Every finding on record at Zumbrota Care Center

Based on interview and record review, the facility failed to ensure that residents whose Medicare Part A services were ending, but who remained in the facility, received the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS-10055) prior to the termination of services to advise them of potential costs and options. This affected 2 of 3 residents (R4 and R31) reviewed for Medicare Part A coverage termination. Findings include:R31's medical record indicated R31 admitted [DATE] on Medicare part A coverage and ended coverage on 5/11/26. On 5/12/26 R31 remained in the facility on private pay. R31's NOMNC signed 5/7/26 by R31 identified R31's Medicare coverage would end 5/11/26. R31's electronic medical record lacked evidence a SNFABN was provided to R31 or their representative to advise on potential cost of staying in the facility after Medicare Part A ends and to offer the choice of receiving the offered services, asking Medicare to be billed or declining the offered services.R4R4's medical record indicated R4 started Medicare part A coverage on 5/4/26 and ended coverage on 6/27/26. On 6/28/26 R4 remained in the facility on private pay. R4's Notice of Medicare Non-coverage (NOMNC) signed 6/24/26, identified R4's Medicare Coverage would end on 6/27/26. The form indicated verbal consent was received from R4's responsible party on 6/24/26 and signed by facility social services employee (SS)-A.R4's electronic medical record lacked evidence a SNFABN was provided to R4 or their representative to advise of potential cost of staying in the facility after Medicare Part A ends and to offer the choice of receiving the offered services, asking Medicare to be billed or declining the offered services.During an interview on 7/28/26 at 11:30 a.m., Social Service (SS)-A stated the facility health unit secretary was originally responsible for completing the appropriate forms and was not aware until 7/28/26 they were not getting done. SS-A stated she spoke to the unit secretary who stated she thought the social worker was completing the forms. SS-A stated she had not been doing them because she was not told she was supposed to do them nor was she trained how to complete them. During an interview on 7/28/26 at 11:43 a.m., the health unit secretary (HUC) stated she received an email from the facility administrator on 4/7/26 indicating the social worker would be responsible for completing the NOMNC/ABN forms going forward. An email sent on 4/7/26 from the administrator to SS-A, HUC, and other facility employees indicated SS-A was responsible for doing the [Medicare]- B NOMNCs going forward. The email did not mention Medicare part A benefits. During an interview on 7/29/26, SS-A was able to explain the purpose of the NOMNC and ABN form however was unsure how to determine the cost of services that is indicated on the ABN form. During an interview on 7/29/26 at 12:25 p.m., the administrator stated SS-A has always been responsible for completing the NOMNC forms and the HUC completes the ABN forms. The administrator stated she would expect the NOMNC and ABN forms to be done completely and in a timely manner. During a follow-up interview on 7/29/26 at 12:30 p.m., the HUC confirmed she had not completed the NOMNC or ABN forms since April 2026. She confirmed R4 and R31 did not receive them. A policy titled Medicare Denial Procedure dated 2/27/24 indicated the facility provides a notice of Medicare denial to Medicare beneficiaries in a timely manner to inform them that Medicare is not likely to provide coverage for specific items or services that are the subject of the notice. The policy indicated the Medicare Denial Notice will be delivered no later than 48 hours prior to discharge from services and far enough in advance to allow the Medicare Beneficiary sufficient time to consider their options and make an informed choice regarding their right to appeal the decision that Medicare will not cover specific services. The policy further indicated if the beneficiary will continue to stay in the care center, the facility would provide the NOMNC and SNF ABN which is the demand bill portion.

Based on observation, interview, and record review, the facility failed to ensure a resident possessed the clinical knowledge and skills required to monitor and manage an indwelling medical device independently, and failed to clinically assess the resident's competency to self-manage the device. This affected 1 of 1 resident (R12) reviewed for an indwelling biliary drain.Findings include: R12's quarterly Minimum Data Set (MDS) assessment, dated 5/15/26, indicated R12 was cognitively intact with no symptoms of delirium. R12 had no history of behaviors. The MDS indicated R12 was independent with activities of daily living, bed mobility, transfers, and ambulation. R12's ability to bathe self was not assessed. The MDS indicated R12 had a history of post traumatic stress disorder, aphasia (struggle expressing words). R12's diagnoses list included kidney disease, chronic gall bladder inflammation, history of gallstones with obstruction, stroke, and history of falls. R12's care plan included gall bladder disease with biliary tube (a tube inserted in the gall bladder to allow fluids to drain) and drainage bag. The care plan indicated daily site care, change drainage bag every two weeks, drink extra fluids, monitor insertion site, and R12 emptied drainage bag independently. R12's nursing assistant care plan indicated R12 may ask for assistance with upper body dressing due to drainage bag, and R12 was independent with morning routine. R12's provider orders included dressing changes to insertion site twice a day, monitor site for signs of infection, and specific site care supplies. During observation and interview on 7/27/26 at 11:47 a.m., R12 was observed with a biliary tube inserted into his right side below the ribcage. The tubing extended across his abdomen and was attached to a drainage bag clipped to his upper left chest-positioning the drainage bag above the level of the tube's insertion site. During an interview, R12 stated he has had the tube for 6 years and empties it himself, but noted it does not always drain well. R12 stated that facility staff explicitly told him to hang the bag on his upper left chest.During observation and interview on 7/28/26 at 9:22 a.m., R12 was observed lying completely flat in bed. The biliary tube extended from his right side across his body and remained connected to the drainage bag attached to his shirt on his upper left chest. R12 reconfirmed he drains the bag himself.During an interview on 7/28/26 at 2:32 p.m., registered nurse (RN)-B stated nurses provide medications and perform dressing changes to R12's biliary tube. R12 performs all other activities of daily living himself, including emptying the biliary tubes drainage bag. RN-B stated staff do not track the amount of drainage and assess the drainage based on what is collecting in the tube. RN-B pointed to her waistband and stated R12 clips the bag under his shirt. RN-B stated she did not receive any specific training regarding management of a biliary drain and does what the order says to do. During interview on 7/28/26 at 3:13 p.m., nurse manager (NM)-A stated R12 was admitted with the biliary tube and has had it for 5-6 years. Nursing staff do site care however R12 manages emptying and changing of the drainage bag. R12 will inform staff if there are issues. NM-A stated R12 clips the bag under his shirt and usually tacks it in his undergarments. NM-A was unaware R12 keeps the drainage bag clipped by his left upper chest stating R12 never used to put it that high. NM-A stated the fluid would not be draining properly if the drainage bag was that high. During an interview on 7/28/26 at 4:00 p.m., the facility medical director (MD) stated prior to admitting to the facility, R12 was living independently in a hotel and was unable to care for himself. The MD stated the biliary drainage bag should hang below the opening for proper drainage and secured on his side properly to prevent it from being dislodged. The MD stated she feels having the drainage bag stored in R12's left upper chest would not be a problem if he was standing because the tube itself would hang below the opening before following to R12's left upper chest. The MD stated securing the bag to the left upper chest would pose a problem if R12 was laying down because the fluid would flow back into his gallbladder. During an interview on 7/28/26 at 4:26 p.m., the facility assistant director of nursing/infection preventionist (ADON) stated R12 lived alone prior to admission to the facility and managed the biliary drain independently. The ADON stated nursing staff observe the drainage each day with dressing changes. The ADON stated she did not recall if the facility did any specific education with staff to care for the drainage bag or what to look for. She also stated she was unable to find an assessment indicating R12 was knowledgeable enough to care for the drainage bag and report concerns independently. During an interview on 7/28/26 at 4:28 p.m., the director of nursing (DON) stated R12 was living independently in poor living conditions prior to being admitted to the facility. The DON stated R12 has had the biliary drain for a number of years and was caring for it independently. She stated facility nursing staff perform site care and she is 99% sure nursing staff also empty the drainage bag. The DON stated staff perform dressing changes to the site twice a day so it would be best if nursing empties it. The DON stated the drainage bag should be stored lower than the insertion site and believes R12 tucks the bag into his pants. the DON stated she was not aware of any assessments performed to determine if R12 could safely empty and care for his biliary drain. The DON stated it is facility staff's responsibility to empty the bag, monitor drainage, and provide site care unless it is determined R12 is safe to do so himself.

Based on interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 resident (R29) who had a history of trauma. Findings include:R29's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated R29 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R 29's diagnoses included post-traumatic stress disorder (PTSD), Parkinson's disease without dyskinesia and anxiety disorder.R29's trauma informed assessment dated [DATE] identified R29 as a trauma survivor and no triggers identified to avoid the potential of re-traumatization.R29's current care plan revised on 6/26/26 lacked identification of any PTSD triggers or interventions. During an interview on 07/29/2026 11:18 a.m., registered nurse, (RN)-A stated, if a resident had PTSD, they needed to be assessed for triggers, and those triggers would be documented on the care plan to help better care for the residents. RN-A completed a brief review of R29's care plan and acknowledged lack of trauma informed care plan in place for R29.During an interview on 07/29/2026 11:38 a.m., nursing assistant (NA)-A stated, if a resident had a history of PTSD and had triggers it would be important to know what their triggers were to better care for them. NA-A stated, was aware of R 29's PSTD diagnosis, however, was unable to locate R29's triggers and intervention on the care plan or Kardex.During an interview on 07/29/2026 11:46 a.m., licensed practical nurse (LPN)-A stated, knew of R29's PTSD diagnoses, however, was not aware of any specific triggers and interventions for R29.During an interview on 07/29/2026 12:14p.m., social services, stated had completed trauma-informed care assessment on 04/16/26, however was unaware of the trauma-informed care plan completion responsibility.Facility Policy titled Trauma Informed Care revised on 09/11/23 indicated, care centers will use a universal screening tool to identify previous trauma emphasizing the value of culture and diversity of others. The Screening tool for trauma will be completed as an assessment in the electronic medical record (Trauma-Informed Care: Resident/Trauma-Informed: Responsible Party) by social services (or designee) with the resident and/their representative on admission or when behaviors may indicate past trauma. Care planning of resident centered behavioral health approaches and goals will be completed in response to the screening or when identified on periodic assessment of resident survivor. Care plan goals and approaches will include individual preferences and routines in response to the emotional and psychological need of the resident survivor.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R2, R29, R31) reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infections. Findings Include: A review of the CDC Shared Clinical Decision-Making document titled PCV20 or PCV21 Vaccination for Adults 65 years or older dated 9/11/24 indicated that adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23. The guidance specified that the determination to administer PCV20 or PCV21 is based on a shared clinical decision-making process between a patient and their healthcare provider, taking into account that an increased risk of exposure to these serotypes may occur among people living in nursing homes or other long-term care facilities. The document further noted that if the provider and patient decide PCV20 or PCV21 is appropriate, one dose should be given at least 5 years after the patient's last pneumococcal vaccine dose.R2's medical record indicated she was [AGE] years old.R2's Minnesota Immunization Information Connection (MIIC) report indicated R2 received PPSV-23 vaccine on 8/28/18 and PCV13 vaccine 12/2/16. R2's medical record lacked documentation of shared decision making with provider and resident/responsible agent regarding administration of PCV20 vaccination. R29R29's medical record indicated R29 was [AGE] years old.R29's MIIC report indicated R29 received the PCV13 on 12/2/16 and PPSV 23 on 11/2/15. R29's medical record lacked documentation of shared decision making with provider and resident/responsible agent regarding administration of PCV20 vaccination. R31 R31's medical record indicated R31 was [AGE] years old. R31's MIIC report lacked record R31 received any pneumococcal vaccines. R31's vaccination consent form indicated R31 had previously received the pneumococcal vaccines however no indication of which vaccination was received.R31's medical record lacked any documentation of a shared clinical decision-making process with the provider and the resident or their responsible agent regarding the administration of the PCV20 vaccination.During an interview on 7/29/26 at 12:50 p.m., the facility assistant director of nursing (ADON) stated R31's family member thought R31 had received the pneumococcal vaccine however the IP confirmed she did not follow-up with the family member which pneumococcal vaccination R31 received. The IP also confirmed neither she nor the facility provider have discussed providing R2, R29, or R31 the PCV-20 vaccine. During a follow-up interview on 7/30/26 at 10:19 a.m., the ADON stated she reviews a residents MIIC report upon admission and offer vaccines to residents who are eligible. The IP again confirmed R2, R29, and R31 have not been offered the PCV20 vaccine. A policy titled Resident Immunizations dated 6/16/26 indicated All residents will be offered vaccinations based on the Centers for Disease Control recommendations and physician orders. The adult immunization schedule, prepared by the CDC, will be utilized to ensure residents are offered and encouraged to accept the appropriate vaccinations. This schedule will be maintained per the CDC website. The policy indicated an immunization history will be taken upon admission including checking the MIIC website. Any immunizations that are not current or unknown vaccination histories will be shared with the attending physician and appropriate physician orders obtained. The resident's immunization history will be documented and maintained in the resident's electronic record. Vaccine information statements will be provided to the resident and/or representative prior to administration of the vaccination. The determination to vaccinate or not will be documented in the electronic medical record. Administration of the pneumococcal vaccine are based on CDC guidelines. Administered immunizations will be documented in the EMR and on the MIIC website.

Based on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R1 and R4) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), unspecified dementia, diabetes, history of falling, and seizure disorder. Further indicated an impairment in range of motion (ROM) on one side of upper and lower extremities and was dependent with transfers with use of mechanical lift.R1's care plan revised 3/28/25, identified a focus of activities of daily living (ADL)'s: R1 had an ADL self-care performance deficit related to hemiplegia. Goal revised 10/21/25, will maintain current level of function in ADLs through the review date. Intervention revised 10/15/25, directed staff to use a Hoyer lift for all transfers. R1 does not go from lying to sitting on the edge of the bed. R1's care plan did not identify the size of sling R1 required for transfers.R1's Therapy/Nursing Communication form dated 10/10/25, directed all staff to use Hoyer (brand of full body mechanical lift) with 2 staff assist for all transfers. The communication form did not identify the size of sling R1 required for lift transfers.R1's Mechanical Lift assessment dated [DATE], identified R1 required the use of a Hoyer lift with total assist. R1's height was 65 inches and weight was 182.6 pounds. Identified R1 should use a large sized sling and that the care plan was updated. Although the assessment identified R1's height and weight it did not include the measurement of the maximum distance from resident's tailbone to base of neck and girth that is required by the manufacturer for appropriate sizing and safety. R1's Kardex (abbreviated care plan for direct care staff) printed 10/21/25, directed staff that R1 required Hoyer lift with assist of 2 staff. R1's kardex did not identify the size of sling R1 required for transfers.During an observation and interview on 10/21/25 at 1:24 p.m., R1 was seated in her chair watching television. R1 stated she now transferred with a Hoyer lift. R1 was unsure what color sling was used or what size it was. R1 stated the staff were aware of what sling size she needed to transfer using the lift. R4's quarterly MDS dated [DATE], indicated R4's cognition was intact, with diagnoses of traumatic subdural hemorrhage with loss of consciousness (a bleed that happens in the space between the brains outer covering and the brain itself caused by physical injury to the head), cerebral infarction (stroke), and history of falling. Further indicated an impairment in range of motion (ROM) on one side of upper and lower extremities and required substantial to maximal assist with mobility and transfers. R4's care plan revised 4/18/25, identified a focus of activities of daily living (ADL) self-care deficit related to ataxia following a cerebral infarction. Goal revised 8/8/25, will maintain current level of function in ADLs through the review date. Intervention revised 7/2/25, directed staff to use an EZ Stand (sit-to-stand mechanical lift) with transfers with assist of 1 staff. R4's care plan did not identify the size of harness that R4 required for transfers.R4's Hospice Plan of care, dated 6/18/25, identified R4 had intermittent confusion, expressive aphasia, right sided hemiparesis, was total assist with all cares and assist of 2 staff with EZ Stand for transfers. R4's hospice care plan did not identify the size of harness that R4 required for transfers.R4's Kardex printed 10/21/25, directed staff that R4 required EZ Stand with 1 staff assist for transfers. R4's Kardex did not identify the size of harness R4 required for transfers.In review of R4's record it was not evident a comprehensive assessment for mechanical lift and for harness size was completed.During an observation and interview on 10/22/25 at 10:22 a.m., R4 was lying in bed. R4 stated the staff used the EZ Stand to transfer her in and out of bed and was unaware of what size harness the staff used for her with transfers. Size medium harness was noted to be laying on the EZ Stand right outside of R4's room. During an interview on 10/25/25 at 10:37 a.m., nursing assistant (NA)-A reviewed R1 and R4's Kardex and stated it did not indicate what size sling/harness to use for transfers with R1's Hoyer lift and R4's sit to stand lift. NA-A stated there was usually a sling/harness in the resident's room to use for each resident and if she had questions on what size to use, she would just ask another aide. NA-A thought R1 would use a large sized sling and R4 would use a medium sized harness based on their weight. During an interview on 10/22/25 at 10:47 a.m., NA-B stated she knows what size sling/harness to use for each resident and was based on the resident's weight. NA-B further stated she would compare the resident's weight to the sling/harness chart the facility had hanging in the tub room. NA-B reviewed R1 and R4's kardex and stated it did not indicate what size sling/harness to use for transfers with R1's Hoyer lift and R4's sit to stand lift. NA-B reviewed the sling harness chart along with R4's current weight of 99 pounds and stated R4 could either be a small or medium sized harness but should probably be using a size small harness because she is so small on the top. NA-B further stated that the chart indicated the torso should be measured and was unsure where to find a torso measurement. NA-B stated for R1 we should be using a medium sized sling instead of a large.During an interview on 10/22/25 at 10:47 a.m., NA-C stated to determine the correct sized sling/harness for residents using a mechanical lift would be to compare their current weight to the sling/harness chart. NA-C reviewed R1 and R4's Kardex and stated it did not indicate what size sling/harness to use for transfers with R1's Hoyer lift and R4's sit to stand lift.During an interview on 10/22/25 at 11:30 a.m., assistant director of nursing (ADON) stated therapy will typically give recommendations to nursing for a resident who requires a mechanical transfer. Slings were used with the full body mechanical lift and harnesses were used with the sit to stand lifts. ADON reviewed R1 and R4's medical records and stated comprehensive sling/harness assessments for R1 or R4 have not been completed which was why their sling/harness sizes are not carried through to their care plans. ADON stated it would be important for the nursing assistants to have access to sling/harness sizes with mechanical lift transfers for resident safety.Requested facility policy and procedure for mechanical lift equipment and was not received. EZ Way Classic Lift operator's instructions, revised 5/5/25, identified.patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.EZ Way Classic Stand operators' instructions revised 4/11/25, identified. The Classic Stand(R) was designed specifically for toileting and changing briefs of patients. The Classic Stand(R) can also be used for transferring the patient from chair, wheelchair, toilet or bed, and can be used for ambulation. As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding if the Classic Stand(R) is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. If a patient does not meet each of these three criteria, an EZ Way total body lift must be used .patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.Ez Way Sling Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and maximum distance from patient's tailbone to base of the neck:Small: gray; 70-100 pounds; 21 inchesMedium: beige; 90-220 pounds, 24 inchesLarge: burgundy; 190-320 pounds; 26 inchesExtra-large: green; 280-450 pounds; 26 inchesExtra extra large: 400 -600 pounds; black; 36 inchesExtra extra extra large: brown; 600 + pounds 37 inches Note: The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgment of the caregiver. It is important to evaluate the width of a patient in relation to the width of the sling. It is important that no portion of the patient overlap the sides of the sling. It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of neck). Note: Slings using Wipeable fabric use beige binding for all sizes and do not follow the color-coding system. Slings using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.Ez Way Harness Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and circumference of patient's torso where harness is applied:Small: gray; 70-100 pounds; 26 to 38 inchesMedium: beige; 90-220 pounds, 34 to 46 inchesLarge: burgundy; 190-320 pounds; 40 to 56 inchesExtra-large: green; 280-450 pounds; 50 to 64 inchesExtra extra large: 400 -600 pounds; black; 55 to 72 inchesExtra extra extra large: brown; 600 + pounds; 65 + inchesNote: The size/weight of designations are merely estimates and basic guidelines. A proper fit will involve the judgement of the caregiver. Color coding applies to the binding of the harnesses. Harnesses and accessories using Wipeable fabric use burgundy binding for all sizes and do not follow the color-coding system. Harnesses using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.

Based on observation, interview, and document review the facility failed to comprehensively assess each fall to identify and analyze causal factors for potential root cause in order to determine individualized interventions to prevent or decrease the risk for future falls for 1 of 3 residents (R2) reviewed for falls.Findings include: R2's Fall Risk Evaluation dated 6/12/25, identified R2 had 1-2 falls in the past 3 months, had intermittent confusion, was ambulatory and continent. R2 had balance problem while standing and walking and required the use of assistive devices. R2 currently takes 3-4 high risk medications. R2 was at risk for falls, with a goal to be free of falls. Interventions: assist R2 with ambulation and transfers utilizing therapy recommendations, determine ability to transfer, and if fall occurs alert provider.R2's quarterly minimum data set (MDS) dated [DATE], identified R2's cognition was intact, and had diagnoses of Lewy body dementia (a progressive condition characterized by dementia, parkinsonism, and fluctuations in attention and alertness, along with other symptoms like hallucinations and problems with movement), non-Alzheimer's dementia, anxiety and diabetes. R2 required extensive assist of 1 person for transfers, toileting and toileting hygiene and was frequently incontinent of bladder and occasionally incontinent of bowel. R2 had one fall with no injury and 1 fall with injury. R2's care plan revised 4/25/25, identified a focus that R2 was at risk for falls related to gait, balance and cognition problems. History of falls with major injury, fracture of left hip requiring surgical interventions. Interventions revised on 4/10/25, directed staff to use a stationary nonreclining chair, be sure call light was in reach, Dycem placed on chair surface, use of a Reacher to help with prevention of falls, low pile mat under stationary chair and sign placed in room to remind to use call light to ask for assist. An additional focus revised 3/28/25, identified R2 was incontinent of bladder. Intervention dated 8/23/24, directed staff to monitor/document/report any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects, clean peri area with each incontinent episode and use medium pull up brief, change daily and prn.Furthermore, an additional focus was revised 6/5/25, with activities of daily living (ADL) performance deficit related to disease process. Intervention dated 5/13/25, directed staff that R2 was assist of 1 with front wheeled walker in room for adl's and 8/15/25, identified R2 was 1 assist to the toilet.R2's Fall incident report dated 9/5/25, identified at 2:30 p.m., another resident notified staff that R2 was on the floor. R2 was found face down on the floor next to his bed. R2's clothing was wet, and water was all over the floor. R2 sustained a skin tear to his right knee and knuckles on the right hand were red. R2 stated that he spilled a cup of water on the floor and was reaching forward out of his wheelchair to pick it up when he fell. Immediate action taken: R2 was placed back in his wheelchair per his request and silent alarm engaged. Reinforced the need to use call light.R2's Post Fall evaluation note dated 9/5/25 at 3:30 p.m., identified contributing factors of R2's fall was water was spilled on the floor and was incontinent at the time of the fall.R2's Fall progress note dated 9/5/25 at 4:00 p.m., identified root cause of fall was R2 spilled a cup of water on the floor and was reaching forward out of his wheelchair to pick it up. Intervention was a silent alarm was engaged, and writer reinforced the importance of using his call light when he needed assistance.R2's Fall interdisciplinary team (IDT) note dated 9/5/25 at 4:12 p.m., identified a root cause analysis that R2 dropped his water cup on the floor and reached forward in his wheelchair thinking he could pick it up off the floor. Intervention was R2's grippy socks were on and did not engage his call light. Follow up: signs were up in room to call for assistance and was wearing his call light. Encourage R2 to be out of his room and out in public spaces around others.Review of R2's record identified R2 was incontinent at the time of the fall on 9/5/25, needed assist with toileting, did not identify the last time R2 was toileted, no toileting care plan in place and toileting was not addressed. Furthermore, interventions the facility identified was a silent alarm, encourage to be out of his room and out in public spaces that were not updated to R2's care plan.R2's Fall Risk Evaluation dated 9/10/25, identified R2 had 1-2 falls in the past 3 months, had intermittent confusion, was chairbound and incontinent. R2 had gait/balance problem and required the use of assistive devices. R2 currently took 3-4 high risk medications within the last 7 days. R2 was at risk for falls, with a goal to be free of falls. Interventions: assist R2 with ambulation and transfers utilizing therapy recommendations and if resident was a fall risk initiate fall risk precaution. Clinical suggestion to utilize a toileting program was left blank.R2's fall care plan was revised on 9/16/25 to include anti-tip bars on wheelchair however there was no corresponding assessment that identified why this intervention was implemented. R2's Fall incident report dated 9/23/25 at 6:20 p.m., identified R2 was found sitting on floor in the bathroom leaning backward in front of the toilet. R2 stated, I was trying to do it by myself. Call light was not engaged. R2 had cut his right thumb and index finger. R2 assisted by using Hoyer lift into his bed. Resident offered complaints of back pain 6 out of 10, PRN (as needed) tramadol (pain med) received. Right thumb and index finger cleaned, steri strip applied, cover with gauze, and rolled gauze. Vital signs within normal limits. Resident Description: Self-transfer. R2 stated he tried to go to the bathroom by himself. Immediate action taken was R2 was assisted into his bed, reeducated on call light use and grippy socks were in place.R2's Fall progress note dated 9/23/25, identified the aforementioned information in addition to, an aide called for assistance in R2's room. Upon arrival R2 was found sitting on floor in the bathroom leaning backward in front of the toilet. Root cause was self-transfer.R2's Post Fall evaluation note dated 9/24/25, identified the fall on 9/23/25 with the aforementioned information. The note also included the contributing factors of this fall were R2 was incontinent at the time of the fall and diagnoses of Lewy bodies, dementia and Parkinson's does not allow R2 to make safe decisions. Root cause of fall was self-transfer. Intervention: R2 was reeducated on call light use and assisted into bed using a Hoyer lift. R2's Fall IDT note dated 9/24/25, identified R2 fell in his bathroom, Root cause analysis was R2 stated, I wanted to do it myself, and unable to make safe decisions due to his dementia, parkinsonism and Lewy Bodies. Interventions: physical therapy occupational therapy (PT/OT) will work with him to build strength and safe transfers, and we will have the physician review his meds to see if anything needs to be removed or added.R2's progress note dated 9/25/25 at 9:48 p.m., identified R2 continued to demonstrate poor safety awareness, in addition to current fall precautions a cushioned floor mat was placed beside the bed on R2's exit side. The bed is on the lower position and locked, call light within reach. R2 denied having pain or discomfort this evening.Review of R2's record identified although the fall record identified causal factors of self-transfer and R2 was incontinent at the time of the fall on 9/23/25, there was no indication a comprehensive assessment to determine individualized interventions was completed to negate R2's risk of falls related to self-transfers due to needing to use the bathroom. In addition, the care plan was not updated to reflect a low bed or floor mat.R2's Fall progress note dated 9/28/25, identified another resident alerted staff that R2 was on the floor in his room on his knees. R2 was trying to get back in his recliner and was visibly upset about the situation. Root cause was R2 wanted to sit in his recliner, intervention was to remind to use the call light, so he does not get hurt. No injury noted with fall. Intervention was frequent checks completed on R2 throughout the evening. R2's Fall incident report for 9/28/25 was not found in R2's medical record.R2's Fall IDT note dated 9/29/25, identified R2 had a fall in his room on 9/28/25 at 6:15 p.m. Root cause analysis identified potential diagnoses that could have contributed to fall are recent fractured left femur, dementia, parkinsonism, Lewy body dementia, low back pain due to spinal stenosis/lumbar, chronic pain, orthostatic hypotension, history of falling, weakness, and major depressive disorder. Care plan was reviewed with current fall interventions in place, most recent was 6/10/25, anti-tip bars on wheelchair. Interventions pending lab results including urinalysis to guide any additional interventions. Potential interventions include bilateral lower extremity wraps to support blood pressure, obtain ortho blood pressures, place non-slip strips next to bed and in front of toilet, IDT review will convene following test results to determine specific intervention. In review of R2's record there is no indication an intervention was developed and implemented that mitigated the risk of falls based on the identified root cause of R2 independently transferring to his recliner. Furthermore, there was no indication the care plan was updated to include interventions of frequent checks, non-slip strips next to the bed and in front of the toilet. During an observation and interview on 10/2/25 at 9:10 a.m., R2 was seated in his recliner with his front wheeled walker within reach. R2 stated he needed help getting to the bathroom so he would not fall. R2 did not always make it to the bathroom in time and had accidents because staff did not always offer to help him to the bathroom. Staff had put a sign in his room to remind him to call for help but did not always remember to look at the sign to call for help. During an interview on 10/2/25 at 1:43 p.m., nursing assistant (NA)-A stated R2 was incontinent of bladder most days. NA-A reviewed R2's Kardex and stated he did not have a toileting care plan, but he should because he needs assist of 1 with toileting and has a history of falling. R2 had diagnosis of Lewy bodies so he did get more confused in the evenings, sometimes had delusions, and did not always remember to use his call light to ask for help with toileting which could lead to him falling. During an interview on 10/2/25, at 2:14 p.m., nurse manager (NM)-A stated two of R2's last three falls identified he was incontinent at the time of the fall and toileting was not addressed and should have been. NM-A stated R2 did not currently have a toileting plan in place but should due to his incontinence and the need for assist with toileting and transfers. NM-A stated each fall should be thoroughly investigated to determine a root cause to ensure the appropriate fall prevention plan is updated to the care plan to direct staff to prevent future falls. NM-A stated R2's last fall was not thoroughly investigated, there was no incident report filled out and there was no post fall incident completed to determine a root cause analysis and there was no new intervention for fall prevention put in place. Facility policy, Fall Prevention and Management, reviewed 6/5/23, POLICY: The care center will assess each resident for risk of falls and identify interventions to assist in preventing falls and/or injuries. PURPOSE: To provide guidance to care center staff on assessing, identifying, and managing care for those residents at risk for falls. PROCEDURE: The care center will assess each resident's risk for falls at move in, quarterly and with any significant change in condition and will identify interventions to help prevent falls and/or to prevent injuries from falls. D. Post Fall Assessment: If a fall occurs while the individual is residing in the care center (or off premises on a care center specific activity) staff will perform the incident fall tracking assessment. a. Nursing staff will complete a fall scene investigation, assess the resident, and call for any additional assistance or 911 as necessary. b. An immediate intervention will be put into place, according to the immediate determination of the potential root cause of the fall, to prevent further falls until the root cause analysis (RCA) of the incident is completed. c. Nursing staff will document the fall by completing an Incident Report in the electronic medical record. From the immediate assessment of the incident, a determination will be made if the incident involved any maltreatment and/or serious bodily injury. If so, administrative staff will be notified, and a report of the incident will be sent to the State agency. e. The interdisciplinary team (IDT) will evaluate the fall by reviewing the fall incident report to determine a Root Cause Analysis (RCA) of the fall and further interventions may be put into place according to the determined cause of the fall, to help prevent further falls. Any further interventions that are developed will be documented.

Based on observation, interview and document review the facility failed to develop an individualized toileting program to maintain or improve bowel/bladder continence for 1 of 3 residents (R2) reviewed for falls. Findings includeR2's quarterly minimum data set (MDS) dated [DATE], identified R2's cognition was intact, and had diagnoses of Lewy body dementia (a progressive condition characterized by dementia, parkinsonism, and fluctuations in attention and alertness, along with other symptoms like hallucinations and problems with movement), non-Alzheimer's dementia, anxiety and diabetes. R2 required extensive assist of 1 person for transfers, toileting and toileting hygiene and was frequently incontinent of bladder and occasionally incontinent of bowel.In review of R2's record there was no indication a comprehensive bowel and bladder assessment was completed. R2's care plan revised 6/5/25, identified a focus with activities of daily living (ADL) performance deficit related to disease process. Goal revised 8/5/25, identified to improve current level of function through the review date, will be back to baseline and assist with adl's. Intervention dated 5/13/25, assist of 1 with front wheeled walker in room for adl's and 8/15/25, identified R2 was 1 assist to the toilet.An additional focus revised 3/28/25, identified R2 was incontinent of bladder. Goal revised 8/8/25, identified R2 will remain free from skin breakdown due to incontinence and brief use through the review date. Intervention dated 8/23/24, identified to monitor/document/report any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects, clean peri area with each incontinent episode and use medium pull up brief, change daily and prn.R2's care plan did not include and individualized toileting schedule/program. During an observation and interview on 10/2/25 at 9:10 a.m., R2 was seated in his recliner and had his front wheeled walker within reach. R2 stated he needed help getting to the bathroom, so he doesn't fall. R2 did not always get to the bathroom in time and would have accidents because staff did not always offer to help him to the toilet. R2 stated staff put this a sign on his dresser to remind him to call for help so he doesn't fall, but he did not always remember to look at the sign to ask for help. R2 explained that it's difficult to remember to look for a sign and press the help button when you instinctively assume you can do things on your own.During an interview on 10/2/25 at 1:43 p.m., nursing assistant (NA)-A stated R2 was incontinent of bladder most days. NA-A reviewed R2's kardex and stated he did not have a toileting care plan, but he should because he needs assist of 1 with toileting and has a history of falling. R2 did get more confused in the evenings, sometimes had delusions, and did not always remember to use his call light to ask for help with toileting. During an interview on 10/2/25, at 2:14 p.m., nurse manager (NM)-A stated R2 did not currently have a toileting plan in place but should have one due to his incontinence and the need for assist with toileting and transfers. NM-A was unable to articulate a treatment and service plan to improve or maintain bowel and bladder. NM-A stated the facility did not really have a process in place for a personalized toileting plan and indicated they need to develop one.Facility policy titled, Urinary Incontinence Program, reviewed 4/16/15, identified POLICY: St. [NAME] Health Services of [NAME], Inc. (SFHS) provides care to those residents who are incontinent that will restore normal bladder and bowel function to the greatest extent possible, or at least prevent related incontinence complications. PURPOSE: Each resident who is incontinent will be identified, assessed, and provided appropriate care and services to achieve or maintain their greatest level of continence. Each resident will receive the appropriate care and services to prevent incontinence related complications to the extent possible. PROCEDURE: A. Each resident will be evaluated upon admission. The evaluation will include completion of a baseline review of the resident's elimination status. A comprehensive assessment, which will include a three (3) day bowel and bladder pattern assessment, will be completed within the initial assessment period. a. Based on the initial urinary incontinence or bowel incontinence history reported by the resident and/or family member(s), the new resident will be assisted in using incontinence products provided by the care center. Measurements of the resident, pattern of reported incontinence, incontinence product protocols for product use, and resident choice will be considered in the choice of incontinence product(s). b. The 3-day bowel and bladder pattern assessment will be completed and documented in hourly increments. A component of the three (3) day bowel and bladder pattern assessment may include bladder ultrasound equipment use. c. The comprehensive bowel and bladder assessment will include a report of prior incontinence history, a physical examination, documentation of genitourinary tract anomalies, results of the three (3) day bowel and bladder pattern, a review of diagnoses and medications that may impact urinary or bowel status, food and fluid intake patterns, environmental concerns as well as the consideration of adaptive devices, review of potential or existing complications of incontinence, and the resident's level of need for assistance due to physical or cognitive impairments. This assessment will be used to determine an individualized bowel and bladder program for each resident. Bowel and Bladder Policy, revised 8/2023, indicated each resident receives the necessary care and service to attain or maintain the highest practicable level of bowel and bladder continence.2. The comprehensive assessment results are used to develop a care plan addressing the individual needs of each resident. Care plan interventions are determined with consideration of: a. the ability of the resident to make decisions and call for assistance to use the toilet. B. The presence of permanent physical impairment or disease which could prevent incontinence. C. Resident's desire to participate in bowel and bladder programing. D. current standards of practice in accordance with state and federal law. 3. Review of the comprehensive assessment and care plan will occur on at least a quarterly basis and more frequently if there is a change in residents' condition.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled and dated appropriately. This deficient practice had the potential to affect 35 residents who received food from the refrigerators. Findings include: During an initial kitchen tour on 8/5/25 at 10:15 a.m., the large walk-in refrigerator contained an undated plastic container 1/2 full of soup. The refrigerator in the kitchen prep area contained an undated 3/4 full plastic container of potato salad and an undated plastic container 1/4 full of diced ham cubes. [NAME] (C)-A was unaware how old the soup was. C-A was unavailable to confirm date of potato salad or ham cubes. During a subsequent tour and interview on 8/7/25 at 11:01 a.m., dietary manager (DM)-A, indicated the soup, ham cubes, and potato salad had been removed from the refrigerators. Initial tour findings were discussed with DM-A. DM-A confirmed the soup, potato salad, and ham cubes were discarded on 8/6/25. DM-A stated leftovers are good for 48 hours and packaged foods are good 1 week after opening. DM-A stated it is expected all prepared foods and opened packages are dated prior to storage. A policy titled Perishable Food Management dated 8/29/22 indicated it is facility policy All perishable food will be appropriately managed to prevent bacteria from multiplying or forming toxins. It defined Use-by-date as the last date recommended for the use of the product while at peak quality. The product should be discarded once it is one day past the 'Use-by' date. Further, Label is defined as: required on all foods not in original packaging. Should include food item description and dates. Dates should include: use-by-date or discard date. The policy further indicated leftover foods will be clearly labeled before being refrigerated or frozen and refrigerated leftover food must be used within 3 days, discarded on the 4th day.

Based on interview and document review, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS 1005) to 1 of 3 residents (R6) reviewed whose Medicare Part A coverage ended and then remained in the facility. Finding include: R6's census record indicated R6's payer source changed to private pay on 5/23/25 and R6 remained in the facility. R6's face sheet indicated R6's primary payer source is private pay with a secondary payer source as Medicare B. R6's Notice of Medicare Non-coverage (NOMNC) form indicated R6's last covered day was 5/22/25. The form indicated verbal consent was obtained from R6's responsible party on 5/19/25. The form was signed by the responsible party on 5/22/25. R6's medical record lacked evidence a SNFABN form had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. During an interview on 8/06/25 at 1:48 p.m., R6's responsible party (FM)-A confirmed R6 was private pay. FM-A confirmed receipt and signing of NOMNC indicating R6's Medicare part A benefits were ending. FM-A stated they did not recall discussing the potential cost of continuing services or completing a SNFABN form. During an interview on 8/6/25 at 1:50 p.m., social services director (SS)-A stated she provides the NOMNC to the beneficiary/responsible party and explains the right to appeal. SS-A stated she was unaware of the SNFABN form and had not been providing them. SS-A confirmed R6's responsible party did not receive the SNFABN. During an interview on 8/6/25 at 2:24 p.m., the administrator (ADMIN) stated it is the expectation the SNFABN is provided to the beneficiary/responsible party when the NOMNC is provided if the beneficiary chooses to remain at the facility. A policy titled Medicare Denial Procedure reviewed 2/27/24, indicated The Medicare Denial Notice will be delivered no later than 48 hours prior to discharge from services and far enough in advance to allow the Medicare beneficiary sufficient time to consider their options and make an informed choice regarding their right to appeal the decision that Medicare will not cover specific services. it continues If the beneficiary will continue to stay in the care center, provide CMS-10123 Notice of Medicare Non-Coverage and CMS-10055 Fee For Services Skill Nursing Facility Advanced Beneficiary Notice of Non-Coverage which is the 'demand bill' portion used for the standard, manual appeal process.

Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharges.During the survey documentation review and preparation process, the designated ombudsman was notified of the upcoming facility survey. Per electronic communication on 8/1/2025 at 10:38 a.m., ombudsman stated she had not received any notifications from the facility about transfers and discharges.During interview on 8/7/25 at 8:57 a.m., social worker (SW) stated she does keep track of admissions, discharges, and transfer. SW stated she was unaware she needed to send the admissions, discharges, and transfer notifications to the ombudsman. SW confirmed she had not sent the admissions, discharges, and transfer to the ombudsman. During interview on 8/7/25 at 9:53 a.m., administrator stated the SW is responsible for keeping a log of the facility admissions, discharges, and transfers. Administrator stated she is unaware if the SW had submitted the admissions, discharges, and transfer to the designated ombudsman. Administrator confirmed she had not sent the facility admissions, discharges, and transfer to the designated ombudsman. A policy was requested but was not received.

Based on observation, interview, and document review, the facility failed to maintain a functioning Wanderguard system and failed to comprehensively assess risk for elopement and appropriate interventions, resulting in elopement for 2 of 7 residents (R1, R2). R1's elopement occurred due to the failure of the Wanderguard system, which did not sound an alarm when R1 exited the building. R2's elopements occurred due to R2's risk of elopement was not accurately comprehensively assessed leading to insufficient supervision and lack of intervention, followed by a failure of the Wanderguard system. The facility's failures resulted in an immediate jeopardy (IJ). The immediate jeopardy began on 5/8/25, when R1 successfully eloped from the building without the alarm sounding and was found by staff outside, unharmed, approximately 15 minutes later, the facility failed to identify malfunctioning alarm system which resulted in subsequent elopements by R2. The administrator, Director of Nursing (DON), nurse manager, and social services director were notified of the immediate jeopardy on 5/20/25 at 3:50 p.m. The immediate jeopardy was removed on 5/23/25, but noncompliance remained at the lower scope and severity level of D, indicating no actual harm but the potential for more than minimal harm, which is not immediate jeopardy Findings include: R1 R1's facesheet dated 5/28/25, identified diagnoses of dementia, delirium, and history of falling. R 1's Minimum Data Set (MDS) assessment dated [DATE], identified R1 had severe cognitive impairment and required supervision or touches for transfers, used a wheelchair and/or walker for mobility with staff supervision or touching. R1's elopement care plan focus dated 2/6/25, identified R1 was at risk for elopement related to history of attempts to leave the facility unattended. Interventions of Wanderguard on left wrist, and distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. R1's progress note dated 5/8/25 at 7:45p.m., identified R1 was observed wandering outside of the building, Wanderguard on left wrist and worked properly, was alert and had intermittent confusion. R1's incident report dated 5/8/25 at 7:45 p.m., identified R1 was observed wandering outside of the building and was orientated to person and time only. No predisposing environmental factors. Predisposing psychological factors included confusion and impaired memory. Door alarm/Wanderguard did not activate when R1 exited the building. R1's elopement care plan was revised on 5/9/25 to include encourage R1 to attend activities during highest wandering times (late afternoon/evening). During an interview on 5/20/25 at 1:21 p.m., registered nurse (RN)-A stated on 5/8/25 R1 had been observed in the facility about fifteen minutes earlier when around 7:30 p.m., staff observed R1 wandering outside of the facility near the gazebo, and then immediately brought back into the facility. The facility doors did not alarm when R1 left the facility, however, did go off when R1 was brought back into the facility. RN-A believed that the alarm not sounding may have been because the Wanderguard tag was on her left wrist and the door did not catch the signal. RN-A stated R1's Wanderguard was changed to a new one because it was due to expire soon. RN-A stated staff tested the doors and R1's Wanderguard when R1 returned and they both were working properly, however did not notify maintenance that the door failed to alarm when R1 had exited the building. During an interview on 5/20/25 at 1:27 p.m., director of nursing (DON) stated R1 eloped on 5/8/25 and R1 left the building without the Wanderguard system door alarm going off. R1 should have had a repeat elopement assessment completed at that time and all nurses were able to complete the assessment. DON indicated staff did not notify maintenance the alarm had not sounded and stated when R1 eloped staff should have notified maintenance immediately. In addition, staff should have assessed all resident Wanderguard devices to ensure proper function, check all doors with Wanderguard sensors to ensure proper function, and provide education to all staff in the building at the time about testing the system. DON stated, None of that was done. DON's expectation was for all doors to be tested for proper functioning if a resident eloped. DON was not aware of the manufacturer's recommendations for testing and did not know how the doors were being tested. R2 R2's facesheet dated 5/28/25, identified R2 had diagnoses including urinary tract infection (can cause confusion in the elderly), Parkinson's disease (progressive neurological disorder that affects movement), altered mental status, unspecified convulsions (sudden involuntary muscle contractions and spasms), unspecified dementia (condition causing loss in ability to think, remember, learn, make decisions, and problem solve and symptoms including personality changes and emotional problems), abnormalities of gait and mobility, amnesia (memory loss), rapid eye movement (REM) sleep behavior disorder (a disorder where people act out their dreams during REM sleep), macular degeneration (progressive eye disease of damage to the retina causing loss of central vision), dystrophies involving the retinal pigment epithelium (eye disease involving deposits of pigment in the retina that can cause central vision loss), vitreous degeneration (degeneration of the vitreous fluid in the eye leading to floaters and vision changes), hypermetropia (far-sightedness causing blurry close-up vision), and presbyopia (decline in eyes' ability to focus on nearby objects). R2's Minimum Data Set (MDS) assessment dated [DATE], identified she admitted to the facility on [DATE]. R2 had moderate cognitive impairment, delusions and verbal behavioral symptoms directed toward others, and had no wandering behaviors. R2 required substantial staff assistance with toileting hygiene, mobility in bed, and transfers. R2 used a wheelchair and was dependent on staff for wheelchair mobility. R2 was not independent with any self-cares or mobility. R2's physician orders dated 4/30/25, included: - Observe for side effects of antipsychotic medication. Side effects listed included disorientation or confusion, increased agitation, and restlessness. - Melatonin (supplement to treat sleep problems like insomnia) 5 milligram (mg) tablet, give 10 mg by mouth as needed (PRN) at bedtime for restlessness/insomnia. R2's progress note dated 4/30/25, identified cognitive impairment of some forgetfulness. R2's Elopement Risk assessment dated [DATE], identified R2 had no history of elopement attempts and was a new resident within the last 90 days. The cognition section identified cognitive deficit of short-term memory loss and a change in cognition in the last 90 days. A pre-populated list of conditions contributing to elopement risk identified R2 had the following: recent infection, dementia, hallucinations, and new medication in the past 30 days. No behaviors, verbalizations, or life experiences that could contribute to elopement were identified and a Wanderguard (wearable bracelets that trigger alarms when a resident approaches a door sensor by an exit or restricted area) was not placed. The analysis noted, not at risk for elopement at time of assessment. The assessment failed to identify R2's conditions contributing to elopement risk of: altered mental status, amnesia, REM sleep behavior disorder, adjustment to new environment, and visual deficits. The assessment failed to identify R2's needed level of supervision or identify how it was determined that she was not at risk for elopement based on the risk factors identified. R2's care plan for psychotropic medications dated 5/1/25, identified she used psychotropic medications. Interventions included monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The intervention failed to identify R2's specific behaviors which were to be monitored and recorded. R2's behavior progress note dated 5/2/25, indicated she was heard calling out for help and found crawling out of bed at 12:20 a.m. R2 stated she wanted to get into her wheelchair, was brought to the common area by staff, requested a sandwich then specifically a fish sandwich, and declined other offered snacks. R2 stayed in her wheelchair until she requested to go to bed at 1:30 a.m. R2's progress note dated 5/2/25, identified she complained of trouble sleeping and requested PRN melatonin. R2's progress note dated 5/3/25, identified she requested PRN Melatonin due to difficulty falling asleep at night. R2's progress note dated 5/4/25, indicated R2 complained of trouble sleeping and took PRN Melatonin. R2's progress note dated 5/5/25 at 2:55 a.m., indicated the facility received a phone call from the police stating R2 called 911. R2 reported to staff that she called because she wanted to talk to her grandson and he was a police officer. R2 was redirected and went back to sleep. R2's progress note dated 5/5/25, noted R2 had trouble following commands, disorganized thinking, moderate cognitive impairment including memory loss and moderate confusion, and sometimes understood others. Behaviors included resident is awake at night. R2's progress note dated 5/5/25, indicated R2 had signs of short-term memory loss, mild cognitive impairment, and chronic confusion demonstrated by refusal of cares, refusal of redirection, and delusions. Mood and behaviors identified intermittent sleep and wandering at night. R2 was educated on safety concerns of impulsivity, poor safety awareness, and confusion. R2's progress note dated 5/5/25 at 9:06 p.m., indicated R2 came walking out of her room at 9:00 p.m. using her wheelchair as a walker. R2 took Melatonin and was up at the nursing station until more tired. R2's progress note dated 5/5/25 at 11:41 p.m., indicated she came out of her room at 11:00 p.m., stated staff needed to call 911 right now, and called 911 herself but would not say why. R2 took papers from the nursing station and refused to return the facility's phone. An officer arrived and spoke with R2, stated she did not complain of anything and the officer was not sure why they had been called. R2 returned to her room at 11:45 p.m. and refused to get into bed. Although R2's progress notes identified R2 had both wandering at night and increased behaviors there was no indication R2 was re-assessed for elopement risk or needed level of supervision nor were appropriate interventions developed, and implemented to prevent or mitigate the risk of elopement. R2's progress note dated 5/6/25 at 12:37 a.m., indicated a new medication, Trazadone (an anti-depressant also used to treat insomnia), was ordered for administration at bedtime as needed for sleep. R2's progress note dated 5/6/25, identified R2 came wheeling out of her room at 12:05 a.m. and went down the north hall. R2 then wheeled down to the end of the hall and turned around, backed her wheelchair by another resident room, began waving to something or someone she was seeing, and then entered the other resident's room. R2 then left the other resident room, propelled down the north hall back to the common area, and began saying good morning to a stationary chair. She signaled come here with her finger while looking at no one and sat next to the chair having a conversation with it. She then wheeled around in the common area, attempted to go behind the nursing station, and asked why those kids were back there. She continued to wheel around into the dining area, came out, was offered and took a PRN Trazadone to help with her insomnia, and wheeled herself back into her room. Progress note dated 5/6/25 at 1:25 a.m., identified R2 has been awake and roaming since beginning of night shift. R2's physician orders dated 5/6/25, included: - Trazadone hydrochloride (HCl) 50 mg tablet, give 50 mg by mouth one time a day for insomnia, difficulty falling, and/or staying asleep. - Observe for side effects of anti-depressant medication. Side effects listed included trouble sleeping and other unusual changes in mood or behavior. R2's Behavior assessment dated [DATE], identified she had verbal behavioral symptoms directed towards others with examples listed including delusions and calling 911 without explanation. The assessment identified her behaviors did not put her at significant risk for physical illness or injury but did interfere with her care and significantly disrupt the care environment. Root cause of behaviors was identified as being newly admitted and diagnoses of Parkinson's disease, dementia, and seizure history. The assessment identified R2 had not exhibited wandering behaviors, despite progress notes indicating she repeatedly left her room at night and wandered around the facility. R2's progress note dated 5/10/25, identified R2 had some forgetfulness, slept intermittently, wandered at night, and wandering had decreased since starting a new sleep medication. R2's progress note dated 5/11/25, indicated she came walking out of her room with a walker at 9:00 p.m. and sat down in a chair. Staff explained she should not walk by herself and to request assistance when ready to return to her room. 15 minutes later R2 was found to have walked herself back to her room and stated she didn't need help and could walk just fine by herself. R2's behavior progress note dated 5/12/25 at 5:56 a.m., indicated R2 was not in her room on last rounds. R2 was found in a room at the end of a different hall, had her brief off, and was ducking down to hide when a nursing assistant opened the door. R2 was naked from the waist down and would not tell staff why she was in the room or what she was looking for. R2 was assisted back to her room and dressed. R2's progress note dated 5/14/25, indicated she wandered at night. R2's record between 5/6/25 and 5/15/25 identified despite R2 demonstrated several episodes of wandering, had confusion, forgetfulness, and had unpredictable ability to ambulate independently. There was no indication a comprehensive assessment was completed that would identify R2's risk for elopement and/or level of supervision nor evidence the care plan was revised. R2's incident report dated 5/16/25 at 8:00 p.m., identified registered nurse (RN)-B assisted R2 with a phone call and R2 then conversed with another resident at the nursing station. RN-B then left to take the other resident to their room and when RN-B came out of the room R2 wasn't at the nursing station. Staff began searching the facility immediately. RN-B went outside to search, and police had arrived and stated R2 had called 911. R2's spouse also arrived. R2 was found outside across the street without a wheelchair talking to her spouse using the neighbor's phone. Police and staff brought R2 back to the facility, she was assessed with no injuries noted and refused vital signs. R2's spouse sat with her until she fell asleep and a Wanderguard was placed on her left wrist. R2's physician orders dated 5/16/25, included: - Check Wanderguard functioning at bedtime. - Check placement of Wanderguard every shift for elopement risk. - Change Wanderguard one time a day every month on the 23rd day. R2's care plan for elopement dated 5/16/25, identified she was unable to leave the facility independently with history of elopement. Interventions included Wanderguard placed on left wrist, staff or family to supervise all outdoor activities, and family to sign R2 out in facility book before leaving. The care plan did not identify interventions that included needed level of supervision, identification and monitoring of behaviors/triggers/risk factors for elopement, or related management. R2's record lacked evidence she was comprehensively assessed for elopement risk prior to or on 5/16/25 despite her successful elopement from the facility that day. R2's record did not identify her needed level of supervision or appropriate interventions apart from placement of a Wanderguard. R2's record did not indicate how documented confusion, delusions, hallucinations, restlessness, agitation, visual and communication deficits, impulsivity, seeking behaviors and verbalizations, and desire to go home were comprehensively assessed, monitored, or mitigated to decrease related risk of elopement. R2's Elopement Risk assessment completed three days after R2 eloped dated 5/19/25, included R2 had made one previous attempt to elope on 5/16/25 when she ambulated unassisted to a neighbor's house across the street. The assessment identified she had a Wanderguard on her left wrist and she was a risk for elopement related to recent elopement. The assessment did not include or identify R2's documented cognitive deficit of intermittent confusion and conditions contributing to elopement risk of delusions, agitation, new medications within past 30 days, visual deficits, communication deficits, and REM sleep behavior disorder. The assessment did not identify R2's documented behaviors of impulsivity, agitation, restlessness, seeking behaviors, and verbalizations of looking for someone and seeking people. Further, the assessment failed to identify R2's needed level of supervision or interventions to mitigate identified risk of elopement apart from placement of a Wanderguard. During an interview on 5/19/25 at 1:30 p.m., R2 stated she had a Wanderguard on her wrist and R2's family member (FM)-A, noted it was placed the day before yesterday (5/17/25). FM-A stated this was placed because she had left the facility, and staff didn't know where she was for a few minutes. R2 stated she had been dreaming that she had to get away and ran out the door a block away barefooted even though she had been unable to walk on her own with therapy. FM-A stated this was confusing because most of the time she couldn't walk without her walker. R2 stated there was a man sitting outside at a house across the street and she used his phone to call 911, but did not remember why she called. FM-A indicated he was present when she returned to the facility, staff assessed her, and he stayed with her until she fell asleep. R2 stated they put the Wanderguard on her after that and she hadn't tried going outside since then (since 5/16/25). FM-A stated R2 had good days and bad days with memory due to her dementia and Parkinson's. Sometimes her moods were like a light switch and she would suddenly get quiet with a drained look and not say anything. R2's progress note dated 5/17/25 at 3:08 a.m., indicated R2 wheeled herself out of her room and around the common area. R2's behavior progress note dated 5/17/25 at 9:02 p.m., indicated she was seen by staff twice walking down the hall with her walker unassisted on the evening shift. R2's progress note dated 5/18/25, identified her thinking was disorganized. During an interview on 5/19/25 at 3:28 p.m., nursing assistant (NA)-E stated she knew if someone was an elopement risk because they would usually have a Wanderguard on and be on a list posted at the nursing station of residents who could not be left outside unattended. NA-E stated R2 was very confused all the time and always thinks she's going to go home. NA-E saw R2 yesterday (5/18/25) with all of her in clothes in her hands and the hangers taken off. R2 was confused since she admitted to the facility and was always trying to get out, wheeling herself around, didn't sleep, and couldn't sit still. R2 once thought it was time to go to bed at 2:00 p.m. R2 would wheel around and say she was going to go home mostly during the night, beginning around 6:00 p.m. when she would start to get anxious and confused. NA-E noted R2 was like fogged out and you could talk to her and she wouldn't respond at times. Staff knew Wanderguards worked when residents got close to the door, though there had been trouble recently where sometimes doors would alarm when a resident with a Wanderguard touched it and sometimes they would not. R2's progress note dated 5/19/25, indicated she had forgetfulness, signs of short-term memory loss, and disorganized thinking. R2's progress note dated 5/19/25, identified it was follow-up on the elopement note. A Wanderguard had been placed on her left wrist with orders to monitor placement and functioning and replace routinely, which was also added to her care plan. Diagnoses that could have contributed were identified as altered mental status, Parkinson's disease, dementia, and amnesia. A new elopement assessment had been completed. During an interview on 5/19/25 at 3:12 p.m., NA-D was not aware if R2 was an elopement risk and did not know R2 had a Wanderguard. NA-D knew if a resident had a Wanderguard because it would be on the resident, reported to staff, and on the care plan. NA-D knew who was at risk of elopement because it was reported to staff and the facility had a Wanderguard system that would detect when an at-risk resident was close to a door so staff could intervene and redirect. During an interview on 5/19/25 at 3:47 p.m., licensed practical nurse (LPN)-A stated residents at risk of elopement had Wanderguards and this was care planned and on the treatment administration record (TAR). LPN-A stated R2 was absolutely an elopement risk and had eloped on 5/16/25. LPN-A noted R2 would walk by herself outside of her room without a walker or footwear, stroll around in her wheelchair, and get antsy. LPN-A noted R2 had more behaviors at night. R2's elopement progress note dated 5/20/25, indicated R2 was sitting calmly in her wheelchair by the nursing station after receiving her pills at 9:10 p.m. RN-A went to the kitchen to put a meal tray away at approximately 9:30 p.m. at which time R2 remained in her wheelchair in the common area watching the birds. At approximately 9:40 p.m., RN-A returned to the nursing station and R2's wheelchair was still there but R2 was gone. RN-A began searching for R2 and alerted all staff, the DON, 911, and family. At approximately 10:20 p.m. the facility received a call from the police stating R2 had been found seven or eight blocks away, had fallen, did not appear injured, and would be transported to the emergency department for follow up. R2's emergency department hospital After Visit Summary dated 5/21/25, indicated she was discharged from the hospital and back to the facility. Imaging, labs, and tests looked good. Referrals were placed for memory care and in the meantime, it was okay for R2 to return to the facility. There were no new orders and no noted injuries. The facility's Nursing Home Incident Report #360607 dated 5/20/25, was submitted to the state agency (SA) and identified R2 had eloped that evening. The incident description included Resident was discovered to not be in room, and subsequent search did not immediately show that she was in facility. Staff say they heard no alarms from the doors, which were armed at the time. During an interview on 5/23/25 at 10:30 a.m., RN-A stated she was working on 5/20/25 when R2 eloped. RN-A noted R2 was sitting and watching the birds when RN-A left the nursing station to go to the kitchen. RN-A stated upon her return approximately 10 minutes later, R2's wheelchair was still there but R2 was gone. RN-A stated the Wanderguard door alarms had not gone off, she was not aware R2 was missing until she returned and saw R2 missing. RN-A called 911, staff began to search, and police called the facility informing RN-A that R2 was found seven to eight blocks away, had stated she fell down, and would be transported to the emergency department. R2's Elopement Risk assessment dated [DATE], included R2 had made previous successful elopement attempts with frequency of one time event and note that R2 eloped five days ago and did elope again that evening, leaving the facility and ambulating seven or eight blocks away without walker or wheelchair. The assessment noted R2 had a Wanderguard on her left wrist due to elopement. The analysis section noted the circumstances of the elopement documented in progress note dated 5/20/25 and noted No pain or discomfort reported before the elopement. wander guard was [on, sic] her left wrist and works properly. The assessment failed to comprehensively or accurately identify all of R2's cognitive deficits, conditions and diagnoses contributing to elopement risk, and behaviors and verbalizations. Further, the assessment failed to identify R2's needed level of supervision or interventions to mitigate identified risk of elopement apart from placement of a Wanderguard. R2's elopement care plan was revised with new interventions on 5/20/25 that included: check placement of Wanderguard every shift, check function of Wanderguard daily, check expiration date of device; notify team (nursing, activities, housekeeping, dietary, social services) if I am observed to be wandering, purposeful wandering, or stating things such as I'm leaving, I need to find **, I am calling 911. R2's cognition care plan dated 5/20/25, identified R2 had impaired cognitive function/dementia or impaired thought processes. Interventions directed staff to cue, reorient, and supervise as needed (was not defined) and monitor/document/report as needed any changes in cognitive function. Additional intervention dated 5/20/25, for focus of psychotropic medication directed staff to identify target behaviors for monitoring/recording including wandering. R2's elopement care plan failed to identify her needed level of supervision or interventions to mitigate the identified risk of elopement apart from presence of a Wanderguard. The care plan identified the need to notify various individuals if wandering behaviors or verbalizations were noted, but did not identify how to manage/respond to these behaviors or mitigate the associated risk of elopement. During an interview on 5/20/25, the facility's nurse manager, RN-C, stated residents were assessed for elopement risk on admission, with significant changes, annually, and as needed. A resident would be re-assessed if there was new or increased wandering, exit-seeking, or talk about leaving and should be done as soon as staff were aware of the behavior. Nurse managers completed the elopement risk assessments, but any nurse could do it. The assessment would be filled out and the nurse would make a decision about whether or not a person should have a Wanderguard on. RN-C stated she utilized the elopement risk assessment to determine if a resident needed a Wanderguard. There was no threshold on the assessment for when to place a Wanderguard or when someone was identified as an elopement risk, it was not an objective scale. RN-C stated she completed R2's initial elopement assessment dated [DATE]. RN-C stated the assessment should have identified R2's communication deficit, adjustment to a new environment, altered mental status, amnesia, and REM sleep behavior disorder because they contribute to elopement risk. If she had identified the aforementioned items on assessment, she would have identified her [R2] as an elopement risk and would have care planned this, though may not have applied a Wanderguard at that time. RN-C stated she had viewed the assessment as does she need a Wanderguard . not so much risk and would be looking at it differently in the future. RN-C confirmed the assessment was not accurate. She reviewed R2's progress notes, stated R2 was completely disoriented at night and exit-seeking, and R2 should have been re-assessed for elopement risk on 5/5/25 when she called 911 looking for her grandson because this was verbalizing looking for/seeking someone. RN-C noted ongoing progress notes prior to 5/16/25 identifying wandering behaviors and R2 should have been reassessed when she started having behaviors. RN-C stated a Wanderguard should have been applied when R2 started wandering at night and this would have helped to mitigate her risk of elopement. RN-C stated it wasn't applied until after her elopement on 5/16/25 and confirmed no other interventions to mitigate risk of elopement were implemented. RN-C confirmed she did not see any comprehensive assessment to determine R2's needed level of supervision and we did not assess for her level of supervision or put any interventions in place. RN-C noted if the Wanderguard system was not functioning properly, then the facility had no interventions in place. She was unaware the Wanderguard system was not functioning properly and did not think R2's current level of supervision was adequate, especially at night. Further noted R2 eloped on 5/16/25 and should have been re-assessed for elopement risk that evening once she was back in the building, but confirmed an assessment was not completed until 5/19/25. During observation and interview on 5/20/25 at 8:44 a.m., Environmental Services Director (ESD) stated the five doors with Wanderguard systems were tested daily using an extra Wanderguard device signaling bracelet to ensure the system was working properly. The ESD noted the tests were recorded in a logbook but, upon review of the logs, stated they had not been completed consistently. The ESD and surveyor proceeded to test the five doors with an extra Wanderguard bracelet and found the following: four of the five doors did not alarm when the Wanderguard bracelet was in proximity of the door alarm, and one of the five doors did not alarm when passed through with the bracelet with the doors already opened by the automatic door button. During a follow up interview at 3:15 p.m., ESD stated he was not aware of any current issues with the Wanderguard system prior to this testing including both alarms not sounding due to Wanderguard bracelet proximity and the ability to exit a door without an alarm sounding. The ESD was not aware of how long these issues had been going on, no concerns had been reported by staff completing routine daily door testing. In a subsequent interview on 5/23/25 at 12:14 p.m., ESD stated the Wanderguard system had been inspected by a technician on 5/21/25 and a dead spot of about one foot on two of the five doors was identified. ESD stated if a resident with a Wanderguard bracelet exited through these doors the alarm would not sound because of the area of not reading the bracelet. New antennas and control box were installed to remove the area where the bracelets were not detected. During an interview on 5/20/25 at 10:35 a.m., the administrator stated staff relied on the Wanderguard system to know if a resident at risk of elopement had left the building. Staff would know because of the beeping at the doors from the Wanderguard alarms. Administrator acknowledged the system had failed. She noted the doors were tested daily by maintenance and she would expect the system to be tested in accordance with manufacturer recommendations. She would expect the Wanderguard system to be functional 24 hours per day seven days per week and a resident with a Wanderguard should not be able to get through the door without the alarm sounding. She noted the doors should be set up to alarm when a resident's Wanderguard device was in proximity, not only upon the door being opened. Administrator was not aware that it was currently possible, as established by the surveyor and maintenance testing the doors, to get a Wanderguard bracelet through a door without it alarming or to approach a door without it alarming. This was horrifying and possibly how R1 was able to elope from the facility. If the door did not alarm, staff wouldn't be aware that a resident had eloped until they were noted to be missing. We obviously need to fix our system. In the absence of a functioning system, staff would check on residents who were elopement risks but that was probably not realistic because the facility was a big place. Staff would not be able to adequately supervise residents with Wand[TRUNCATED]

Based on interview and document review, the facility failed to be in compliance with the supplemental nursing service agency (SNSA) requirements when the facility obtained nursing services from Swenswen Staffing, LLC (an SNSA) which was not registered with the commissioner as required. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff. Findings include: Review of the SNSA website on [DATE], did not identify [NAME] Staffing, LLC as being registered with the commissioner as required. Email communication sent on [DATE] at 3:09 p.m., the staffing coordinator (SC) verified that Swenswen Staffing had provided staff in the facility in the past month. Review of the staffing schedules from [DATE] through [DATE], verified that Swenswen Staffing, LLC provided supplemental nursing staffing to the facility on the following days: -[DATE] nursing assistant 6:00 p.m. to 6:30 a.m. -[DATE] trained medication aide 1:00 p.m. to 2:00 p.m. -[DATE] trained medication aide from 6:00 a.m. to 6:00 p.m. -[DATE] trained medication aide from 6:00 a.m. to 6:00 p.m. -[DATE] trained medication aide from 6:00 a.m. to 6:00 p.m. -[DATE] trained medication aide from 6:00 a.m. to 6:00 p.m. -[DATE] trained medication aide from 6:00 a.m. to 6:00 p.m. -[DATE] nursing assistant from 6:00 p.m. to 6:30 a.m. Review of the Minnesota Department of Health approved SNSA's current as of [DATE] did not include [NAME] Staffing, LLC. Review of an email dated [DATE] at 6:50 p.m., Swenswen Staffing, LLC forward a certificate for registration as a SNSA, however it had expired on [DATE]. During an interview on [DATE] at 4:09 p.m., the Administrator stated she was not aware that Swenswen Staffing, LLC was not registered as required and was not aware of the facility's responsibility to verify that the SNSA was registered prior to obtaining staff from the agency. A policy on supplemental staffing was requested but was not provided.

Based on interview and document review, the facility failed to review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs. Findings include: In an email dated 5/19/25 at 5:50 p.m., the administrator noted overnight staff at the facility also worked at the assisted living facility. She noted this was an oversight if that isn't listed in the facility assessment and she would work on getting it corrected as soon as possible. In a subsequent email at 6:02 p.m., the administrator indicated there was a tracking log and provided an hours log of nursing home staff covering at the assisted living (AL) titled AL Filling In Time Book. Facility document titled AL Filling in Time Book was a log book with dated entries from 3/9/25 through 5/19/25. The log directed staff: Please write down times for the following: counting meds, rounds, any call lights/calls you get, falls, potential emergencies. Any time you go over there please document it! signed by the director of nursing (DON). Additional hand-written note directed Please fill out when you get calls/go to the ALF [assisted living facility]. Thanks, [DON]. Please write down rounds too! & how long those take. The log book sheet entries identified that overnight staff spent time working in the assisted living nearly every single day, multiple times per shift. The facility assessment dated [DATE], noted it was coordinated by the current administrator and last reviewed and approved at Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAA/QAPI) on 2/7/25. The assessment included a staffing plan with assessment date 4/8/25. The staffing plan identified staff positions and total number needed or average or range for each position with note to indicate any shared positions. The staffing plan identified licensed nurses providing direct care included two on day shifts, two on evening shifts, and one on overnight shifts for both weekdays and weekends. Nursing assistants (NA's) and trained medication aides (TMA's) included three to four NA's/TMA's on days shifts, three NA's/TMA's on evening shifts, and two NA's/TMA's on overnight shifts for both weekdays and weekends. The staffing plan did not identify any of the licensed nurse, NA, or TMA positions or shifts as being shared with the assisted living or reflect the needed number of staff or hours worked in the facility for each role adjusted for time spent working in the assisted living. The facility assessment failed to accurately identify the number of staff needed to meet resident needs and was not updated to identify that nursing staff were shared with the assisted living. During an interview on 5/20/25 at 4:55 p.m., the DON stated facility staff had been providing services at the assisted living since before she started working there in October of 2023. She was not sure exactly when this practice began. During an interview on 5/20/25 at 10:35 a.m., the administrator stated the facility was typically staffed with one nurse and two NA's at night. The administrator confirmed these staff assisted with providing cares at the assisted living during their shifts at the facility. In a subsequent interview on 5/23/25 at 3:43 p.m., the administrator stated the facility assessment was completed prior to her employment at the facility which began two months ago. She believed it was last updated in 2024. This was not consistent with documentation in the facility assessment. In a subsequent interview on 5/27/25 at 4:59 p.m., the Administrator stated the facility assessment was not reflective of the actual hours worked in the nursing home because the staff hours worked in the assisted living had been counted towards the facility's identified staffing hours determined by the assessment. The administrator further noted the current facility assessment was therefore not correct. Facility assessment policy requested but not received.

Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect wander/elopement alarm use for 1 of 2 residents (R1) reviewed for MDS accuracy. Findings include: R1's quarterly MDS assessment dated [DATE], included section P0200: Alarms with alarm type wander/elopement alarm. The wander/elopement alarm was coded 0 indicating it was not used during the look-back period. R1's Elopement Risk assessment dated [DATE], indicated R1 had a Wanderguard placed on her right wrist. The analysis section noted for the assessment reference date (ARD) of 1/31/25 through 2/6/25, information was collected per review of documentation, observation, and interviews with direct care staff and resident. The analysis further noted, is at risk to wander or elope from facility. Wanderguard in place right wrist. Placement and proper function checked daily. R1's elopement care plan dated 8/28/24, identified she was an elopement risk. Intervention dated 8/28/24, noted R1 had a Wanderguard on her left wrist. On 5/19/25 at 4:01 p.m., the facility's nurse manager, registered nurse (RN)-C, confirmed R1 was one of the residents with a Wanderguard device. At 4:16 p.m., RN-C tested R1's Wanderguard device which was observed to be in place on her left wrist. During an interview on 5/23/25 at 2:05 p.m., the MDS Coordinator (MDS-C) stated R1's quarterly MDS dated [DATE] should have identified R1 had a Wanderguard in place and was not accurate. MDS-C noted she must have missed adding this to the MDS and she would be doing a modification to R1's MDS to correct it. Facility MDS assessment policy requested but not received.

Based on interview and document review, the facility failed to report an elopement immediately to the administrator and to the State Agency within 2 hours for 1 of 1 resident (R1) who had eloped from the facility. Findings include: R1's face sheet dated 5/28/25, identified diagnoses of dementia (decline in mental ability and memory), delirium (a temporary state of mental confusion), and history of falling. R 1's Minimum Data Set (MDS) dated 2/6 /25, identified R1 needed supervision for transfers and had severe cognitive impairment. R1's elopement care plan focus dated 2/6/25, identified R1 was at risk for elopement related to history of attempts to leave the facility unattended. Interventions of wandergard on left wrist, encourage to attend activities during highest wandering times (late afternoon/evening), and distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. R1's progress note dated 5/8/25 at 7:45p.m., identified R1 had been observed wandering outside of the facility, R1 had a Wanderguard (a wander management system designed to help protect memory impaired residents from elopement) on her left wrist and worked properly, was alert and had intermittent confusion. R1's incident report dated 5/8/25 at 7:45 p.m., identified at R1 was found wandering outside of the building and R1 was orientated to person and time only. No predisposing environmental factors. Predisposing psychological factors included confusion and impaired memory. Door alarm/wandergard did not activate when R1 exited the building. Review of a report made to the state agency (SA) on 5/9/25 at 11:40 a.m., that R1 was found outside of the facility on the sidewalk in front of the building. R1 was brought back into the facility and reported that the Wanderguard alarm did not go off when R1 left the building, however the alarm did sound when R1 waw brought back in the building. The nurse did not report the elopement to the on-call nurse, administrator, or director of nursing to communicate R1's elopement. During an interview on 5/23/25 at 12:56 p.m., director of nursing (DON) stated that when R1 eloped from the facility it should have been reported to the administrator and the state agency immediately, but no later than two hours, but was not reported until the following day due to not being reported immediately after R1's elopement. Review of the facility's maltreatment reporting guidelines policy dated 11/26/24, identified any alleged maltreatment involving abuse neglect or financial exploitation injuries of unknown source or misappropriation a vulnerable adult property must be reported by the supervising employee of the building to the administrator of the care center immediately and to the state agency, but no later than two hours. Review of the facility's Elopement policy dated 8/1/22, identified when the resident who eloped is located: a. Complete a medical evaluation to identify potential injuries. b. Notify family and persons previously contacted. c. Notify the physician. d. Investigate to determine how the elopement occurred to correct any underlying contributing factors. e. Complete an Incident Report and document incident in the medical record. f. Report the 'elopement' incident to the state agency (MDH) as 'potential Neglect'.

Based on interview and document review, the facility failed to post accurate data reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care on a daily basis. This had the potential to affect all 34 residents residing in the facility and their visitors who may wish to review the information. Findings include: The facility's nurse staff posting form with date revised 4/17/25, included two pages for each calendar day. The first, titled [Facility] Nursing Schedule, included the following information: Nursing staff roles/titles (nurse, charge nurse, trained medication aide (TMA), nursing assistant (NA), and nurse on-call); names of staff filling the specific role for a given shift; scheduled hours of the shift with start time and end time. The second, titled Report of Nursing Staff Directly Responsible for Resident Care, included the date and daily census as well as a list identifying position (registered nurse (RN), licensed practical nurse (LPN), TMA, and NA), shift worked, hours (number of staff who worked the specified shift in the specified role), and total hours covered. The facility's Nursing Schedule dated 5/17/25, included an NA, NA-F, identified as working from 10:00 p.m. to 6:30 a.m. with letters AL written in and circled next to the name. There were no modifications made to the listed shift hours of 10:00 p.m. to 6:30 a.m. The Report of Nursing Staff Directly Responsible for Resident Care dated 5/17/25, included an entry for position of NA, shift worked from 10:00 p.m. to 6:30 a.m., hours times one, and total hours worked of eight. In an email dated 5/19/25 at 5:50 p.m., the administrator noted the facility's overnight staff covered the assisted living center in addition to the facility and did not believe those hours were being tracked. In a subsequent email at 6:02 p.m., the administrator indicated there was a tracking log and provided an hours log of nursing home staff covering at the assisted living (AL) titled AL Filling In Time Book. Facility document titled AL Filling in Time Book was a log book with dated entries from 3/9/25 through 5/19/25. The log directed staff: Please write down times for the following: counting meds, rounds, any call lights/calls you get, falls, potential emergencies. Any time you go over there please document it! signed by the director of nursing (DON). Additional hand-written note directed Please fill out when you get calls/go to the ALF [assisted living facility]. Thanks, [DON]. Please write down rounds too! & how long those take. The log book sheets with entries from month of May 2025 included columns for room number, time of call, total time spent, what they needed, and any other information. The room number column was used by staff to document the date and other information column used by staff to sign their initials. AL Filling in Time Book entries corresponding with NA-F's shift from 5/17/25 at 10:00 p.m. through 5/18/25 at 6:30 a.m. included the following: - 5/17/25 at 10:00 p.m., 10 minutes total time spent for key handoff, with NA-F's initials. - 5/18/25 at 1:00 a.m., 20 minutes total time spent for rounds, with NA-F's initials. - 5/18/25 at 3:15 a.m., 20 minutes total time spent for rounds, with NA-F's initials. - 5/18/25 at 6:00 a.m., 10 minutes total time spent for key handoff, with NA-F's initials. The total documented time NA-F spent working at the assisted living and not in the nursing home during the shift from 10:00 p.m. to 6:30 a.m. was one hour. The facility's nurse staff posting dated 5/17/25, failed to reflect the time NA-F spent working at the assisted living and not the nursing home. Neither the actual hours worked (listed as 10:00 p.m. to 6:30 a.m.) nor the total hours worked (listed as eight) accurately reflected NA-F's time spent providing resident care in the facility. Based on documentation provided and reviewed above, accurate documentation would have included actual hours worked of 10:10 p.m. to 1:00 a.m., 1:20 a.m. to 3:15 a.m., 3:35 a.m. to 6:00 a.m., and 6:10 a.m. to 6:30 a.m. as well as total hours worked of seven. During an interview on 5/19/25 at 3:28 p.m., nursing assistant NA-E stated nursing staff were responsible for the residents at the connected assisted living at night and had to take care of the residents in both facilities simultaneously. NA-E indicated staff from the nursing home would go over to the assisted living facility to provide cares and assistance. During an interview on 5/23/25 at 11:45 a.m., the staffing coordinator (SC) stated the nurse staff postings for the facility did not reflect the hours staff worked in the assisted living and therefore were not accurate. The SC further stated the hours should be adjusted in real time such as if someone called off for their shift, but this was not completed until the next day when she came in to work. During an interview on 5/20/25 at 10:35 a.m., the administrator stated the facility was typically staffed with one nurse and two NA's at night. The administrator confirmed these staff assisted with providing cares at the assisted living during their shifts at the facility. During an interview on 5/20/25 at 4:55 p.m., the DON stated facility staff had been providing services at the assisted living since before she started working there in October of 2023. She was not sure exactly when this practice began. In a subsequent interview on 5/23/25 at 11:54 a.m., the DON stated the posted nurse staffing hours included identification of certain staff assigned each day to cover helping in the assisted living (staff with AL written next to their names), however the postings did not reflect the specific time or amount of time that was spent working outside of the nursing home. Facility policy on staffing was requested but not received.

Based on interview and document review the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff. Findings include: CMS CASPER Report 1702S titled Staffing Summary Report for dates 1/1/25 through 3/31/25, was a Payroll Based Journal (PBJ) report and included a summary of staffing hours listed by job title. The reported identified the following total nursing staff hours for Quarter 2: - Certified nurse aide (nursing assistant, NA), 5,491.52 hours - Registered nurse (RN), 2,393,98 hours - Licensed practical/vocational nurse (LPN), 2,018.75 - RN director of nursing (DON), 488.00 - Medication aide/technician (trained medication aide, TMA), 131.00 In an email dated 5/19/25 at 5:50 p.m., the administrator noted the facility's overnight staff covered the assisted living center in addition to the facility. In a follow-up email at 6:02 p.m., the administrator indicated there was a tracking log and provided an hours log of nursing home staff covering at the assisted living (AL) titled AL Filling In Time Book. Facility document titled AL Filling in Time Book was a log book with dated entries from 3/9/25 through 5/19/25. The log directed staff: Please write down times for the following: counting meds, rounds, any call lights/calls you get, falls, potential emergencies. Any time you go over there please document it! signed by the director of nursing (DON). Additional hand-written note directed Please fill out when you get calls/go to the ALF [assisted living facility]. Thanks, [DON]. Please write down rounds too! & how long those take. The log book sheets with entries from month of May 2025 included columns for room number, time of call, total time spent, what they needed, and any other information. The room number column was used by staff to document the date and other information column used by staff to sign their initials. AL Filling in Time Book included entries from various staff members during Quarter 2 dated 3/9/25 through 3/31/25, documenting time spent working at the assisted living and not the facility. The total documented time spent by facility staff working at the assisted living from 3/9/25 through 3/31/25, was greater than 50 hours. Some entries were illegible or identified time was spent at the assisted living but did not identify the total amount of time spent. During an interview on 5/20/25 at 4:55 p.m., the DON stated facility staff had been providing services at the assisted living since before she started working there in October of 2023. She was not sure exactly when this practice began. During an interview on 5/20/25 at 10:35 a.m., the administrator stated the facility was typically staffed with one nurse and two NA's at night and confirmed these staff members assisted with providing cares at the assisted living during their shifts at the facility. During an interview on 5/23/25 at 12:03 p.m., the director of human resources (DHR) stated he assisted with staff timecards (clock in/out time punches) and used the timecard data for the facility's PBJ reporting of staffing hours. However, the DHR stated he had not been subtracting the time staff spent in the assisted living to reflect the actual time spent working in the facility for the PBJ reporting. The DHR noted they would subtract the hours moving forward now that the facility realized they should have done this. The DHR stated he started working at the facility a few months ago and, since then, the PBJ hours submitted would have been incorrect. Facility PBJ policy requested but not received.

Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 32 residents who resided in the facility. Findings include: During an interview on 5/28/24 at 5:24 p.m., dietary manager (DM)-D stated she had been employed at the facility for about a year and was not a certified dietary manager. DM-D stated she had been talking about taking a course but didn't know which course to take. DM-D stated she had recently received her ServSafe certificate. During a telephone interview on 5/29/24 at 4:30 p.m., registered dietician (RD)-E stated she was aware DM-D did not meet the required credentials for dietary manager. RD-E stated she was at the facility every four to six weeks, otherwise worked online with staff to oversee dietary operations, conduct resident assessments and evaluations. RD-F stated she was aware the administrator had been encouraging DM-D to obtain the required credentials. During an interview on 5/29/24 at 5:09 p.m., the administrator was aware DM-D was not certified as a dietary manager and had been discussing it with her. The administrator stated they would get DM-D enrolled in a course. Dietary manager job description, undated, indicated the individual must be a graduate of an approved dietary manager's course that met the requirements for state and federal long-term care regulations or have the ability to complete the course in a timeframe determined by the facility administrator.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for licensed nursing staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed - FY (fiscal year) Quarter 1 2024, (October 1 - December 31), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report indicated the following: Failed to have licensed nursing coverage 24 hours/day on the following dates: 12/16/23, 12/17/23, 12/30/23, 12/31/23. On 5/29/24 at 2:04 p.m., health unit coordinator (HUC)-A, who was known as the facility scheduler, stated she was responsible for the nurse staff schedules. HUC-A stated the staff schedule ensured a licensed nurse was scheduled each shift (days, evenings, and nights) and 24 hours every day. Utilizing nursing staff schedules from 2023, and for each infraction date, HUC-A identified a licensed nurse by name and title, and verified a licensed nurse was employed by the facility or was agency staff for the infraction dates identified. On 5/29/24 at 2:37 p.m., human resources (HR)-A stated she entered staffing data into a spreadsheet and then corporate submitted the PBJ data to CMS. HR-A confirmed the data submitted on the infraction dates was not accurate to include all licensed staff who had worked. HR-A stated there was a misunderstanding of the data that needed to be entered and she would ensure accuracy of the spreadsheet submitted to corporate going forward. Timecard information was requested for each of the licensed nursing staff identified by HUC-A and HR-D confirmed licensed staff were scheduled on the infraction dates. Review of the documentation verified each of the licensed nursing staff worked on the dates they were scheduled. The facility Payroll Based Journal policy dated 4/1/19, indicated: PBJ data gathering and preparation. SFHS will gather complete and accurate direct care staffing information: For all care center, agency and contract staff (i.e. medical director, therapy, dietician, pharmacy consultant) SFHS' Employment System Department (ESD) will review all PBJ data for accuracy and submit prior to the CMS mandated deadline ( 45 days after quarter end).

Based on observations, interviews, and document review, the facility failed to ensure it stored, prepared, and served food in accordance with professional standards for food safety. This could affect all 31 residents at the facility. Findings include: Observation and interview on 08/07/23 at 12:10 p.m., during the initial kitchen tour, revealed the handwashing sink in the large main kitchen closest to the kitchen area was lacking soap and paper towels. The dietary manager (DM) indicated maintenance or housekeeping took care of changing soap and paper towels, not the kitchen staff. Observation of the ice machine on 08/07/23 at 12:10 p.m., in the main kitchen near the sink, revealed no record or log of cleaning the ice machine. During interview at the time of the observation, the DM stated she would get the records from maintenance. Interview with the maintenance director (MD) on 08/08/23 at 10:50 a.m., MD stated he had no records or logs of cleaning the ice machine as a service company had been cleaning the ice machine. He did not think it had been serviced since it was installed. Review of the specifications obtained from the administrator file cabinet of the ice machine on page 13 indicated the ice machine shall be cleaned two times per year or every six months to ensure safe use. The front page of specifications had a handwritten note revealing installed 6/22. Observation on 08/07/23 at 12:10 p.m., of the main kitchen walk-in refrigerator, revealed a large amount of chicken breasts in an open garbage bag resting in a plastic container unlabeled without a date. During interview at the time of the observation, the DM indicated she did not know how long the chicken had been in the refrigerator thawing. She indicated the policy stated three days for thawing, however, she could not produce this policy during the survey and was unable to verify the date the chicken was placed in the walk-in refrigerator. Observation on 08/07/23 at 12:15 p.m., of the microwave in the main kitchen near the appliances and kitchen sink, revealed large food particles too numerous to count of various colors including red and yellow stuck to the top of the microwave inside. Interview with the DM at the time of the observation verified the condition of the microwave and indicated housekeeping was in charge of cleaning. Observations on 08/07/23 at 12:25 p.m., revealed the refrigerator on the first floor serving area was large amount of yellow, red, brown, and white crumbs too numerous to count and spills throughout the refrigerator and freezer section of the refrigerator. Further revealed, the refrigerator contained five small cheesecakes in serving dishes on a tray, with cellophane covering half of the cheesecakes, lacking a date. Interview with the DM at the time of the observation verified the condition of the refrigerator and indicated it was housekeeping responsibilities to clean the device. DM stated she did not know how long the cheesecake had been in the refrigerator and stated they were going in the garbage. Observation 08/07/23 at 5:45 p.m., of the refrigerator near the serving area on the first floor revealed 11 thawed mighty shakes on a tray without dates of thawing. The side panel of the mighty shake container indicated use within 14 days of thawing. Interview with dietary aide (DA)-1 at the time of the observation indicated the shakes were generally used within the day they are brought up. DA-1 indicated he brought the shakes up this afternoon from the kitchen but could not state which shakes he brought up from the kitchen. DA-1 also indicated he did not know how long each shake had been thawing. Observation 08/07/23 at 5:50 p.m., of the floor of the walk-in refrigerator, revealed the floor had standing water near the thawing chicken bin, along with paper, tape from boxes, and a large amount of brown and white food debris. Interview with the DM at the time of the observation stated we do not have a cleaning process in place or working order at this time and verified the walk-in refrigerator needed cleaning. On 08/08/23 at 10:30 a.m., five additional thawed shakes were in the walk-in refrigerator in the main kitchen. Interview with the DM at the time of the observation verified she did not know how long the shakes had been thawing in the main kitchen or in the service area. She also clarified the facility has no system to determine the length of time thawing for each shake before serving. Review of the contents of the shakes revealed each shake contains skim milk as it's main ingredient. Observation on 08/08/23 at 12:55 p.m., of the dish machine running, revealed as dishes were running through the machine, the gauges to the dish machine were not moving despite the dishwasher going through the cycles. Three more attempts were made without the gauges moving. The washed items were faintly warm after leaving the dishwasher. Interview with the DM at the time of the observation indicated she has only been here six weeks and has not noticed the dishwasher temperature gauges not working. Review of the temperature gauge log filled out by staff indicated the gauges were working and recorded 120 degrees washing cycle for low temperature dishwashing for the first seven days of the month. A placard on the side of the dishwasher indicated the washing and rinsing cycle shall be 120 degrees for low temperature dishwashers. When strips were used at this time to read the amount of sanitizer present after the wash, the strip read zero parts per million (PPM) or no sanitizing agent present. Further interview on 08/08/23 at 1:30 p.m., the DM and maintenance director on 08/08/23 at 1:30 PM indicated we had it serviced, the technician told us we did not need the booster to work or heat the water, only the sanitizer. Further interview revealed that both the DM and maintenance director had no idea of the temperature of the water during the washing and rinsing cycle. Interview on 08/09/23 at 3:15 p.m., the administrator indicated she did not have a procedure when the dishwasher was not working correctly. She went onto indicate the dishwasher was to be replaced in January 2023 and June 2023 as shown in leasing contracts signed by the facility. She stated she did not know why the dishwasher had not arrived or been replaced. She stated, we have not fixed the dishwasher because we planned on replacing it. Interview on 08/09/23 at 12:00 p.m., the Registered Dietitian (RD) indicated she had not been in the kitchen for six weeks and was not aware of the above noted sanitation issues. Review of the facility policy on use of the dishwasher machine provided by the DM from the computer titled Care Center-Dietary Department, Policy for Sanitation and Safety, Cleaning Dishes/Dish machine, dated 04/20/22, indicated on page one, halfway down that Low Temperature Dishwashing (chemical sanitizer) shall have a final rinse of 50 PPM. Review of the document titled Job Description-Dietician, dated 10/14/22 and provided by the Administrator from her computer, revealed on page four, sixth bullet from the top monitors all components of dietary services for regulatory compliance.