveyors on 8/27/21.

Based on observation, interview, and document review, the facility failed to keep the resident safe for 1 of 3 residents (R1) whom was identified at risk for elopement that resulted in an immediate jeopardy (IJ). The facility failed to prevent the elopement of R1, who had severe cognitive impairments, for approximately four hours in below freezing winter temperatures without appropriate winter attire resulting in risk of potential serious harm, injury, impairment, or death for 1 out of 3 residents (R1) reviewed for risk of elopement. The immediate jeopardy began on 1/1/21 at 12:48 p.m. when R1 whom had a security alert alarm on his ankle, breached the secured doors at front entrance without any alarms sounding to alert staff. Staff were not aware R1 was gone until 1:06 p.m. and police were notified. R1 was found approximately 7.6 miles from the facility later that evening. The administrator and director of nursing (DON) were notified of the immediate jeopardy at on 1/5/21, at 5:50 p.m. The immediate jeopardy was removed on 1/6/21, but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitively impairment, and was able to ambulate independently. The MDS indicated R1 had a [DIAGNOSES REDACTED]. R1's Wander/Elopement Risk Evaluation dated 11/19/20, indicated R1 was at risk of wandering and elopement, with risks factors including independent mobility, a history of leaving the building unsupervised, exit seeking and wandering the building, and early evening confusion. A progress note dated 11/20/20, at 8:36 a.m. indicated, Wander guard (wander alarm) placed on L (left) ankle based on residents wander assessment and resident being observed outside of the facility. R1's care plan dated 11/20/20, indicated R1 was at risk of elopement related to disorientation. The care plan goal was to keep R1 safe. R1's interventions included a photo on the list of wandering residents, distractions and diversions, staff assessment of wandering behavior motivation and triggers, offering to call family and a wander alert personal safety device on the left ankle. Review of R1's December 2020 medication and treatment administration record (MAR/TAR) included an order to check functioning and placement of wander device every shift. On the night shift 12/29/20, 12/30/20, 12/31/20 this was marked by a licensed practical nurse (LPN)-B as not completed for R1. TMA-B marked this task as not completed on 12/30/20 evening shift and 12/31/20 day shift. On the day shift for 1/1/21, this order was marked by (LPN)-C as not completed with a note to see nurses notes. There was no indication if R1's alarm was functioning properly during these time frames. R1's nurse note dated 1/1/21, at 3:06 p.m. indicated R1 was out of the building without staff knowledge. A Code White (the emergency code for a missing resident) was called. Family, police and the nurse practitioner were notified. The facility investigation of R1 elopement identified the following: Licensed practical nurse (LPN)-D's interview/statement record form dated 1/1/21, indicated LPN-C notified LPN-D that the front doors were left open. Housekeeper (H)-A notified LPN-D that he observed R1 heading towards a nearby store. H-A and LPN-D checked the store and did not find R1. LPN-D then notified the facility administration of R1's elopement, and began searching for R1 in her vehicle. This statement was part of a facility investigation. Nursing assistant (NA)-A's interview/statement record form undated, indicated the wander alarm did not sound. NA-A accounted for all of her residents after the code white was initiated, and noted R1 was missing. LPN-C's interview/statement record form dated 1/1/21, indicated LPN-C was serving lunch when she noticed the sliding doors were out of their tracks. This resulted in the doors being open. LPN-C tried to fix the doors. H-A notified her that he observed R1 at the nearby store. LPN-C stated the wander alarm system did not sound. LPN-C did not check R1's wander alarm placement that day, noting she did not have a chance. A Code White was initiated. This statement was part of a facility investigation. An email from the front desk receptionist (FDR) dated 1/4/21, indicated FDR came in to the facility to give a vendor cash, and restock candy store at around noon. The vendor was already in the building. FDR left around 12:20 p.m., let the vendor out the front doors, and locked both outside and inside doors securely. H-A's interview/statement record undated, indicated H-A was on a break outside, walking to the local store and engaged in a phone conversation. H-A observed R1 near the store. H-A returned to the facility and notified LPN-D he observed R1 at the store. H-A could not recall R1's behavior or what he was wearing, noting he was preoccupied with a phone call. R2's interview/statement record dated 1/5/21, indicated R2 stated, I told (R1) how to get outside. I thought he was coming right back. This statement was part of a facility investigation. On 1/4/21, at 1:26 p.m. the DON was interviewed and stated R1 walked and paced hallways in the facility, and at times appeared tense. The DON stated R1 could be kind and sweet one moment, and [MEDICAL CONDITION] next. During the interview, R1 approached the DON, and stated his head felt clogged and overbearing. The DON took a set of vitals, and encouraged R1 to sit down, and ask for help when he felt dizzy. On 1/4/21, at 3:09 p.m., the administrator reported she did not report to the SA that R1 left the building unsupervised as it was not considered an elopement by the facility. The administrator added the facility had identified R1 was missing within 3 minutes of leaving and the family found him unharmed in an old residence. The administrator reported she would provide all follow up related to this incident. On 1/5/21, at 10:19 a.m. LPN-A was interviewed and stated she was unsure if R1 had a wander alarm. LPN-A pulled up R1's sweat pants, and a wander alarm bracelet was present on R1's left ankle. LPN-A demonstrated how she checked functioning by putting a portable sensor near R1's wander alarm, and R1's sensor beeped. R1 twice walked up to within a few feet of the exit doors for the unit and turned around, without pushing on the door. On 1/5/21, at 10:26 a.m. trained medication aide (TMA)-A stated she checked R1's wander alarm to ensure it was present on his ankle. TMA-A stated she was not aware of a method to ensure it was functioning. TMA-A stated R1 was not allowed to go on outings on his own. The nurse or the TMA working the cart was responsible for checking the wander alarm system. On 1/5/20, at 11:34 a.m. R1's follow up from the incident was provided by administrator. The follow up included interviews with staff about the incident, but no prevention plan or education. On 1/5/21, at 11:46 a.m. R1 stated he did not recall leaving the building, I don't remember. It might come back to me. On 1/5/21, at 12:04 p.m. TMA-B was interviewed and stated R1 had a wander alarm on his leg. TMA-B stated she checked to see if it was functioning with a portable sensor in the medication cart. TMA-B stated R1 wandered, and needed direction to locate his room. On 1/5/21 at 12:22 p.m. LPN-B was interviewed and stated R1 had a wander alarm. LPN-B stated he worked with R1 on night shifts, including night of 12/31/21. LPN-B stated he did not check to verify presence and function of R1's wander alarm if R1 was in bed during his shift. LPN-B stated R1 was normally in bed during his shift. On 1/5/21, at 11:06 a.m. LPN-C was interviewed and stated R1 walked around the building a lot. LPN-C stated she was serving lunch on the day R1 left, when she noted the door was open. LPN-C stated she looked around, and called a Code White to alert staff of a missing resident. R1 did not tell LPN-C he was leaving. R1 did not sign out. LPN-C stated, He escaped. LPN-C stated a vendor and the receptionist had been at the desk earlier in the day. LPN-C stated R1 rarely wore shoes so he must have seen an opportunity to leave and put his shoes on. LPN-C stated a staff member told her R1 had left the building. LPN-C stated the wander alarm system did not sound and she was concerned because of the opened front door. LPN-C stated R1 had been wearing gray or khaki pants and a sweater that day, and was not sure if he had a coat on when he left. LPN-C explained R1 was not supposed to leave the building without supervision. LPN-C stated she had not had time to check R1's wanderguard functioning that day, but saw it on his left leg. LPN-C noted it was a busy day, she was the only nurse on the unit where R1 resided and she had too much work to do. R2's quarterly MDS dated [DATE], indicated no assessment of R2's cognition. R2 was able to ambulate independently, and had [DIAGNOSES REDACTED]. R2 was not noted as using a wander/elopement alarm. R2's admission MDS, dated [DATE], revealed R2 was cognitively intact and had delusions. On 1/5/21, at 12:50 p.m. R2 was interviewed and stated he instructed R1 how to leave the building by pushing and holding the front door, facing Penn Avenue. R2 reported no alarm went off. R2 reported he witnessed R1 leave the building. R2 did not recall what R1 was wearing, but reported, He wasn't wearing much and noted R1 was not wearing a coat when he left. During an observation on 1/5/21, at 12:56 p.m. R2, with a wander guard on his ankle showed administrator and director of maintenance how he could walk through the door without triggering the alarm. Even though R2 wore a wander guard on the ankle, similar to R1, the door did not alarm. During interview at this time, the director of maintenance and administrator explained when the door is pushed and held, it released and opens due to fire safety. They explained the wander guard sensor was separate and attached to the side of the door frame, approximately 2 feet off the ground. The alarm should have sounded when the door was opened if the resident had an wander guard on. On 1/5/21, at 2:08 p.m. the front desk receptionist (FDR) was interviewed and stated she came in to the facility at noon on 1/1/21, for approximately 15 minutes to assist a vendor. The FDR stated she did not see R1 leave the building. The FDR stated she did ensure the door was locked prior to leaving. The FDR stated she worked at the front desk and had seen R1 walk towards the door. The FDR stated she redirected R1 when he approached the front door. The FDR stated she could not recall if R1 had ever pushed at the door before. The FDR stated she worked the day shift and there was not another receptionist that replaced her when she left. FDR stated she was aware R1 was not to leave the building because of her familiarity with the residents, and because of a book at the front desk with pictures that had residents at risk for elopement in it. On 1/5/21, at 12:56 p.m. the administrator was interviewed and stated the facility completed wander and elopement assessments at admission, quarterly, and as needed. The administrator stated R1 left the building unsupervised on 1/1/21. The administrator stated facility staff notified her at 1:20 p.m. they could not find R1, had called a Code White, and a staff person had seen R1 at the corner store nearby the facility. The administrator stated she arrived at facility at 1:45 p.m. and the police were already onsite. The administrator stated she finished speaking with police at 2:15 p.m., and left a message for R1's family to notify them R1 had left the building. The administrator stated she sent nursing staff to look for R1 with their cars, and also went looking for R1 in her vehicle. The administrator stated family member (FM)-B informed her of the location R1 had previously worked, so she went to look for him at that location. The administrator stated she received a call at 4:45 p.m. from FM-B to notify her they found R1 at an apartment complex he had previously resided with his mother. The administrator stated the family returned R1 to the facility at 6:00 p.m. The administrator stated R1 was allowed to leave the building on his own, however, R1 used a wander alarm due to his cognition. The administrator stated she viewed the video, of R1 leaving the facility, R1 pushed the front door and it did not do anything. Then R1 turned towards R2, who was sitting nearby, pushed on the door and proceeded out of the building. A Microsoft electronic map of Minneapolis indicated a distance of 7.6 miles between the location of the facility and the location where R1 was found by family. Review of the National Weather Service historical weather data for 1/1/21, indicated the weather was 23 degrees Fahrenheit for a high and 12 degrees Fahrenheit for a low that day. On 1/5/21, at 1:00 p.m. the administrator and environmental director (ED) observed the functioning of the front door and wander alarm system with the surveyor. A sensor was placed on the door frame approximately 18 to 24 inches from the ground as well as about shoulder height. The door was a sliding door, but opened and stayed open after being pushed and held with force due to fire code. R2, sitting in the lobby, walked through the front door with a wander alarm on his ankle. No alarm sounded. R8, a resident sitting in the lobby nearby, had a wander alarm on his wrist which triggered the alarm system. The administrator stated it may be the positioning of the wander alarm that caused the alarm not to activate. The administrator stated she instructed nursing staff to move wander alarms to resident's wrists, but R2 must have slipped by. The administrator stated there was frequently a receptionist at the door during the day shift, but not during night or evening shifts. On 1/5/21, at 3:19 p.m. security footage for 1/1/21, at 12:54 p.m. was observed with the administrator and DON. The administrator stated there was no audio available on the security footage. At 12:54 p.m. R2 was observed walking into the lobby and sitting down in a chair near the front door. About 20 seconds later, R1 was observed approaching the front door, paused and then turned towards R2. R1 then turned back to the door, pushed at and held the door. The door opened. R1 walked out of the building wearing a red sweatshirt, gray pants, athletic shoes and green undershirt. R1 was not wearing a a coat, hat, gloves, mittens or a mask. The door remained open. LPN-C approached the open door at 12:58 p.m., went through the open door outside, and then returned inside at 12:59 p.m. and was pulling at the door. At 1:00 p.m. NA-A walked to the lobby and stood near LPN-C. During interview on 1/5/21, at 3:19 p.m. the administrator stated residents had a right to leave the facility and explained, We can't lock them in. The DON stated residents would be asked to sign a form saying they were leaving against medical advise if they wanted to leave the facility without discharge orders. The administrator stated R1 had a purpose to his leaving, wanting to go home, made his way to a location and was found in a safe location. The administrator stated R1 was safe to leave the facility if he knows where he is going. The administrator stated R1 had short term memory impairments, but good long term memory. R1's wander and elopement risk assessment was completed in November 2020, and he had a wander alarm placed on him due to confusion and short term memory impairments. The administrator reported she reviewed the manufacture recommendations and residents were able to wear the wander alarm on the wrist or ankle. The administrator reported an additional alarm had been purchased to sound when the door was open. This had not been installed. A receptionist was present at the front door only during business hours. There were no additional prevention measures were in place, such as education of staff or reassessment of R1 and other residents with wanderguard. Also, there was no indication residents whom had wanderguards located on their ankles had these checked to ensure they were functioning properly at the exit doors with the current alarm system. Review of R1's Wander/Elopement Risk Evaluation, updated on 1/5/21, at 7:28 p.m., revealed R1 was assessed as having a history of wandering and elopement, cognitively impaired, ambulatory, independently mobile, physically able to leave the building on his own and had a history of [REDACTED]. On 1/6/21, at 10:01 a.m. housekeeper (H)-A was interviewed and stated he was outside smoking a cigarette on break on 1/1/21, at 1:00 p.m. about a half a block from the facility. H-A stated he was engaged in a conversation on his cell phone and then entered a nearby store and observed R1 in the same location. H-A stated he returned to the facility and notified LPN-D that he had seen R1 at the store. H-A stated he was not paying attention to R1's behaviors or clothing. H-A estimated he saw R1 at the store at approximately 1:06 p.m. On 1/6/21, at 10:34 a.m. R1's primary care nurse practitioner (NP)-A was interviewed and stated R1 had amnesia. NP-A stated she was concerned about R1 leaving, and did not want R1 to leave the facility unsupervised again. NP-A stated R1 was not safe to be outside the facility unsupervised. NP-A worried R1 was at risk of harm if he left the facility unsupervised. NP-A stated it was fortunate R1 worked off long term memory, and his familiarity with the area of the metro he resided to find a familiar location. NP-A stated it would not be reasonable to expect R1 would learn and retain new information. NP-A stated R1 had a short attention span, and anxiety built throughout the day. R1 was always needing reassurance about his surroundings, which were unfamiliar to him. R1 exhibited aggression towards others when he misinterpreted their actions. NP-A stated she was the on call provider the day of R1's elopement, and was not notified of R1's elopement. NP-A stated the facility notified her of the elopement on 1/5/21, at 6:30 p.m., four days after the event occurred. NP-A stated she would expect to be notified of R1's elopement on the same day it occurred. On 1/7/21, at 9:21 a.m. family member (FM)-A was interviewed and stated he was aware of R1's leaving the facility without supervision because of a phone call from the facility on 1/1/21 at 2:52 p.m., as well as phone calls to FM-B at 3:32 p.m. FM-A stated several family members started searching for R1 in areas R1 had previously worked, visited, and resided. FM-A reported FM-B found R1 at 4:55 p.m. at an apartment building lobby where he had previously resided with FM-D. FM-A then met R1 at the apartment building. FM-A stated R1 had not lived there in several months and had since traveled, lived with FM-A and FM-C, was at the hospital, and resided at the facility for past couple months. FM-D also no longer lived at the apartment complex. FM-A stated R1 was wearing summer weight sweat pants, a long sleeve shirt, possibly an undershirt and mesh slip on shoes. FM-A stated R1 was not wearing a mask, coat, hat or mittens/gloves, despite traveling approximately seven miles from facility to apartment complex in winter weather. FM-A reported R1 did not appear injured, but was coughing and appeared fuzzy with a troubled, furrowed brow. FM-A thought R1 might be thirsty, so FM-A purchased R1 an electrolyte beverage and a bag of chips. FM-A stated R1 was less hazy after drinking and eating a little. FM-A stated R1 previously resided with FM-A and FM-C prior to being hospitalized , and transferred to the facility. FM-A stated R1 could not safely travel on his own. FM-A and FM-C had previously provided supervision for walks and travel in the community when R1 resided with them due to concerns with R1's cognition FM-A stated, We knew if he was away from us that he would probably be lost. FM-A stated R1 had become lost for approximately one month, 3/26/20, to 4/26/20, while traveling internationally during the past year, related to impaired cognition and use of intoxicating substances. FM-A stated this required intervention from the United States Embassy and family escort to return R1 safely home. FM-A stated he was disappointed the facility had lost track of the whereabouts of R1 for several hours, as they were in charge of keeping him safe. On 1/7/21, at 10:34 a.m. LPN-D was interviewed and stated she was working on station two, and an unidentified nurse notified her the front doors were open. LPN-D stated she directed the unidentified nurse to call a Code White, and determine if any residents were missing. LPN-D stated staff searched the building and nearby building on foot as well as farther out, in vehicles. LPN-D stated R1 should not have been able to leave the building on his own as he was not safe to be on the streets alone. LPN-D stated there was no alarm sounding when she approached the front door. On 1/7/21, at 10:51 a.m. LPN-D, R1's nurse manager, was interviewed and stated R1 would get frustrated and did not know how to release his anger, which meant he exploded and had been physically and verbally aggressive towards others when he was frustrated. R1 had a variable attention span. At times R1 could be preoccupied for an hour with an activity and at times, only 5 minutes. LPN-D stated R1 was not allowed to leave the building unsupervised. LPN-D explained R1 was not safe to leave on his own due to cognition. On 1/7/21, at 11:33 a.m. R1 was observed resting under his covers on his bed in a private room. R1 had moved rooms and was in an unsecured unit on the 1st floor. R1 reported he was not sure where he was but named a rural town. R1 noted he was employed and lived with FM-A and FM-C. On 1/12/21, at 3:32 p.m. R1's mental health case manager (CM) was interviewed and stated R1 was not safe in the community without appropriate supports due to cognition, short term memory, and orientation. CM noted he had been informed R1 was found without a coat on and in a previous residence. CM was notified of R1's elopement by family, and then several days later by the facility. CM reported he would expect the facility to notify him in a timely fashion for appropriate coordination of care. The Wandering and Elopement Guideline dated 3/16/17, directed staff upon admission, re-admission, through quarterly review and change in condition residents would be evaluated for potential elopement risk to determine appropriate placement within the facility. Residents identified at risk would have an elopement risk bracelet placed on them, such as a wander alarm. Bracelets would have validation of functioning and expiration prior to placement. Bracelets would be checked for placement and functioning every shift. Expiration of the bracelet would be checked for functioning and placement every shift. Each facility would have a process to communicate the admission or re-admission of a resident at risk for elopement across all units. Representatives would receive education, upon admission, regarding memory care unit security, as applicable. The facility Observation of a Resident Exiting the Facility procedure dated 3/16/17, directed staff to attempt to prevent the departure- provide diversional techniques, re-direction and apply resident specific intervention as directed by the plan of care. The procedure also directed staff to obtain assistance from staff members in the immediate vicinity. Instruct another staff member to inform the charge nurse or director of nursing assistance is required. The facility Missing Resident procedure dated 3/16/17, directed staff to conduct an organized search immediately when a resident was determined missing. Staff were also directed to report immediately to the Charge Nurse missing, OR a suspected missing resident. The Charge Nurse should immediately determine if resident was on an authorized leave, pass or medical appointment; announce on the overhead paging system for CODE WHITE followed by the resident room number. Code White was a code to notify the staff that a resident was missing. After the resident is found, notify the charge person (the charge person will notify the Administrator, Director of Nursing and police). Upon return of the resident to the facility, the Director of Nursing or Charge nurse should: Examine the resident for injuries. Consult with the attending physician and report findings and condition of the resident. Notify the Resident Representative. The Touchpad Exit Controller Administration Guide, dated 7/2018, directed users, Resident generated alarms-Do no rely exclusively on resident generated alarms for resident care and safety. The alarm function of equipment in the possession of residents must be verified periodically and regular resident surveillance is recommended. The guide further directed users, Resident Monitoring-The most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. It is the responsibility of the facility to periodically check on residents in possession of RF Technologies Inc.'s equipment (i.e. pendants, pull cords, control units) to mitigate risks of inappropriate use of equipment or strangulation and stumbling hazards from cables and cords. The immediate jeopardy that began on 1/1/21, was removed on 1/6/21, when the facility educated all staff on elopement procedures, audited functioning of wander alarm system, ensured each resident with a wander alarm had a wander/elopement assessment and care plan in place, and ensured treatment orders in place to monitor presence and functioning of wander alarms for each resident with a wander alarm in place, but the noncompliance remained at the lower scope and severity level of a D, isolated scope and severity level, which is no actual harm, with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to assess smoking and develop interventions to mitigate risks of spreading infection/disease, including Covid-19. The facility failed to adequately supervise the smoking patio resulting in an immediate jeopardy situation with the potential to spread COVID-19 for 7 out of 56 smokers at the facility (R6, R11, R16, R19, R20, R21, and R29). The immediate jeopardy began on 4/1/20, when R6, R11, R16, R19, R20, R21 and R29 were observed to engage in smoking practices that included shared cigarettes and cigarettes taken from an ash tray and smoked. This put these residents at risk to spread and become infected with infections such as Covid-19. The administrator and regional director were notified of the immediate jeopardy at 3:45 p.m. on 4/3/20. The immediate jeopardy was removed on 4/4/20, but noncompliance remained at the lower scope and severity level of: E (more than a very limited number of residents are affected, and/or the situation has occurred in more than a limited number of locations but the locations are not dispersed throughout the facility), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility also failed to ensure the smoke patio was sanitary and residents abided by the social distance recommendations (maintain at least six feet of distance between people) in common areas to prevent the spread of Covid-19 for 22 out of 106 residents (R5, R6, R7, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R28 and R29) reviewed at high risk of severe illness for Covid-19. In addition the facility failed to adhere to adequate precautions, based on the current federal and state government guidelines related to Covid-19 for 1 of 1 residents (R4) who had been exposed to COVID-19. Findings include: R5's most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed R5 had moderate cognitive impairment and a [DIAGNOSES REDACTED]. R5 smoked cigarette butts from ash trays and was identified as a potentially unsafe smoker. R5's smoking care plan, last revised 3/8/18, revealed, The resident is a smoker. Hx (history) of begging for cigarettes from her peers, including buying cigarettes from other residents. Hx of refusing to follow facility safe smoking policy. Interventions included, The resident can smoke UNSUPERVISED. No interventions were in place to address R5 who begged and bought cigarettes from others. The care plan did not identify R5 was at risk for smoking butts from ash trays. R6's most recent quarterly MDS, dated [DATE], revealed R6 was cognitively intact. R6 had [DIAGNOSES REDACTED]. R6's smoking risk evaluation, dated 2/20/19, revealed R6 smoked cigarettes hourly, begged or stole smoking material from others and was careless with smoking materials. R6's smoking care plan, last updated 2/3/20, noted, The resident is a smoker. The care plan directed staff, Resident is allowed to smoke 8:00-8:30 AM Monday, Tuesday, Wednesday, Thursday and Friday. She is to follow station smoke times on Saturday and Sunday. R7's most recent quarterly MDS, dated [DATE], revealed R7 was cognitively intact and required extensive assistance of one staff for locomotion on and off the unit. R7 was over [AGE] years old. [DIAGNOSES REDACTED]. R7's annual MDS assessment, dated 12/12/19, identified R7 as a current tobacco user. R9's most recent quarterly MDS, dated [DATE], revealed R9 had moderate cognitive impairment and independent with locomotion on and off the unit. [DIAGNOSES REDACTED]. R9's admission MDS, dated [DATE], revealed R9 as a current tobacco user. R10's most recent quarterly MDS, dated [DATE], revealed R10 had no assessment of cognitive status and was independent with locomotion on and off the unit. [DIAGNOSES REDACTED]. R10's admission MDS, dated [DATE], identified R10 as a current tobacco user. R10's smoking risk evaluation, dated 12/10/19, revealed R10 smoked cigarettes less than hourly and had no risks identified. The smoking care plan, last revised 1/8/20, identified R10 as a smoker and did not address any risks. R11's most recent quarterly MDS, dated [DATE], revealed R11 was not assessed for cognitive status and was independent with locomotion on and off the unit. R11's smoking risk evaluation, dated 12/19/19, revealed R11 did not smoke. R11's admission MDS, dated [DATE], identified R11 was not a current tobacco user. R11's care plan, last revised 3/24/20, did not identify R11 smoked. R12's most recent admission assessment, dated 2/3/20, revealed R12 was cognitively intact and required supervision for locomotion on and off the unit. R12's care plan dated 1/29/20 did not identify that R12 smoke. R13's most recent quarterly MDS, dated [DATE], revealed R13 was cognitively intact and independent with locomotion on and off unit. R13's [DIAGNOSES REDACTED]. R13's admission MDS, dated [DATE], revealed R13 was a current tobacco user. R15's most recent significant change MDS, dated [DATE], revealed R15 had moderate cognitive impairment and was independent with locomotion on and off unit. R15's [DIAGNOSES REDACTED]. R15 was identified as a current tobacco user and over [AGE] years old. R15's smoking risk evaluation, dated 8/21/19, revealed R15 smoked cigarettes hourly. No risks were identified. R15's smoking care plan, last revised 9/2/16, revealed, (R15) is a safe smoker with smoking apron and The resident can smoke unsupervised. He gets 6 cigarettes per day, 3 on day shift and 3 on pm (evening) shift. The care plan did not address R15 who begged and stole smoking materials from others. R16's most recent quarterly MDS, dated [DATE], revealed R16 was not assessed for cognitive status and required supervision for locomotion on and off unit. [DIAGNOSES REDACTED]. R16's 12/23/19, admission MDS revealed R16 had moderate cognitive impairment and was a current tobacco user. R16's smoking risk evaluation, dated 12/16/19, revealed R16 smoked cigarettes less than hourly and had no risks identified. R16's smoking care plan, last revised 12/18/19, revealed R16 was a smoker and allowed to smoke unsupervised. No smoking risks were addressed. R17's most recent quarterly MDS, dated [DATE], revealed R17 had moderate cognitive impairment and delusions. R17 was independent with locomotion on and off the unit. R17's [DIAGNOSES REDACTED]. R17 was over [AGE] years old. R17's smoking assessment dated [DATE], identified R17 did not smoke. R18's most recent quarterly MDS, dated [DATE], revealed R18 was not assessed for cognitive status and was independent with locomotion on and off the unit. R18 had [DIAGNOSES REDACTED]. R18's care plan with revision date of 3/25/20 and smoking assessment dated [DATE], identified R18 was an independent and safe smoker. R19's most recent admission MDS, dated [DATE], revealed R19 was cognitively intact and was independent with locomotion on and off the unit. R19's [DIAGNOSES REDACTED]. R19 was identified as a current tobacco user. R19's smoking risk evaluation, dated 3/11/20, identified R19 was an unsafe smoker, smoked cigarettes hourly, inappropriately provided smoking materials to others, begged or stole smoking materials from others and had extrapyramidal symptoms (EPS). R19's smoking care plan, last revised 2/26/20, revealed R19 was a smoker. R19's risks were not identified on the care plan. R20's quarterly MDS, dated [DATE], revealed R20 had no problems with long or short term memory or recall ability. R20 was independent with decision making. R20 was independent with locomotion on and off unit. R20 had [DIAGNOSES REDACTED]. R20's admission MDS, dated [DATE], identified R20 was a current tobacco user. R20's smoking risk evaluation, dated 12/26/20, revealed R20 smoked cigarettes hourly and was a safe smoker with no risks. R20's smoking care plan, last revised 10/3/17, identified R20 was a safe smoker and was able to smoke unsupervised. R21's most recent quarterly MDS, dated [DATE], revealed R21 had moderate cognitive impairment and was independent with locomotion on and off the unit. R21 had [DIAGNOSES REDACTED]. R21's smoking risk evaluation, dated 1/28/20, revealed R21 smoked cigarettes less than hourly and had no known risks. R21's care plan, last revised 2/19/20, did not identify smoking. R22's most recent quarterly MDS, dated [DATE], revealed R22 was cognitively intact and independent with locomotion on and off the unit. R22 was diagnosed with [REDACTED]. R22's admission MDS, dated [DATE], identified R22 was not a tobacco user. R23's most recent quarterly MDS, dated [DATE], revealed R23 had moderate impairment for daily decision making and experienced delusions and rejected care 4-6 days per week. R23 was independent with locomotion on and off unit. R23's had [DIAGNOSES REDACTED]. R23's care plan dated 3/8/18, identified R23 was a safe smoker with no identified issues. R24's most recent annual MDS, dated [DATE], revealed R24's cognitive and behavior status was not assessed. R24 required supervision for locomotion on and off unit. R24 had [DIAGNOSES REDACTED]. The MDS identified R24 did not use tobacco. R25's most recent annual MDS, dated [DATE], revealed R25's cognitive status was not assessed. R25 was independent with locomotion on and off unit. R25 had [DIAGNOSES REDACTED]. R25 was identified as a tobacco user. R25's quarterly MDS, dated [DATE], revealed R25 was cognitively intact. The MDS identified R25 used tobacco. R26's most recent admission MDS, dated [DATE], revealed R26's cognitive status was not assessed. R26 required supervision for locomotion on and off unit. R26 had [DIAGNOSES REDACTED]. The MDS identified R26 used tobacco. R28's most recent quarterly MDS, dated [DATE], revealed R28's cognitive status was not assessed. R28 was over [AGE] years old. R28 was independent with locomotion on and off unit. R28's had [DIAGNOSES REDACTED]. The MDS did not identify if R28 used tobacco. R29's most recent quarterly MDS, dated [DATE], revealed R29 was severely cognitively impaired and experienced delusions. R29 rejected care and wandered one to three days per week. R29 was independent with locomotion with on and off unit. R29's [DIAGNOSES REDACTED]. R29's smoking risk observation, dated 2/7/2019, revealed R29 was a potentially unsafe smoker. R29 smoked cigarettes less than hourly, begged or stole smoking materials from others and smoked cigarette butts from ash trays. R29's smoking care plan, last updated 8/21/18, revealed, The resident is a smoker. Hx of begs/steals cigarettes, smoking cigarettes butts from ashtrays. R29's care plan directed staff, Re-education completed on smoking patterns and policies. Provide redirection and education on site if unsafe practices s (sic) witnessed. Supervision will be provided during smoking hours. On 4/1/20, from 11:11 a.m. to 11:35 a.m. the following was observed in communal areas inside and outside on the patio. R13 was observed to converse next to R12 on the patio. R12 and R13 pointed out wet and dry spit on the patio ground and a dark mark on the wall near the door where they reported a resident frequently urinated. There were pieces of bread and wrappers on the ground and used tissue on the table. The patio was the size of the side of the building and fenced in. There were metal tables with open metal ash trays on top of them and a closed standing receptacle for cigarettes. There were multiple metal chairs at each table within one to three feet of each other. R12 and R13 noted residents helped clean the patio and it was regularly dirty. At 11:14 a.m. R6 and R16 walked closely together from the dining room to the patio and both sat down near R10. The residents sat at the same table at the side of the patio, within four feet of each other. R6 and R16 smoked cigarettes. There were no staff on the smoke patio. At 11:16 a.m. R11 briefly conversed with R17, sat a few feet away from group and then sat down near R6, R10 and R16. R6 and R11 shared a cigarette, each smoked the same cigarette. (R11's most current care plan did not identify R11 smoked) At 11:19 a.m., R18 joined R6, R10, R16, and R11. At 11:21 a.m., R6 and R18 went inside. R16 moved next to R19 and handed him a used cigarette to smoke. At 11:25 a.m. R19 walked inside, and pushed R15's wheelchair. At 11:35 a.m. R20 handed R21 the cigarette she had smoked. R21 smoked the cigarette butt from R20. R21 had her shoes on the pools of spit near the building. On 4/1/20, the patio was observed from 12:35 p.m. to 12:47 p.m. At 12:39 p.m., R9, R13 and R22 were observed to converse with each other and sat right next to each other on the patio. R9, R13 and R22 reported they were aware of the social distance guidelines (to stay six feet distance from other people) but it was habit to sit next to each other. At 12:37 p.m., R17 was observed to push R7 in his wheelchair. R17 and R7 declined to talk to surveyor. At 12:38 p.m., R23 was observed next to R15 who shared his lighter for R23 to light his cigarette. R23 and R15 reported they were aware of the social distance guidelines but they were hard to follow at the facility. At 12:39 p.m., R25 and R24 were observed to converse next to each other on the patio while R25 smoked. Both stated they were aware of the social distance guidelines, but thought that it applied only to people who were not residents and that it was safe to sit next to other residents. The infection control registered nurse (RN)-A came out to patio for one minute to encourage residents to maintain social distance. RN-A reported there was not a system to monitor the patio, staff would come outside periodically to redirect residents and explain risks and benefits to maintain social distance to prevent spreading Covid-19. RN-A was not aware of any concerns with residents who shared cigarettes. On 4/1/20, at 12:52 p.m. the trained medication aide (TMA)-A reported she was not aware of any procedure to monitor the smoke patio. She reported she thought that was the job of the nurses and nursing assistants. On 4/1/20, at 1:00 p.m. (LPN)-A reported, I don't know. I can get back to you when asked about the procedure to monitor and supervise the smoke patio. LPN-A requested assistance from the infection control registered nurse (RN)-A. RN-A reported there was no official procedure to monitor the smoke patio. Staff were supposed to look out the window and check the smoke patio as they walked by the window to the smoke patio. On 4/1/20, at 1:05 p.m. the licensed practical nurse (LPN)-B reported she was not aware of any residents who shared cigarettes. There was no formal system to monitor the smoke patio. Staff would look out the window to the patio as they walked by. On 4/1/20, at 1:30 p.m. R29 was observed to lean over R5, who sat at a table with an open ash tray on it. R29 was observed to smoke a butt of a cigarette as he stood up. R29 confirmed he took the cigarette butt out of the ash tray and declined to comment further. R10 reported R29 regularly smoked butts from ash trays. R5 approached R28 and leaned over him. R5 reported she was aware of the social distance guidelines, but had no lighter so needed to use R28's lighter. On 4/1/20, at 1:51 p.m. the administrator reported she had worked at the facility since November and was not aware of any assessment of the smoke patio and potential concerns since then or prior. On 4/3/10, at 2:34 p.m. the administrator reported smoking assessments were done by nurses at the quarterly MDS assessments by an observation of the residents as they smoked. The administrator reported open ash trays were in use on tables because of resident preferences. The administrator reported the smoke patio was not supervised. Residents were educated on guidelines for prevention and control of infections included [REDACTED]. The administrator was informed of the observations of residents taking cigarette butts from each other and open receptacles. The administrator responded the residents were aware of the risks and benefits of that behavior and were independent smokers. The Smoking Covid-19 Education, undated, was reviewed, With COVID-19 being the main focus of the world, the safety of our residents is our main focus here at Villa at Bryn Mawr. Below are detailed reminders and mandates for all smokers within our building to ensure we are abiding by social distancing rules. No smoking materials are allowed to be shared between residents or staff. Residents must stay on back smoking patio and staff must smoke in designated parking lot area. All residents and staff must maintain a 6 foot distance at all times while outside smoking. Proper distancing will be marked for reminders. No outside visitors are allowed in back of building by smoking areas. If bringing smoking supplies it MUST be brought to back door and ring doorbell for staff. Disposal of all cigarettes are to be placed in the provided disposal bins on back patio prior to returning into building. We are a HEALTHY building and want to keep it that way. FAILURE TO FOLLOW THESE GUIDELINES CAN RESULT IN LOSS OF SMOKING PRIVILEGES (sic). The document had a space for a printed name, signature and date. The education did not include information on facility staff responsibilities to support residents in ensuring guidelines were followed. Further information on smoke area assessment and plan related to infection control and Covid-19 was requested but not provided. A handout from the Centers for Disease Control and Prevention (CDC), last revised 4/3/20, entitled, What You Can Do if You are at Higher Risk of Severe Illness from Covid-19, revealed, Based on what we know now, those at high-risk for severe illness from COVID-19 are: People aged [AGE] years and older, People who live in a nursing home or long-term care facility, People of all ages with underlying medical conditions, particularly if not well controlled, including: People with [MEDICAL CONDITION] or moderate to severe asthma, People who have serious heart conditions, People who are immunocompromised: Many conditions can cause a person to be immunocompromised, [MEDICAL CONDITION] treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly [MEDICAL CONDITION] AIDS, and prolonged use of corticosteroids and other immune weakening medications, People with severe obesity (body mass index(BMI) of 40 or higher) People with diabetes, People with [MEDICAL CONDITION] undergoing [MEDICAL TREATMENT], People with liver disease. The immediate jeopardy that began on 4/1/20, was removed and the deficient practice corrected on 4/4/20, when the facility re-educated R6, R11, R16, R19, R20, R21 and R29 about the smoking policy, their care plans were updated and new smoking assessments were completed. The open ash trays were removed and smoking receptacles were locked to prevent residents who took cigarette butts and smoked them. Staff monitored the smoking patio during scheduled smoking times, visual marks were placed in the hall and on the smoking patio to alert residents to social distance. All residents who smoked were re-assessed for safe smoking and care plans were updated. All staff were educated in regards to the smoking times. All residents were educated about the smoking policy and social distancing practices. Daily audits were initiated and completed by the director of nursing and unit managers and will integrate review through the quality assurance and performance improvement (QAPI) process and monitor for trends, patterns and recommendations for continuation. R1's progress note dated 3/26/20, at 8:34 p.m. indicated the physical therapist found R1 had difficulty breathing. Nursing staff were notified. Vital signs included temperature of 102 degrees Fahrenheit, oxygen saturation 84%, pulse rate 134 and blood sugar high. R1 appeared responsive but had labored breathing and 911 was called. R1's progress note dated 3/27/20, at 10:18 a.m. indicated R1's wife shared with staff that R1 passed away at hospital on [DATE], due to multiple complications from [MEDICAL CONDITION]. Wife stated hospital tested R1 for COVID-19 due to the suddenness of R1's symptoms. Timeline of facility response to COVID-19 and activities done in the building provided by nursing home administrator indicated on 3/29/20, it was noted R1 tested positive for COVID-19 on Friday 3/27/20. R4's (R1's roommate) progress notes were reviewed and included: -On 3/27/20, at 12:16 p.m. indicated late entry note that R4 was placed on droplet precautions related to roommate being diagnosed with [REDACTED]. -On 3/29/20, at 10:31 p.m. nose swab obtained and sent to lab. -On 3/30/20, at 1:39 a.m. temperature 99.4. No symptoms of COVID-19, no cough or complaints of sore throat. Awaiting swab results. -On 3/30/20, at 11:36 a.m. R4 continued to have low grade fever. -On 3/31/20, at 3:55 p.m. lab result for COVID-19 undetected. Contact precautions materials removed from room. -On 4/2/20, at 12:09 p.m. administrator updated writer R4 can come off droplet precautions. R4 had no known exposure to COVID-19. Isolation kit from outside room removed. R4's Care Plan dated 4/2/20, indicated R4 had exposure to COVID-19. COVID-19 test came back negative on 3/31/20, and droplet precautions were removed. Minnesota Department of Health (MDH) advised to re-instate droplet precautions x 14 days then retest for COVID-19 again. Interventions include: -droplet precautions x 14 days -encourage social distance at least 6 feet. Encourage to stay in room while on droplet precautions. Give mask if he insists on going out -monitor for signs/symptoms of COVID-19 -monitor/document/report to medical doctor as needed for dehydration, dry skin and mucous membranes, poor skin turgor, weight loss, anorexia, malaise, [MEDICAL CONDITION], increased heart rate, fever, abnormal electrolyte levels -monitor for cough, abnormal vitals, shortness of breath, sore throat -resident to eat in room -vital signs every shift On 4/2/20, at 9:19 a.m. the administrator confirmed during a telephone interview that R4 had been placed on droplet precaution isolation on 3/27/20, was tested for COVID-19 on 3/29/20, and removed from isolation precautions on 3/31/20, when R4's test result came back negative. Administrator stated that is how they would handle any infectious disease, such as the flu, once the test was negative, precautions would be removed. Administrator did not feel R4 should have be kept in isolation for 14 days following contact with a positive COVID-19 resident. Administrator also stated they only used droplet precautions with COVID-19 suspected cases and indicted they would not have enough personnel protective equipment to do otherwise. According to the Center for Medicare & Medicaid Services (CMS) the COVID-19 virus is thought to spread mainly from person-to-person through respiratory droplets produced when an infected person coughs, sneezes or talks. Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms. It may be possible that a person can get COVID-19 by touching a surface or object that has [MEDICAL CONDITION] on it and then touching their own mouth, nose or possibly their eyes. [MEDICAL CONDITION] that causes COVID-19 is spreading very easily and sustainable between people. The facility provided polices and decision making items which included, About Coronavirus Disease 2019 (COVID-19) from the MDH memo dated 3/19/20, which indicated symptoms usually appear about 5 days after a person is exposed to COVID-19, but can appear anywhere between 2-14 days after exposure.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R1) was free from abuse when another resident (R2) pushed him, resulting in a fall. This resulted in actual harm for R1 who suffered a [MEDICAL CONDITION] as a result of the fall. In addition, the facility failed to ensure 1 of 1 resident (R1) was free from verbal abuse when a staff member verbally abused R1 following the fall. Findings include: R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment, and had delusional behavior. The MDS indicated R1 sometimes could make self understood and could understand others, and responded adequately to simple, direct communication. The MDS indicated R1 had delusional behavior, but during the look back period ending 10/20/18 exhibited no wandering behavior. The MDS further indicated R1 required supervision with transferring, and needed help, supervision and the physical assistance of one staff to ambulate in the room or corridor. R1's care plan, updated 7/19/18, identified focus areas of impaired cognitive function/dementia or impaired thought process, R1 was a wanderer, related to impaired safety awareness, and listed various interventions which included: secured unit; re-direct when wandering into other rooms; and intervene as necessary and remove from situation and take to alternate location as needed. The care plan indicated staff were aware of R1's wandering. R2's annual MDS dated [DATE], indicated severe cognitive impairment. R2's [DIAGNOSES REDACTED]. R2's care plan identified a history of showing physical and/or verbal aggressiveness towards staff/others related to anger, depression, poor impulse control, and history of delusions/paranoid thinking. R2's care plan directed staff when R2 became agitated, intervene before agitation escalates. An initial Incident Tracking report dated 11/5/18, indicated the facility reported an allegation of maltreatment to the State Agency (SA). The report indicated R1 was pushed by another resident (R2), which caused R1 to fall. A follow up Investigation Report Summary dated 11/12/18, indicated R1 wandered into R2's room, while R2 was sleeping, and this startled R2. R2 pushed R1 out of R2's room, causing R1 to fall. Licensed practical nurse (LPN)-A witnessed R2 push R1 from his room. LPN-A immediately separated the two residents (R1 and R2), moved R1 away from R2's door. Unidentified staff stayed with R1 until R1 was sent to the emergency room and was admitted with a [MEDICAL CONDITION]. When interviewed on 2/13/19 at 1:18 p.m. nursing assistant (NA)-B said R1 had his moments and stated R1 would tell people to move, or get off the phone because R1 actually believed he owned the place. NA-B stated is was no secret R1 wandered into other residents' rooms on the unit, and likely did wander into his former room, which is R2's room. NA-B stated R1 probably thought that was still his room, even though R1 only was in that room (R2's) for only a short time. NA-B stated R1 and R2 did not get along. When interviewed on 2/13/19 at 1:28 p.m. LPN-C stated R2 is aggressive especially if he does not get what he wants, and usually the issue has to do with food. LPN-C stated you can give R2 food, for example, and he will eat it, then when he sees someone else eating, R2 thinks that food is his, and gets angry. LPN-C stated she has seen R2 stand up from the table, and get in another resident's space and get angry, and I think sometimes R2 could be a danger to residents. R1's Hospital Discharge Orders and Information document, printed 2/14/19, indicated R1 was admitted to the hospital on [DATE], had a discharge [DIAGNOSES REDACTED]. The document indicated R1 was discharged to the nursing facility on 11/9/18. A review of R1's nursing progress note, dated 11/6/18, indicated: IDT (interdisciplinary team) met to review and discuss resident incident resulting in fall and hospitalization . Resident (R1) noted to be crawling on the floor out of another resident's room (R2). Staff asked resident (R2) what happened, resident responded he pushed (R1) in order to make him leave. Resident witnessed by staff on floor. Resident complained of pain and sent to hospital where it was verified he had a left [MEDICAL CONDITION]. An additional, initial report, also dated 11/5/18, indicated Report made by staff member that another staff member was speaking inappropriately to a resident. The follow-up report dated 11/12/18, indicated LPN-A made inappropriate statements to R1 when laying on the floor, after suffering a fall (on 11/5/18). The report indicated therapeutic recreation assistant (TRA) reported, LPN-A told R1 to get himself off the floor after R1 asked LPN-A for help to get up. The TRA reported LPN-A screamed at R1 not to move while LPN-A was taking R1's blood pressure and overheard LPN-A yelling at R1, saying things like you deserve a broken hip and karma is always going to come back and get you and it's your own fault your hip is broken. TRA remained on the unit until nursing assistant (NA)-C arrived back on unit to supervise R1. The TRA notified the therapeutic recreation director (TR-D) by phone of the situation. Approximately 10 minutes later, after the administrator and director of nursing (DON) were notified, LPN-A was escorted out of the building and suspended pending further investigation. LPN-A has since been terminated. As part of the facility's investigation, LPN-A provided a statement on 11/9/18 at 3:15 p.m. LPN-A's statement indicated the following: LPN-A reported she heard yelling at approximately 5:15 p.m. on 11/5/18, while she was in the med room. LPN-A reported she was the only nursing staff member on the unit at the time. LPN-A reported she looked in the hallway and saw R1 by R2's room. LPN-A then ran down to R2's room and by the time she got there, R2 had pushed R1, which caused R1 to fall. R1 was lying on the floor stating I don't' know what happened. LPN-A reported she tried to move R1 away from R2's door. LPN-A reported R1 did not appear to be severely injured at this time and stated to R1: This is what happens when you go into other's rooms. LPN-A reported she asked therapeutic recreation (TR) staff who was present to call another nurse's station for help and to get a blood pressure cuff. LPN-A reported the TR staff was unable to get in contact with the nurse's station and LPN-A then asked the TR staff to go down to nurse's station to get help. LPN-A reported she also placed call to the nurse manager (LPN-B) who told LPN-A not to send R1 to the ER (emergency room ) because they need to get an x-ray at the facility first. LPN-A reported she called for an on-call doctor and left message to return call. As LPN-A waited, another nurse (unidentified) came from station 1 and continued to wait for a return call from the doctor. On call nurse (LPN-B) placed call to ER. LPN-A reported at this time she had been asked to leave the unit, pending investigation, and left facility around 7:15 p.m. Review of LPN-A's personnel records were reviewed and indicated LPN-A was hired 7/2/18. The records further indicated LPN-A completed abuse prohibition training on 9/23/18. A Physical Therapy Plan of Care document dated 11/12/18, indicated R1's [DIAGNOSES REDACTED]. The document indicated R1 was a resident on the locked unit, sustained a fall on the unit with subsequent [MEDICAL CONDITION] femur. R1 was independent with prior level of functional mobility skills. During interview on 2/14/19, at 9:08 a.m. the recreational service director (RSD) stated he recalled the incident between R1, R2 and LPN-A, that happened a few months ago. RSD stated he was in the neighborhood of the facility when he received a call from therapeutic recreation assistant (TRA)-A, who was working during the late afternoon/evening shift of the day of 11/5/18. The RSD stated TRA-A called and reported one of the residents on station 3 (the locked unit) had a fall and stated I am very uncomfortable about how the nurse (LPN-A) was handling the situation. The RSD stated TRA-A reported the nurse who was assisting R1, was standing over R1 and telling R1 things like (R1) you deserved what happened and this is what you get for coming into R2's room. The RSD stated he immediately thought there was verbal abuse and R1 was abused by the staff (LPN-A). RSD stated he attempted to call the administrator and DON, but both were initially unavailable, but called the nurse manager and let her know what had been reported to me, and also called former assistant administrator. The RSD stated from his stand point, his staff did the right thing, made the report, and stated he understood LPN-A was removed from the facility shortly thereafter. RSD stated he was unaware and had not seen any behaviors with LPN-A prior to this event that would have raised concern. The RSD stated he heard in general that LPN-A was quick to use profanity, but stated he personally could not verify that. The RSD stated what LPN-A was reported to have done and said and that kind of behavior and response to a resident, berating a resident after a fall was clearly abuse, and was not acceptable. During interview on 2/14/19, at 10:06 a.m., therapeutic recreation assistant (TRA)-A stated she witnessed first hand the situation involving R1, R2 and LPN-A. TRA-A stated she had been employed at the facility since the beginning of October, (YEAR), and added she had worked at nursing homes in the past. TRA-A stated she immediately knew when she heard how LPN-A was talking to R1 this was abuse and also it was immediately reportable. TRA-A stated she knew right away LPN-A had to be removed from the situation. TRA-A stated on the evening of the incident, when she came on the unit she saw R1 lying near the dining room on the floor. TRA-A stated LPN-A was facing R1 and LPN-A's back was toward TRA-A, and LPN-A did not realize I had come on the unit right away. TRA-A stated she heard R1 say to LPN-A Please help me get up, and LPN-A replied, in a condescending tone,NO, get up yourself! At that point, LPN-A turned around saw me, and then tried to haphazardly try to assist R1. TRA-A stated LPN-A asked her to get a vitals tree (a portable, wheeled vital sign equipment), and did, but needed to call down and get it from another unit, so left the unit for a few minutes to get the vitals tree. TRA-A stated when she returned to the unit, R1 had scooted himself to the other side of the dining room. TRA-A stated LPN-A continued to be rude and continued to say horrible things to R1. TRA-A stated LPN-A told R1 Sit still, Karma is a [***] , I hope you break your hip, and you deserved this. TRA-A stated at this point she was crying, and at that point, I call(ed) my supervisor. TRA-A stated she knew right away this was not right, and this was abuse. During interview at 2:11 p.m. on 2/14/19, the DON discussed the incident between R1, R2 and LPN-A. The DON stated what was reported and investigated was the nurse, LPN-A, was verbally inappropriate with R1. The DON stated she would call this verbal abuse by a staff member. The DON also acknowledged the resident to resident incident between R1 and R2, and stated she could not say if R2's actions of pushing R1 were intentional, as both R1 and R2 had dementia. The DON stated the investigation report was, R1 wandered into R2's room, and was pushed by R2, causing R1 to fall. The DON stated R1 was then transported to the hospital and had a [MEDICAL CONDITION]. When asked if there were enough staff on the floor, DON stated she felt the supervision was adequate. DON did not know the census on the locked unit the day of the incident, but said today we have eighteen residents, with two staff. The DON acknowledged during break times, there were was only one staff from nursing on the floor. DON explained the facility followed their policy, nurse manager was immediately notified, and LPN-A was suspended immediately, and an OHFC (Office of Health Facility Complaints or State Agency) report was completed. The facility administrator was also interviewed and stated the staff acted appropriately, and stated they had a system in place to respond to abuse, and it worked. We followed our process. A facility policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective 11/28/17, indicated in its purpose, that An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. The policy defined abuse as .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also indicated abuse included verbal abuse, indicated Wilful, as used in this definition of abuse, means that individual must have acted deliberately, not that he individual must have intended to inflict injury or harm.

Based on record review and interview, the facility failed to provide the necessary treatment and services in notification of the physician/nurse practitioner of changes in cardiac status for 1 of 1 resident (R68) in the closed record sample identified as having cardiac-related issues; and failed to offer non-pharmacological interventions to treat pain, for 1 of 3 residents in the sample (R7) who had identified pain, resulting in actual harm to both residents. Findings include: R68 experienced an increase in weight and fluid retention. Facility nurses did not notify the physician/nurse practitioner of changes in the resident's cardiac condition 5/9/11 until 5/16/11, when the resident was transferred to the hospital. The resident suffered actual harm when nursing staff did not provide timely assessment when the resident experienced a change in condition. R68 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. R68's hospital history and physical indicated he received treatment for severe [MEDICAL CONDITION], acute kidney failure, and [MEDICAL CONDITION]. The physician's recommendation was that R68 be discharged to a long term facility due to his de-conditioned status, until he was ready for discharge to a treatment center. R68's admission weight on 4/27/11 was recorded as 234 pounds. The physician ordered to encourage fluid intake of 1.5 - 2 liters per day, a regular cardiac, consistent carb-med, low fat low cholesterol diet, and the medication [MEDICATION NAME] to remove excess fluid in the tissues. On 5/3/11, the physician ordered a chest x-ray, due to decreased lung sounds and a slight cough. The chest x-ray results were as follows: "Moderate right possible patchy infiltrate in left lower lung. Superimposed volume overload can't be excluded. Continue the antibiotic from the hospital." On 5/4/11, the nurse practitioner (NP) ordered to push fluids for four days and to check laboratory results based on the resident's [MEDICAL CONDITION] diagnosis. Five days later on 5/9/11, the NP ordered the discontinuation of "push fluid" and increased the [MEDICATION NAME], as R68's face appeared "puffy." On 5/10/11, R68's 14-day nutritional assessment revealed the following: "Diet appropriate, per intakes record, eats 75-100%. Current weight 253 pounds (admission weight 234 pounds). Due to significant weight gain since admit, asked for re-weigh which was 270 pounds. Nursing spoke with (R68) who reported he noticed he was heavier since admission and nursing stated his face was puffier." The resident was experiencing increased shortness of breath and was on oxygen. Daily weights were initiated, and the NP would be notified due to weight gain. Documented daily weights were as follows: 5/13/11--275; 5/14/11-- 275; 5/15/11--no documented weight; and 5/16/11--286. R68 remained on oxygen which did not interfere with his independence with all personal cares and mobility levels. A nurses note dated 5/13/11 documented that R68 called an emergency care department (ECD) without informing a nurse and informed them, "'I'm concerned with my weight, sometimes being short of breath and want them to take care of me before leave here.'" The nurses note was written within two minutes, indicated R68 was encouraged to use TED stockings (used to reduce [MEDICAL CONDITION] and/or risk of clotting). The resident was measured for the stockings and an order was placed. During this time, the laboratory results and the medication administration records (MARs) were faxed to ECD per their request. The nurses note also documented R68's weight was 275 pounds. R68 then left to go shopping with his brother for the evening. The TED stockings arrived 5/14/11 and R68 did wear the stockings. On 5/16/11, ECD called the facility and ordered R68 be transferred to the ECD for evaluation. He was subsequently admitted to the hospital with [REDACTED]. R68's care plan prior to his hospitalization (dated 4/28/11 and revised 5/10/11) addressed his diet noting his intake was 50-100% and no difficulty with chewing/swallowing, and the resident's increased weight. The plan was to "continue to monitor weights daily due to fluid retention and labs (laboratory work) as available. Continue oxygen as ordered and encourage (R68) to limit smoking, check lung sounds as needed if had shortness of breath. Lab values drawn and results called to NP/ECD." The director of nursing was interviewed on 7/28/11 at 12:10 p.m. She confirmed the NP and/or physician had not been notified of R68's weight increase. She reported that when the resident was re-weighed, the weight may have been incorrect. She also said R68 should not have had to call to ECD about his condition, and she had not been apprised of R68's change of condition until the day he was sent to the hospital. She was unable to provide documentation of communication between the facility staff nurses and the ECD physician/NP from 5/13/11 through 5/16/11. On 7/28/11, at 1:00 p.m. R68's NP was interviewed. The NP stated R68 was admitted to the nursing home for rehabilitation and to stabilize his kidney status. R68 then developed an exacerbation of his long-standing [MEDICAL CONDITIONS]. The NP added that labs were ordered and an increase of the [MEDICATION NAME] was ordered on [DATE] because of puffiness of the face. Because the NP did not want to over-[MEDICATION NAME] (removing too much excess fluid from the body) because of his unstable kidney status, which the NP stated could inadvertently cause more problems. The NP then stated she was unavailable for an extended time, however, no calls from the facility were received by other NP's during that time. Upon her return, there was a message reporting R68 had been sent to hospital on [DATE]. She added that the guidelines for notification of a resident's weight gain was three pounds or more in a week. The NP said that with R68, she would have expected to be notified when he gained 14 pounds in such a short time, and then gained another 20 pounds. R7 had chronic pain and had a history of [REDACTED]. Non-pharmacological interventions, other than physical therapy, had not been offered. The resident suffered actual harm when alternative measures were not identified and offered to minimize the resident's pain. On 7/25/11, at 5:05 p.m. R7 stated he had multiple problems [MEDICAL CONDITION], a bad shoulder and spine, and experienced chronic daily pain, but took only Tylenol. He stated he would like to have had something more for pain particularly at night to help him sleep. In a follow up interview on 7/28/11, R7 reported he refused to take [MEDICATION NAME] prescribed for pain, due to his belief that body fluid levels must be closely monitored. He did not trust the facility to monitor him closely enough, and he did not feel the medication provided him much pain relief. R7 was asked whether non-pharmacological interventions, such as cold packs or topical [MEDICATION NAME] had been effective. He said he used hot and cold packs in the past, at a different facility, and it had given him some relief. He also used a Transcutaneous Electrical Nerve Stimulation (TENS) unit in the past with good results. R7 had [DIAGNOSES REDACTED]. R7 had a history of [REDACTED]. R7 was prescribed and received a [MEDICATION NAME], which provided 25 micrograms [MEDICATION NAME] per hour, as well as Tylenol 1000 milligrams four times daily for pain. A physical therapy note dated 6/3/11, indicated the goal for decreased pain in lower extremities had been met. R7 rated pain as moderate with "patient unable to sleep through the night and limited ambulation tolerance to within physical therapy room." No interventions other than exercises were indicated. A pain assessment dated [DATE], indicated R7 had pain in the past five days located in neck, shoulder, arm, chest, abdomen, and leg. R7 rated his pain as almost constant, severe throbbing pain. R7 described the affect on his quality of life as, "I stay in bed most of day-- Only able to eat about 50% of my meals." The summary indicated that R7 had pain every day. R7's annual Minimum Data Set (MDS) assessment dated [DATE], indicated no non-pharmacological interventions had been tried, and his pain was constant and rated at a level of 10, on a scale of 0-10 (ten being the most pain). The care plan with target date of 9/27/11, indicated right upper quadrant pain, somatic nocioceptive pain in left lower quadrant, and [MEDICAL CONDITION] disc disease of lumbar-sacral spine. Also noted was a [DIAGNOSES REDACTED]. The goal for R7 was to state comfort. Interventions directed staff to continue to monitor pain, assess pain according to subjective scale in the pain assessment, notify the physician of any increased discomfort , and follow up at the pain clinic as indicated, administer medications as ordered, and anticipate the resident's comfort needs, since he did not always make his needs known to staff. A licensed practical nurse (LPN-B) was interviewed on 7/28/11, at 10:00 a.m. She related that R7 did Internet searches about his medications, and decided [MEDICATION NAME] was contraindicated with persons [MEDICAL CONDITION]. The LPN explained that R7 directed his own care, and he made the decision not to take it anymore. When he stopped taking the [MEDICATION NAME], LPN-B stated there was no change in the frequency of his complaints of pain. He did not often make complaints of pain, and if he did, then a nursing note was to be completed. Occasionally R7 complained of heartburn. The LPN was unaware of any non-pharmacological interventions used to aid in alleviating the resident's pain. In a nurse practitioner (NP) progress note dated 7/21/11, identified the problem of chronic pain in left leg and right shoulder. The note read, "The patient continues to be symptomatic though physical exam does not always reflect a lot of pain, and this is baseline for the patient. He is not losing functional ability. He had previously been attending physical therapy for his pain issues." On 7/28/11, at 12:00 p.m. the NP stated that many different oral [MEDICATION NAME] had been tried for R7 but he had refused all treatments. He had consistently accepted the [MEDICATION NAME], however, the NP did not want to add other narcotics in addition to the patch. He had been given leeway to direct times of medications and his guardian was very involved with his care. Also, R7 had received medications at night for pain and then refused them. The NP verified that non-pharmacological interventions, other than physical therapy, had not been offered for R7. The NP stated she was open to providing any non-pharmacological interventions appropriate and acceptable to R7. The director of nurses stated, on 7/28/11 at 1:30 p.m. specific non-pharmacological interventions were not identified for R7, and the facility "could do a better job" in regard to offering non-pharmacological interventions to residents experiencing pain.