**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure episodes of leaving the building unsupervised were evaluated or assessed to determine what, if any, additional supervision or monitoring was needed to help prevent subsequent exits from the building for 1 of 3 residents (R1) reviewed for elopement and whom had cognitive impairment. R1 left the care center without staff knowledge was found outside in an adjacent alleyway.Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS outlined R1 demonstrated no wandering behaviors, however, did have dementia and Alzheimer's Disease. Further, the MDS recorded R1 as being independent with most mobility tasks (i.e., walking, transferring). R1's Wander Risk Assessment, dated 3/6/25, identified R1 had been in the care center for less than 30 days, was un-familiar with the surrounding area(s), and had both short and long-term memory loss. The evaluation identified R1 was unable to safely cross streets and did not have the skills to navigate independently in the community. The evaluation added these points and others for a combined score which read, 25 pts [points], with dictation adjacent, High Risk. A summary was listed which read, Resident high risk, she is unable to leave facility unsupervised. The evaluation outlined R1's care plan was updated with this information on 3/13/25.R1's care plan, printed 7/29/25, identified R1's actual or potential problems as of that date along with each' respective initiation and revision date. The care plan outlined a section labeled, ASSESSMENT OF RESIDENT'S ABILITY TO LEAVE THE FACILITY SAFELY, which dictated R1 was deemed unsafe to leave the facility unsupervised. The care plan outlined, 5/22/25 Deemed unable to sit outside unsupervised. The care plan listed several interventions to help ensure R1 didn't leave the facility unsupervised including having social services provide reminders to R1, working to find a memory care setting and, SS [social services] and TR [therapeutic recreation] will do Wandering Risk Assessment Annually [sic] and/or as needed. IDT [interdisciplinary team] will determine if resident is able to leave the facility unsupervised. This section was last revised on 6/11/25; with no interventions being revised since 3/13/25.The care plan continued and outlined a section labeled, VULNERABLE ADULT STATUS, which dictated, 7/17/25: Resident found coming out of alley off facility property by SSD [social services director]. Brought to nurses station. The interventions listed outlined R1 as being on hourly checks and reminders since 4/10/25 and reporting incidents to the common entry point (CEP) as required. On 7/17/25, an intervention which read, Staff will stay with resident at all times when door is unlocked, was initiated.On 7/29/25 at 9:12 a.m., a tour of the second floor of the care center was completed. The unit consisted of a single, long hallway with resident' rooms on each side and a central commons area. The North side of the hallway opened into an open stairwell which lead to the main entrance of the care center. The main entrance had signage posted which directed residents to sign out before leaving, and about hours which the door would best be used for safety reasons. The South side of the unit had a closed, un-alarmed door which opened to another stairwell. This lead down to an exterior door which opened to a back alleyway with cars parked outside. The exterior door had a red-colored, alarm-type stop sign placed which was deactivated at this time. An unidentified male resident was seen walking through the door to outside and the door did not alarm. R1's progress notes, dated 3/1/25 to 7/21/25, identified the following: On 3/1/25, R1 admitted to the care center and presented as confused and/or forgetful. The note outlined R1 was placed on hourly checks. On 3/13/25, the IDT met to review R1's Wandering Risk Assessment. R1 was determined to be unsafe to leave the facility unsupervised. On 3/17/25, R1 was found sitting outside the facility on a bench around 6:25 a.m. without staff present. The note outlined R1 was looking for a lighter and added, . was reminded that she cannot be out smoking without staff . came into building with staff. On 4/3/25, R1 was . up a number of times going into other rooms looking for cigarettes . was redirected to go back in her room. On 5/22/25, the IDT reviewed R1's ability to leave the facility unsupervised or sit outside without staff present. The note outlined, . in consensus that she would not be safe unsupervised . will incorporate supervised times to sit outside and encourage to participate in TR activities and walking. On 6/10/25, R1 was again found outside in front of the building. The note outlined, . reminded [R1] that she is unable to sit outside unsupervised . redirected and came inside of the building right away. On 7/17/25, R1 was seen outside without staff coming out of the alley way onto the sidewalk next to an adjacent building. R1 stated she was going for a walk. A subsequent note, dated 7/17/25, identified the IDT discussed R1 leaving the facility unsupervised to go for a walk adding, SS director will follow up with [R1] family about placement and will continue looking for placement. On 7/24/25, R1 was discharged from the care center to another venue. However, R1's medical record was reviewed and lacked evidence R1 had been comprehensively reassessed or evaluated for what, if any, additional interventions had been needed or discussed after R1 was found outside on 6/10/25. There was no evidence documented in the record to support the IDT had reviewed this incident; nor any rationale for what, if any, changes to the interventions in place were considered to reduce the risk of subsequent incidents despite R1 being found unsupervised outside again. When interviewed on 7/29/25 at 9:23 a.m., nursing assistant (NA)-A stated they had worked with R1 multiple times and described her as having a memory problem, adding R1 would likely not have known how to find her way back if she'd ever have left the campus unsupervised. NA-A explained when a resident was on hourly checks, then staff would pop in and check on them just to ensure they were onsite, and these were tracked on a paper flow sheet which were saved by the care team. NA-A stated the building was not locked and there was no full-time wander/exit alarms to secure it (i.e., Wander-guard System). NA-A recalled the care team trying to find new placement for R1 as Birchwood was not a memory ward unit. NA-A stated they were aware R1 had been found outside in the alleyway (7/17/25), however, was unaware of the other incidents adding, I think it was only one time [found outside]. NA-A stated after R1 was found outside on 7/17/25, the activities staff then got more directly involved with R1. When interviewed on 7/29/25 10:05 a.m., activities aide (AA)-A stated they had worked at the campus only a few weeks, but recalled working with R1. AA-A stated R1 would repeatedly want to go outside and smoke adding, She [kept] wanting to go smoke outside. AA-A stated they often tried to keep R1 entertained with card games but, again, would often ask about smoking. AA-A stated they were not working when R1 was found outside on 7/17/25, however, expressed they did not recall any changes to their (activities) approach with R1 for the duration of her stay. At 10:11 a.m., the activities director (AD) joined the interview and expressed it was just that last week R1 was there when activities increased their one-to-one and oversight of R1. Prior to 7/17/25, AD stated activities staff would go outside to smoke with R1 but didn't always remain with her. AD verified the one-to-ones were added due to R1 being found outside on 7/17/25, as they determined they gotta do something here.On 7/29/25 at 10:32 a.m., licensed practical nurse (LPN)-A and LPN-B were interviewed, and LPN-A verified they helped to oversee the entire building. LPN-A explained residents were evaluated upon admission to determine if they could leave the building unsupervised. LPN-A stated the 'Wandering Risk Assessment' would be completed by social services and then reviewed by the IDT and, from there, the care plan would be developed. LPN-A recalled R1 had memory issues and the IDT had determined in the very beginning that she was unable to safely leave the building or campus without supervision. LPN-A verified the building was not locked or armed with a wandering system, and explained R1 had been placed on hourly checks for a long time prior to 7/17/25 due to her cognition. LPN-A acknowledged R1 as being found outside multiple times unsupervised and expressed social services had been actively working to get other placement for R1 in addition to the ongoing hourly checks being done. LPN-A reviewed the medical record and verified the progress note (6/10/25) which R1 was found outside the building unsupervised. LPN-A and LPN-B both expressed that would have been reviewed by the IDT. However, LPN-A verified there was no documented progress note in the record to support that had happened. LPN-B reviewed the collected IDT meeting minutes which were contained in a white-colored binder, and expressed they were unable to locate evidence R1's incident of being found outside unsupervised was discussed or reviewed by the IDT. LPN-A and LPN-B both felt it had been discussed in the IDT; however, LPN-A confirmed the IDT discussion and/or review would typically be recorded in the progress notes, too. The interview continued and LPN-A stated on 7/17/25, the social worker (SW)-A was coming into work and found R1 outside in the alleyway. LPN-A stated it was at that point the IDT determined R1 needed more one-to-one oversight so they had AA-A coming in to just sit more with R1 and keep closer supervision on her. At 10:57 a.m., SW-A joined the interview. SW-A explained R1 had been on hourly checks since she admitted to the care center, and they had been attempting to find better placement throughout her stay. SW-A expressed re-doing the Wandering Risk Assessment after the 6/10/25 incident likely wouldn't have changed their approach or interventions. SW-A stated after the 7/17/25 incident is when they decided a more secured unit was needed and accelerated R1's discharge planning process. SW-A stated the incidents prior to the 7/17/25 incident would have triggered new interventions as R1 wasn't leaving the grounds. SW-A verified the incidents of being found outside were something that would typically be reviewed by the IDT, and they expressed they thought such had been done. However, SW-A and LPN-A both verified the lack of medical record documentation to support this had happened, and LPN-A added aloud, I think something got missed. SW-A stated the incident on 7/17/25 triggered a more immediate response as R1 was then attempting to leave the physical grounds instead of just sitting outside unsupervised. LPN-A reiterated the interventions already in place throughout R1's admission but acknowledged, Maybe we did not get everything we should have in there [record], but we did do it. Further, SW-A stated ensuring residents were properly supervised was important to keep them safe. On 7/29/25 at 11:18 a.m., the director of nursing (DON) was interviewed. DON stated any incident, including elopements, were reviewed by the IDT and a progress note was typically entered into the medical record with their evaluation or decision-making on it. DON reviewed R1's medical record and verified it lacked such evidence about the 6/10/25 incident when R1 was found outside unsupervised adding aloud, I don't see anything. DON stated it was important to ensure the IDT reviewed incidents and recorded them in the record as it was all part of keeping her safe. DON added, It's the process we have in place to make sure we're addressing it [incident]. A facility-provided Elopement Risk Assessment Policy, dated 1/2025, identified the facility would assess upon admission, quarterly and as needed for this risk adding, Elopement is wandering away from the facility and is dangerous for the resident. The policy outlined any resident with a score of 7 or higher would have a safety plan incorporated into their care plan adding, IDT will meet during weekly meeting to discuss ability to keep safe and determine if the resident needs a higher level of care if they score greater than 7 on the Wandering Elopement Risk Assessment. In addition, a facility-provided Birchwood/Grand Avenue IDT Policy, dated 4/2025, identified the team would meet daily (Mon-Fri) and discuss falls or behaviors. The policy directed, 6. A progress note will be put in the residents chart with interventions put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure grievances were acted upon and if needed investigated or resolved for 1 of 1 residents (R46) reviewed for grievances. Findings include: R46's Annual Minimum Data Set (MDS) dated [DATE], indicated it was very important to choose what clothes to wear, take care of personal belongings. R46's quarterly MDS dated [DATE], indicated intact cognition, did not have inattention, disorganized thinking, or an altered level of consciousness, did not have hallucinations or delusions, behaviors, and did not reject cares. R46's progress notes were reviewed from 8/7/2023, and lacked information R46 was missing clothing items. R46's progress notes dated 10/4/23, indicated R46 reported missing money and a vulnerable adult report and online police report were completed. R46's care plan dated 2/4/25, indicated R46 had intact cognition. During interview on 3/17/25 at 3:52 p.m., R46 stated when he first came, his clothes were missing and never got them back. R46 stated he reported it and thought he completed a form and stated he was missing two pairs of shorts and a number of shirts adding his memory was not the greatest and further stated he asked to be reimbursed, but nothing came of it and stated his clothes were old, but he had no income for replacing them. During interview and observation on 3/18/25 at 11:37 a.m., the laundry assistant (LA)-A stated if a resident reported missing items, she had a list she wrote down and stated she would search in closets and had a 90% success rate in finding items and stated missing clothing happened a lot. LA-A provided a handwritten list located in the laundry room that indicated a date, 9/25/24, with R46's name and a list that contained a shirt, shorts, and boxer shorts and stated she had not yet been able to locate the items and further stated if she cannot locate something, she updates the supervisor. During interview on 3/19/25 at 8:57 a.m., nursing assistant (NA)-B stated R46 was an accurate historian and if residents reported missing items, they look for the missing items and if they cannot locate them, report to social services. During interview on 3/19/25 between 12:54 p.m., and 12:56 p.m., social worker (SW)-A stated they try to locate missing items and sometimes residents miss place items and they try to track steps when they last saw the missing item. SW-A stated she has residents make a list and if they are unable to locate it, a notification is sent to maintenance, and nursing. At 12:56 p.m., social services assistant (SSA)-B stated a grievance form was normally completed in order to track it and asks to conduct a room search, and if items are clothing articles, goes to the laundry room and documents on the grievance form. SW-A and SSA-B stated they don't always document other than on a grievance form. SSA-B viewed the grievance log and stated she did not recall R46 reporting missing clothing items and verified there were no grievances in the grievance log for R46. SW-A stated she was not aware of R46 missing any items. SW-A further stated they completed an inservice on grievances and stated staff were supposed to report to her or SSA-B. During interview on 3/19/25 between 1:04 p.m., and 1:07 p.m., with LA-A and SW-A, LA-A stated she informed SW-A of the missing items and showed SW-A the missing items list dated 9/25/24, and read off the missing items stating R46 was missing a green shirt with gray on the back, a pair of white shorts with blue stripes and a pair of boxer underwear. LA-A further stated R46 was looking for reimbursement for the items. At 1:07 p.m., SW-A stated she did not recall being informed of missing items and stated there should have been a grievance form completed by now. SW-A viewed R46's chart and verified there was no documentation regarding missing clothing items and stated the facility reimbursed if they determine they were responsible for losing items and stated it was important to complete a grievance form in order to follow through on missing items. During interview on 3/19/25 at 1:34 p.m., LA-A stated R46 reported the missing items on 9/25/24, and added she thought R46 completed a grievance form, but stated SW-A could not recall. During interview on 3/19/25 at 1:50 p.m., the director of nursing (DON) stated a grievance form is completed when a resident reports missing items and staff update social services and try to locate the missing items and follow up as soon as possible. The DON further stated it was important to complete the grievance in order to follow up. A policy, Procedure for Missing Items dated 6/23/24, indicated it was the policy of the facility that all missing items were acknowledged and investigated. When a resident reports a missing item or money, staff will assist resident to search for it in all appropriate locations, including but not limited to talking to other staff members. This will be completed within 24 hours of original complaint and documented in resident's chart. If the item is not found upon the initial search, staff will complete a grievance form and turn it into the grievance officer and or designee. Social services director or designee will make copies of the grievance form and forward them to the appropriate department for further follow up. The department manager(s) that receive a grievance form will do a thorough search and or investigation regarding missing item, money, etc and complete the grievance form and return it to social service director and or designee within 72 hours of receiving the grievance form. the director of social services and or designee and appropriate staff will discuss possible actions to take to prevent re-occurrences, room changes, labeling clothing, putting money in a trust fund etc, final outcome and actions will be documented in resident's chart and care planned for as deemed appropriate. The director of social services and or designee will maintain a log of all missing items in order to monitor for trends and or patterns. A policy, Grievances, dated 8/8/23, indicated the facility will make every effort to resolve the issue within three working days of receipt of the grievance or complaint, and the resolution will be communicated to the resident, resident representative, family member, friend, or health care agent who originated it. A copy of the written response with proposed resolutions may be given to the grievant if the resident, family, friends, or health care agent does not accept the proposed resolution, an appointed administrative designee may request an appropriate advocacy organization to intervene. All files and information pertaining to the grievances are confidential and will be kept by the grievance official and administrator or designee and the facility will maintain original written responses and three years of grievance records and logs. All grievances will be reviewed with resident voicing concern to ensure they are satisfied with the resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure physician's orders were in place for 1 of 1 resident (R46) who self catheterized. Findings include: R46's Optional State Assessment (OSA) dated 2/7/25, indicated intact cognition, did not have hallucinations, delusions, or behaviors, and did not reject cares. The OSA further indicated R46 was independent with activities of daily living (ADLs), was not on a urinary or bowel toileting program. R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 did not have an indwelling catheter, external catheter, ostomy, or had intermittent catheterizations and was always continent of bowel and bladder. R46's Medical Diagnosis form indicated R46 had the following diagnoses: fusion of the spine, lumbar region, and an unspecified disorder of the prostate. R46's Orders form was reviewed and lacked physician orders on how R46 self catheterized, why R46 self catheterized, what type of catheter was used, how often catheterization was required, or where R46 obtained catheter supplies from. R46's medication administration record (MAR), and treatment administration record (TAR), was reviewed for January 2024, February 2024, and March 2024, and lacked information how R46 self catheterized, why R46 self catheterized, what type of catheter was used, how often catheterization was required, or where R46 obtained catheter supplies from. R46's care plan dated 2/4/25, indicated R46 had intact cognition. R46's care plan dated 8/24/23, indicated R46 was continent of bowel and bladder, would remain continent of bowel and bladder and interventions included to review and assess on a quarterly and annual basis. Further, R46 self catheterized due to a medical history and retention. R46's goal indicated he would report no difficulties in self catheterization and stay free from infection. Interventions included staff would make and alert R46 of urinary and urology appointments, and staff will report any difficulties that resident expresses to urology. The care plan lacked information what type of catheter R46 used, how often R46 self catheterized, and where R46 obtained catheter supplies. R46's Bladder Assessment Documentation dated 2/7/25, indicated no further assessment was necessary and further, R46 performed self catheterizations, but was continent of bladder. Under a heading, Potentially Reversible Causes of Urinary Incontinence a check box was marked for a history of urinary retention. The assessment further indicated R46 had prostatitis (inflammation of the prostate gland)/BPH (benign prostatic hyperplasia). The form indicated a physical exam was not performed and recorded and registered nurse (RN)-A attempted the examination for the second time on 2/7/2027 and was not appropriate for toileting or a retraining program. Under the heading, Progress note indicated R46 was continent of his bladder and intermittently self catheterized when having a CRPS (complex regional pain syndrome) flair and was in severe pain due to retention. No further assessment or examination needed at this time, no concerns at time of assessment. R46's Care Area Assessment (CAA) Summary form dated 8/9/24, indicated urinary incontinence and indwelling catheter was not triggered for a care planning decision. R46's History and Physical dated 3/18/25, indicated R46 had a status post lumbar fusion, complex regional pain syndrome type two (CRPS) of the left lower extremity (a chronic pain condition that causes severe, persistent pain, along with other symptoms like swelling, skin temperature changes, and sensitivity to touch in the affected limb), BPH with urinary hesitancy, and urinary retention. R46's admission progress note dated 8/7/23, indicated R46 did not urinate on his own, and straight cathed himself when he knows he needs to empty his bladder. R46's Care Conference note dated 5/22/24, indicated R46 straight cathed for his bladder. R46's Care Conference note dated 8/21/24, indicated NA under the heading Urology. R46's Care Conference note dated 11/20/24, indicated R46 straight cathed for his bladder. R46's Aide Task form did not include a task for self catheterization. During interview on 3/17/25 at 3:57 p.m., R46 stated he self catheterized 3 times a week due to his CRPS affecting his groin area. R46 stated it didn't matter how full his bladder was, he was unable to urinate and added he does void sometimes. During interview on 3/19/25 at 8:57 a.m., nursing assistant (NA)-B stated she was not aware R46 self catheterized and stated LPN-A ordered supplies and further stated R46 was alert, an accurate historian, but had pain all the time and needed encouragement, but was cooperative. During interview on 3/19/25 at 9:10 a.m., licensed practical nurse (LPN)-A stated the facility did not have any paper charts and doctor visits were located in the computer and it was determined what medical supplies were needed based on the physician orders. LPN-A further stated staff knew what cares a resident required based on the care plan, but was more a tool the social worker used and staff looked at the orders. LPN-A stated she was responsible for ordering supplies and added they did not have catheters at the facility and added R46 self catheterized himself as needed three to four times a day and obtained his own supplies adding that R46 was completely with it. LPN-A stated R46 had been self catheterizing since prior to admission to the facility. During interview on 3/19/25 at 9:25 a.m., registered nurse (RN)-A stated R46 self catheterized, and staff did not assist and did not know how often R46 self cathed, what size catheter, and stated they did not have an order and added it would be helpful for nursing to know because if they had the physician's order they would know there is an issue and when R46 would be out of supplies and could follow up. During interview on 3/19/25 at 9:41 a.m., the director of nursing stated R46 did not self cath, then reviewed R46's bladder assessment and RN-A verified the assessment indicated R46 self catheterized and stated R46 should have an order in the chart for the nurse to supervise and stated it was important to ensure it was going well and if there were any complications and would need to know the catheter type. A policy, Catheter Use, dated 1/25/25, indicated resident self-catheterization may be done by a resident to relieve the bladder of residual urine if approved by a urologist and performed with nursing supervision. The nurse supervises and promotes techniques to allow for correct procedure and reduced chance of infection. Both the nurse and the resident will wash hands prior to procedure in accordance with infection control policy. Nurse will wear gloves during this procedure. Position the resident on the toilet with enough room to allow end of catheter to drain into the toilet freely. The nurse will remove sterile wipe from the package and hand to the resident. The resident will open the wipe by shaking and cleanse peri area by wiping front to back. The nurse will remove the lubricant packet being careful not to touch the tip or end of the catheter. The resident will open the lubricant packet and the nurse will place the tip of the catheter into the lubricant, then hand the catheter to the resident. The resident will place the tip of the catheter into the urinary meatus allowing end of catheter to drain residual urine while the nurse ensures that the catheter is draining into the toilet. When the draining stops, the catheter will be removed by the resident and placed into the waste receptacle. Both the resident and the nurse wash hands after the procedure is complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and document review, the facility failed to ensure interventions for safe smoking were implemented for 1 of 2 residents (R6) reviewed for smoking. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have range of motion impairment to upper extremities, did not have physical or verbal behaviors directed towards others, and did not reject care. R6's Medical Diagnoses form indicated the following diagnoses: tobacco use, and mild intellectual disabilities, and schizophrenia. R6's Orders form was reviewed and lacked information regarding safe smoking. R6's care plan dated 12/26/24, indicated R6 had moderate cataracts and a surgical consult was provided, however R6 declined treatment, interventions included staff to observe for visual changes or ability to maneuver safely in the environment. R6's care plan dated 12/26/24, indicated R6 heard voices and had paranoid accusations others wanted R6's money or were in her business. R6's care plan dated 12/26/24, indicated R6 was a safe cigarette smoker with proper safety interventions. R6 had burned fingertips and nose and had been observed with holes in clothes and was encouraged to use a smoking apron, refused a cigarette holder, and was able to light her own cigarette with a no-flame lighter, or staff would light R6's cigarettes. Interventions included assessing smoking safety upon admission, significant change, and annually, and staff would offer praise to R6 for safe smoking and redirection as needed. R6's care plan dated 3/6/25, indicated R6 required re-direction and cuing to make appropriate decisions related to mild intellectual disabilities and interventions included staff conducting one to one visits to re-direct and cue when R6 made poor decisions as needed and as resident allowed. R6's care conference progress note dated 9/11/24, indicated R6 smoked, and a policy was explained to R6 and R6 agreed and was reminded of interventions rec. Apron/ no flame lighter. [NAME] Smoking review completed 8/2024. R6's care conference progress note dated 12/11/24, indicated R6 smoked, and a policy was explained to R6 and R6 agreed and was reminded of interventions rec. Apron/ no flame lighter. Safe smoking review completed 8/16/24. Resident is safe to smoke unsupervised. Resident now pays the facility to purchase her cigarettes, tubes and roll her cigarettes. Resident receives 20 cigarettes/day. R6's progress note dated 3/7/25, indicated staff witnessed resident providing a cigarette to another resident. R6's care conference progress note dated 3/12/25, indicated R6 smoked, and a policy was explained to R6 and R6 agreed, interventions included rec. Apron/ no flame lighter. Safe Smoking review completed 8/16/24. Resident is safe to smoke unsupervised. Resident now pays the facility to purchase her cigarettes, tubes and roll her cigarettes. Resident receives 20 cigarettes/day. R6's Safe Smoking Evaluation form dated 8/16/24, indicated R6 smoked, had cognitive loss, did not have a vision deficit, could light her own cigarette, smoked only in designated areas, did not have a history of injuries secondary to smoking, did not need a lighter and cigarettes stored by the facility, check boxes for whether R6 required adaptive equipment were left unmarked. The adaptive equipment check boxes included smoking apron, cigarette holder, supervision, and one on one assistance. Further, the assessment indicated R6's clothing had burn holes and additional check boxes were included under clothing condition if clothing had burn holes. The check boxes included what R6 wanted to do with the clothing if R6 had burn holes: throw away the clothing, keep and continue to wear clothing, and N/A. Not Applicable. N/A was documented. The assessment further indicated R6 knew how to put cigarettes out correctly, knew not to save cigarettes and put them out half way, and was given the risk and benefits of smoking. During interview and observation on 3/17/25 at 3:06 p.m., R6 stated she kept cigarettes with her all the time and was wearing a dark gray sweater with a burn hole and a few smaller holes. R6 stated she didn't burn herself, and put cigarette butts out in the pail and pointed to a small green canister with a small circular opening located on the floor in her room and stated she could not smoke in her room and used the canister for smoking on the third floor. During interview and observation between 3/18/25 at 11:51 a.m., and 11:59 a.m., R6 was at the dining room table and at 11:55 a.m., got up, filled a cup near the water dispenser and left the dining room. At 11:57 a.m., R6 went out the front door, took out a roll of several cigarettes and lit a cigarette with a lighter that had an obvious flame. R6 was wearing a gray shirt that contained burn holes and was not wearing a smoking apron. R6 took out a light blue lighter to light the cigarette. No staff were located outside. At 11:59 a.m., social worker (SW)-A, came outside assisting another resident. SW-A did not ask or encourage R6 to use an apron. During interview and observation on 3/18/25 between 12:05 p.m., and 12:20 p.m., SW-A stated staff looked to care plans to know what cares a resident required and stated R6 was supposed to use an apron in the smoke room if there was one available because R6 got ashes on herself, but because R6 had an ashtray in her room, staff were going to have another smoking assessment completed. Social services assistant (SSA)-B stated she planned to complete the smoking assessment. SW-A verified R6 was not wearing a smoking apron when outside smoking and stated it would be important to encourage the apron because R6 had burn holes on her clothing and the apron prevented cigarette holes because R6 dropped on her clothing. SSA-B stated a no flame lighter was an electric lighter and added she never used or saw a no flame lighter. At 12:15 p.m., SSA-B stated they had an apron that hung in the smoking room, but staff didn't do anything if residents went outside. At 12:19 p.m., R6 pulled out a BIC blue lighter and SSA-B verified R6's lighter was not a flameless lighter at 12:20 p.m., and would look for the flameless lighter identified on the care plan. During interview on 3/18/25 at 12:27 p.m., the director of nursing stated she expected care plans be followed and was important to have an apron to protect R6's clothing and the possibility of burns and planned to follow up as to why R6 did not have an apron and stated they should be closely monitoring. A policy, Resident Smoking, revised 3/18/25, indicated residents will be safe while smoking, policies will be reviewed upon admission and annually with residents, a smoking assessment will be completed at admission and annually for each resident. Additional assessments will be completed upon significant change or if any safety concerns are identified. The care plan will reflect outcomes of the safe smoking assessment. If there are suspected safety concerns staff will follow up immediately interventions included remind and encourage safe smoking practices, request another safe smoking assessment, document the behavior in the electronic medical record, use of smoking apron, supervised smoking, regulated use of smoking materials, and discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 5 of 5 residents (R9) reviewed for restraints, (R26) reviewed for dialysis and Preadmission Screening and Resident Review (PASARR), and (R27, R53) reviewed for falls. Findings include: The Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2024, directed staff under section J to identify whether a resident had any falls since admission, entry or reentry or prior Assessment (OBRA or Scheduled PPS), whichever was more recent. If a resident fell, the RAI directed staff to continue to J1900, number of falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS). The RAI further defined prior assessment as the most recent minimum data set (MDS) assessment that reported on falls. J1900 directed staff to code either none, one, or two or more falls in three separate boxes that included: 1. No Injury, defined as no evidence of injury was noted on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident, no change in the resident's behavior is noted after the fall, 2. Injury (except major) defined as skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain of pain, and 3. Major Injury defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematoma. R27's annual MDS dated [DATE], indicated R27 had moderate cognitive impairment, and had not fallen since admission or prior assessment. R27's quarterly MDS dated [DATE], indicated R27 had severe cognitive impairment, had falls since admission, entry or reentry or prior assessment (OBRA or Scheduled PPS) whichever was more recent, had two or more falls without injury, had 2 or more falls with injury (except major), and had 2 or more falls with a major injury. R27's care plan dated 9/15/24, indicated R27 was at risk for falls due to multiple risk factors. Interventions indicated R27 had fallen on 12/3/24, 12/24/24, and 12/29/24. The fall on 12/3/24 resulted in no injuries noted. The interdisciplinary team (IDT) discussed R27's falls on 12/24/24, and 12/29/24, and R27 was encouraged to call for assistance upon ambulation and was educated to stay in bed during ECT treatment and to call for assist if she required help. The care plan lacked information whether R27 received any injuries on 12/24/24, and 12/29/24. R27's physician's orders dated 8/28/23, indicated to monitor for falls and unsteady gait every shift. R27's progress notes dated 12/3/24 at 11:27 a.m., indicated R27 fell on [DATE], and denied any pain or discomfort, was assessed and found to have no injuries. R27's progress notes dated 12/24/24 at 9:45 a.m., indicated R27 fell at ECT (electroconvulsive therapy) and there were no signs of acute injury, R27 had full range of motion, R27 dug her fingernails into her arm and injured a fingernail that was wrapped. R27 denied pain or discomfort. R27's progress notes dated 12/29/24 at 4:35 p.m., indicated R27 had a questionable fall and directed staff to see the risk assessment for further information. R27's Fall Risk Assessments located under the Assessments tab indicated the most recent fall risk assessment was dated 1/3/25, and then again on 10/4/24. R27's Fall Risk assessment dated [DATE], indicated R27 was mostly steady during transitions from sitting to standing, walking, turning, and transferring on and off the toilet and was independent with all mobility without any device. R27 had no functional limitation in range of motion. After ECT treatments, R27 can sway or not fully watch where she is going and can be tired and obtunded and had every shift orders to monitor for gait and stability changes. The form lacked information pertaining to falls and injuries. R27's Fall reports dated 12/3/24, 12/24/24, and 12/29/24, were reviewed and R27 had no injuries on 12/3/24. On 12/24/24, R27 dug her fingernails into her arm and injured a fingernail and otherwise was documented as having no acute injury. On 12/29/24, R27 was on the floor and no injuries were noted. During interview on 3/19/25 at 9:25 a.m., registered nurse (RN)-A stated she was the MDS nurse and was still training and working with the director of nursing and took over the MDS in August or September and stated she completed the coding and helped with the care plan. During interview on 3/19/25 at 11:26 a.m., licensed practical nurse (LPN)-A stated when a resident falls, they are assessed and if injured, call 911 and send the resident to the hospital and complete a risk assessment. LPN-A stated the risk assessment was documented under care management and stated she saw R27 had two falls dated 12/3/24 and 12/29/24. LPN-A stated R27 did not have any injuries from the falls and further stated R27 had not had any falls she was aware of that resulted in injury. LPN-A stated the MDS may be documented in error. During interview on 3/19/25 at 11:43 a.m., registered nurse (RN)-A stated if a resident fell, the facility assesses the resident and if the fall was unwitnessed, complete neuro checks, update the family, doctor, director of nursing, and complete a progress note. Further, they care plan and discuss at IDT in order to create fall interventions. RN-A viewed the risk management reports since 10/4/24, and stated R27 had a fall on 12/3/24, 12/24/24, and 12/29/24. RN-A stated R27 had no injuries after viewing each of the notes and verified R27 had three falls since October. Both RN-A and the director of nursing (DON) verified R27 had no injuries and the DON stated the MDS should have indicated R27 had no injuries. A policy, Interdepartmental MDS Review, dated January 2025, indicated it was the policy of the facility to ensure that each resident's MDS will be completed on admission, quarterly, annually and significant change using current, accurate documentation and assessments specific to that resident. Each resident will be assessed on admission, quarterly, annually and significant change for the purpose of the completion of the MD. Each department represented by the IDT will complete the following assessments for the purpose of gathering the most accurate information specific to each resident. Nursing will complete bowel and bladder assessment with summary note, monthly self administration of medication with summary note, pain, falls, EPSE, foot, DISCUS assessments, care plan initiation, review and updating, nursing will review MDS/Care Conference schedule and distribute to all IDT members on a quarterly basis. Documentation in progress notes upon completion of the MDS interviews. Nursing will be responsible for the MDS sections B, GG, H, I, J, L, M, N, O, P, plus CAAs (care area assessments) triggered for these areas. Nursing is also responsible for sections J and L. R53 R53's quarterly Minimum Data Set (MDS) dated [DATE] indicated R53 was cognitively intact, had delusions, hallucinations, had no behaviors, was independent with activities of daily living but needed set up for eating and showers. MDS indicated R53 had a fall with major injury. R53's clinical diagnosis report printed 3/20/25, indicated schizoaffective disorder, bipolar disorder, anxiety and renal disease. R53's progress note dated 1/23/25, indicated R53 reported she fell in her room at 2:00 a.m. R53 stated she fell by her bed on her way to the bathroom and did not hit her head. Progress note indicated a head-to-toe assessment was completed and no injuries were noted. During interview on 3/17/25 at 1:33 p.m., R53 stated she fell, didn't harm herself, and added I took responsibility, but I don't want to talk about it. During interview on 3/19/25 at 2:09 p.m., registered nurse (RN)-A stated she started to do the MDS assessments in September 2024 and was still learning the MDS process. RN-A indicated she completed R53's MDS. RN-A reviewed the R53's record, and verified R53 didn't injured herself when she fell. RN-A stated it was a coding error. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and diagnoses of anxiety and schizophrenia (a chronic mental condition that affects a person's ability to think, feel, and behave clearly). Her MDS further indicated she utilized a limb restraint less than daily. R9's order summary report printed 3/21/25, showed her active orders as of 12/1/24 and lacked an order for a limb restraint. R9's assessments were reviewed 3/19/25 and lacked documentation of an assessment for a restraint. R9's care plan was reviewed 3/19/25 and lacked documentation of the use of a limb restraint. R9's electronic health record (EHR) was reviewed on 3/19/25 and lacked documentation of the use of a limb restraint. Per interview on 3/19/25 at 11:46 a.m. with licensed practical nurse (LPN)-A, there was no use of restraints in the facility. Furthermore, LPN-A stated R9 gets anxiety and gets nervous, but is nobody that would ever need to be restrained. LPN-A could not think of any device that would be considered a restraint for R9. During interview on 3/19/25 at 2:43 p.m., registered nurse (RN)-A verified completing R9's quarterly MDS dated [DATE] and the affirmative response to the use of a restraint for R9. RN-A stated, nobody here uses a restraint. This was an error. R26 R26's annual Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and had diagnoses of cirrhosis (chronic liver disease), kidney failure, kidney stones, liver failure, and diabetes. The MDS also indicated he was considered by the state level II Preadmission Screening and Resident Review (PASARR) process to have a serious mental illness. Furthermore, the MDS reported he was not receiving dialysis. R26's order summary report printed 3/19/25, included the following orders: - assess thrill ad [sic] bruit each shift. If not present, notify MD. No blood pressure on left arm, dated 11/18/08. - daily weight one time a day for dialysis, dated 11/16/24. R26's care plan dated 2/9/24, identified his risk for complications related to chronic kidney disease and indicated he was receiving dialysis on Mondays, Wednesday, and Fridays. Additionally, his care plan identified his potential for complication related to his permcath (a type of long-term venous access to the bloodstream used for hemodialysis) hemodialysis access, which was placed in the hospital on [DATE]. A Davita treatment details report dated 1/2/25, indicated R26 received hemodialysis treatment on 1/2/25. A Davita treatment details report dated 1/4/25, indicated he received hemodialysis treatment on 1/4/25. A Davita treatment details report dated 1/6/25, indicated he received hemodialysis treatment on 1/6/25. A Davita treatment details report dated 1/13/25, indicated he received hemodialysis treatment on 1/13/25. A Level I: Screening for Mental Illness or Mental Retardation dated 11/17/08, indicated R26 did not meet the requirements to be referred for a level II evaluation and determination. R26's electronic health record (EHR) was reviewed 3/19/25 at lacked documentation of a level II PASAAR. Per interview on 3/17/25 at 6:39 p.m., R26 confirmed he went to dialysis three times per week, on Mondays, Wednesdays, and Fridays. Per interview on 3/19/25 at 11:42 a.m. with licensed practical nurse (LPN)-A, R26 had been on dialysis for about a year. During interview on 3/19/24 at 2:44 p.m., registered nurse (RN)-A verified completing his annual MDS dated [DATE] and confirmed he was on dialysis. RN-A stated R26's MDS should have identified his use of dialysis. A request was made for R26's level II PASARR on 3/19/25 at 2:39 p.m. During interview on 3/19/25 at 3:18 p.m., social worker (SW)-A stated he did not have a level II PASARR because he did not require one. SW-A reviewed his annual MDS dated [DATE] and verified the incorrect data and stated, that was coded wrong, it should have been no. A facility policy pertaining to MDS accuracy was requested, but the director of nursing (DON) stated the facility did not have one.

Based on observation, interview, and document review, the facility failed to ensure food items were properly stored, labeled, and dated to reduce the risk of physical cross-contamination and potential foodborne illness. This had the potential to affect all 59 residents, staff, and visitors who consumed food from the kitchen. Findings include: On 3/17/25 at 12:11 p.m., an initial kitchen tour was completed with dietary aid (DA)-A. In the walking refrigerator a sheet pan cart with several unwrapped and undated trays contained the following items: * Three trays with about 20 cheese and eggs English muffin sandwiches with a piece of parchment paper on top * Two trays with tater tots with a piece of parchment paper on top * Two trays with apple bran bowls, each containing about 35 bowls with a piece of parchment paper on top. * One tray of mint and chocolate dessert with a piece of parchment paper on top * In the bottom of the cart there were two trays of breaded pieces of chicken, with no parchment paper on top. During interview on 3/17/25 DA-A verified the unwrapped and undated trays and stated, The cook should wrap the trays before she puts them on the freezer. DA-A stated the trays have food prepared in advanced. The food on the trays will be cooked and served for dinner tonight or the next day. During interview on 3/18/25 at 8:15 a.m., the director of nutritional services (DNS) stated we didn't know we had to wrap the trays. DNS stated storing unwrapped food items could posed a risk for cross contamination, especially if something drips. During interview on 3/20/25 at 9:46 a.m. the administrator stated all the food should be labeled with dates and wrapped. It's an infection control issue due to contamination and the risk for foodborne illnesses. Administrator added It's not acceptable. A Food Storage policy was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for one of one resident (R1) when reviewed for care plans. R1 did not have adequate interventions in place after a history of eloping/wandering from the facility. Findings include: R1's admission Record printed on 6/17/24 indicated R1 was admitted to the facility on [DATE]. The admission Record stated R1's medical diagnosis included schizoaffective disorder. R1's minimum data set (MDS) dated [DATE] indicated R1 had a brief interview for mental status (BIMS) score of 15, which indicated R1 was cognitively intact. R1's care plan dated 2/14/24 indicated R1 has command voices that are loud, whispers that can be intense that tell him things to do and if he is decompensating, he will act on those commands. Interventions indicated staff to ask questions to bring R1 back to reality such as 1. Are you having whispers, intense, or screaming voices? And 2. What are the voices telling you? The intervention indicated to remind R1 that it is not ok to take off his clothing and that he is not going to hell if he does throw away his clothing. Another intervention indicated staff will ask R1 on every shift if he hears voices. The care plan does not indicate what staff are to do when R1 is hearing command voices. R1's care plan dated 2/14/24 indicated R1 is not safe leaving the facility unsupervised when command voices are present. The indicated goals were R1 would be safe when in the community, R1 will notify charge nurse when leaving building and when returning, and R1 will use the sign out book when leaving the facility. The intervention indicated staff would provide hourly checks on R1 as needed when R1 has increased symptoms of hearing command voices related to the diagnosis of schizophrenia, staff would assess resident psychotic symptoms every shift, and staff would remind R1 to notify nurse when leaving building and when he returns. The care plan does not indicate what staff are to do when R1 is hearing command voices or how to assess if R1 is hearing command voices. R1's care plan dated 2/14/24 indicated R1 self-isolates and does not ask for as-needed medications when he hears command voices. The care plan indicated R1 decompensates rapidly if R1 does not take his as-needed medication when he is hearing command voices. The care plan does not indicate signs to look for when R1 is decompensating or interventions when R1 is decompensating. R1's care plan dated 2/14/24 indicated R1 currently uses a GPS tracker to monitor R1's whereabouts. The care plan stated R1 gets the tracker from the charge nurse and the charge nurse will turn on the GPS tracker. The care plan stated R1 confirms he has his cell phone on. The care plan stated R1 left the facility due to his command voices telling him to leave on 3/9/24 and 3/11/24 without the GPS tracker. The care plan indicated R1 returned both of those instances with no injury. The interventions included R1 seeing Associated Clinic of Psychology (ACP) therapist weekly or bi-weekly, the staff would call R1's cell phone if he does not return to the facility when he stated he would, staff would follow the missing person/wandering resident policy and procedure, staff would monitor resident whereabouts hourly and document on hourly monitoring sheets whereabouts and visible symptoms of increased command voices, and when R1 went to the nurse to request a tracking device the nurse would have R1 fill out a worksheet that asked: 1. Do you have a specific destination in mind? If yes, where? 2. Are your voices telling you not to return? 3. Do you feel like you have to listen to the voices? 4. Do you feel safe? and if R1 indicated a yes to any of those questions the nurse would complete flow chart for elopement risk assessment and management and follow interventions as listed. The care plan does not indicate what staff should do if R1 has high intensity command voices. An interview was attempted with R1 on 6/17/24 at 11:08 a.m. and R1 declined to be interviewed. During an interview on 6/17/24 at 11:31 a.m., the director of social services stated when there is more activity going on in the facility, is when R1 starts to hear more command voices and he gets overwhelmed. The director of social services stated if R1 gets overwhelmed, he will not sign out in the sign out book and he will not grab his GPS tracker. The director of social services stated there is nothing the facility can do to stop R1 from leaving. During an interview with registered nurse (RN)-A on 6/18/24 at 9:16 a.m., RN-A stated the facility needs to be able to help him control his command voices when his command voices are too loud because that is when he gets overwhelmed and leaves the facility without signing out in the sign out book or getting his GPS tracker from the nurse's station. During an interview with the certified nursing assistant (CNA)-A on 6/18/24 at 9:29 a.m., CNA-A stated she was not sure what she should do if she found R1 in a distressed state. CNA-A stated she was unaware of interventions to be done when R1 is in a distressed state. An interview was attempted with R1 on 6/18/24 at 9:26 a.m. and R1 declined to be interviewed. During an interview with the director of nursing (DON)-A on 6/18/24 at 10:12 a.m., the DON stated R1's intervention for a GPS tracker was placed on his care plan about a year ago and does not think there has been any new interventions since his last elopement. The DON stated he has done so many elopements that it is hard to keep track on them. During an interview with the DON on 6/18/24 at 11:24 a.m., the DON stated if staff is noticing R1 having more anxious or overwhelmed behaviors, they chart those behaviors and based on those behaviors staff should figure out what to do to help R1. The facility procedure titled Missing Resident Reporting Procedure, not dated, indicated find out why the resident was missing, where they were, then document in nursing notes. The procedure did not identify the development of resident interventions to prevent future missing person incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the medical provider of on-going medication refusals for 1 of 1 resident (R14) reviewed for notification of change. Findings include: R14's quarterly Minimum Data Set, dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all ADLs. R14 had diagnoses of diabetes mellitus and schizophrenia. R14's Care Area Assessment (CAA) dated 11/3/23, dlirium triggered for inattention and disorganized thinking. The CAA identified the symptoms were not new and had abnormal blood sugar levels due to R14's refusal to take insulin. The CAA cognitive loss triggered due to refusal of cognitive assessment and staff indicating short and long-term memory loss, poor decision making, inattention, and disorganized thinking. The CAA indicated R14 received frequent reorientation, reassurance, reminders to help make sense of things, and redirection and cues for appropriate responses and better decisions. The CAA psychotropic drug use trigged for antipsychotic use and behavioral symptoms triggered related to rejection of care and noted behavior as worse. R14's cognition care plan revised 12/8/19, indicated R14 believed they had an allergy to insulin and listed interventions such as nursing will update doctor/Psychiatrist about any reports of increased delusions, ACP therapist periodic and/or as needed, medications per doctor/psychiatrist order, social services will follow up with resident as needed with delusional beliefs, staff to attempt to re-direct when delusions are bothering self and/or other residents, and staff to offer reality based support and reassurance to R14 when experiencing delusions. R14's other cognition care plan revised 4/8/24, identified R14 had a court commitment 11/16/23 through 5/22/24, and R14 had to follow up with primary care and psychiatry and take all prescribed medications including insulin. The care plan listed an intervention for resident services to contact appropriate case manager if there is a violation of the commitment or [NAME] order. Another cognition care plan regarding decision making skills revised 12/8/15, also listed R14 as refusing insulin. Interventions included 1:1 visits to re-direct and cue when making poor decisions as needed and as resident allows, and staff to petition for guardian if resident unable to make good decisions with assistance from staff, family, and case manager. R14's behavior care plan revised 11/22/22, identified R14 refused insulin and other diabetic medications since September 2015, doctor shopping to get one to agree with them, leaves appointments if provider attempts to challenge delusional beliefs, and takes insulin at hospital but chooses not to take medication when returns to facility. Interventions included house psychologist will see as needed and/or desired, medications per doctor order, nursing will monitor resident blood sugars per doctor order, and re-direct and cue resident. The potential for complications care plan revised 4/30/24, again identified R14 was noncompliant with insulin and blood sugar checks. Interventions included to administer medication as ordered, nursing to assess resident's resistance to treatment, nursing will encourage resident to express feelings and fears and clarify misunderstandings, nursing will involve doctor/family for continued refusals, and nursing will reiterate the purpose and advantages of treatment for the resident as appropriate to cognitive understanding. R14's injection administration record (AR) identified insulin degludec subcutaneous solution 100 unit/mL with directions to inject 25 unit subcutaneously one time a day at 7 p.m. and start date of 12/20/23. The February AR identified administration until 2/24/24, which was marked with an indicator for Drug Refused. The March AR identified the injection was refused. The April AR identified the injection as refused throughout the month. The AR indicated to check R14's blood sugar three times a day with start date of 7/9/21. The February AR identified blood sugar levels until 2/26/24, which was marked as refused for the rest of the month. The March AR identified one blood sugar level of 87 on 3/3/24 for 8:00 a.m The April AR did not indicate a blood sugar level and marked as refused throughout the month. The injection AR identified insulin aspart flexpen solution pen-injector 100 unit/mL with directions to inject eight units subcutaneously three times a day and hold until after R14 ate if blood sugar was under 90 and had a start date of 12/20/23. The February AR identified blood sugar levels and administration until 2/25/24. The March AR identified R14 refused the medication throughout the month, and the April AR indicated refusals throughout the month. The injection AR identified insulin aspart penfil solution cartridge 100 unit/mL with sliding scale parameters and to inject subcutaneously three times a day and further directions for six units with meals plus coverage. The order had a start date of 10/20/22. The February AR identified consistent refusals started 2/26/24. The March AR identified refusals throughout the month. 3/24/24 identified a blood sugar of 222 and administration of one unit for 8:00 a.m The April AR identified refusals throughout the month. R14's blood sugar report dated 5/2/24, identified blood sugar levels multiple times a day until 2/25/24. 222 mg/dL was recorded on 3/24/24 at 9:02 a.m R14's facesheet dated 5/3/24, indicated nurse practitioner (NP)-A as R14's primary physician. A behavior note dated 2/25/24 at 9:38 a.m., indicated R14 started refusing insulin 2/24/24. Writer explained R14 had a [NAME] order and had to send R14 to hospital if they did not take their insulin. Writer called DON and R14's parents to notify them R14 was transported to HCMC. The progress note did not indicate a medical provider was notified. A physician visit/call note dated 2/25/24 at 8:28 p.m., indicated R14 returned from HCMC emergency room at approximately 4:15 p.m R14's blood sugar was checked before supper and was at 87. R14 refused insulin after eating and stated their feet were cold and squishy because of the insulin and was not taking insulin until they see a doctor. HCMC indicated labs were drawn and identified to follow up with primary care provider (PCP) from M Health Fairview Clinic. The progress note did not indicate a medical provider was notified. A behavior note dated 2/26/24 at 11:01 a.m., indicated R14 refused all diabetic cares. The registered nurse (RN) educated R14 about diabetes mellitus and possible outcomes and symptoms of refusing diabetic cares. The RN told R14 to notify staff if R14 was having symptoms of a diabetic emergency. The progress note did not indicate a medical provider was notified. A general condition note dated 3/8/24 at 7:16 p.m. and indicated R14 continued to decline insulin and blood glucose checks. The progress note did not indicate a medical provider was notified. A behavior note dated 3/12/24 at 5:42 p.m., indicated R14 continued to refuse blood sugar checks and insulin and did not indicate a medical provider was notified. A general condition note dated 3/26/24 at 4:40 p.m., indicated R14 declined blood sugar checks and insulin and did not indicate a medical provider was notified. A physician visit/call note dated 4/17/24 at 7:56 a.m., indicated R14 cancelled primary provider appointment for 5/20/24 and scheduled an appointment with a different provider for 6/10/24. A behavior note dated 4/23/24 at 12:53 p.m., indicated R14 complained of dizziness and lethargy and declined to have vitals taken. R14 stated the insulin made her feet spongy and was tired and ill feeling. R14 stated they had a psych appointment in June and would likely schedule an appointment with a physician after then. R14 was looking for a provider who would not endorse insulin or diagnosis of diabetes. R14 stated they would not take insulin again as it has caused their health problems. The note did not indicate a medical provider was notified. A behavior note on 4/28/24 at 12:58 p.m., indicated R14 refused insulin, and the note did not indicate a medical provider was notified. The After Visit Summary from HCMC emergency department dated 2/25/24, indicated R14 should follow up with primary care provider (PCP) from M Health Fairview Clinic, and the resident was seen for delusions and noncompliance with diabetes treatment. R14's blood sugar was 301 mg/dL. A Nursing Home Visit Encounter note dated 3/5/24, indicated R14 had no recent acute care stays, was on a commitment with mental health, required ongoing observation and support with diabetes, and in denial of diabetes and neuropathy. NP noted R14's blood sugars had been stable and tend to be a little hyper glycemic and ranged from 87 to 243. R14 had no new concerns. NP noted Northern Lights Health will take over primary care provider relationship going forward and would follow-up for routine check-up, or sooner if needed. NP would monitor patient and work with nursing staff to work towards positive patient outcomes. During interview on 4/30/24 at 1:48 p.m., nursing assistant (NA)-A stated when resident refused cares, they reapproach for a total of three attempts and then report to the director of nursing (DON) or someone else higher up. NA-A stated there were target behaviors in the application they charted in, and R14 had history of refusing insulin. NA-A stated R14 was more comfortable now with allowing NA-A to help with cares and conversing. During interview on 4/30/24 at 2:58 p.m., licensed practical nurse (LPN)-B stated when residents refused cares or medications, staff reapproached and sometimes staff had to approach in a different way to assist the resident to comply. Behaviors and refusals were charted in progress notes or under a behavior tab in their charting system. If residents refused psych medications, they notified the psychiatrist right away, so they knew what was happening and talk about refusals and behaviors in their stand-up meetings as well. Notifications and responses should be documented in progress notes. LPN-B stated R14 did not believe they were diabetic, got angry when staff spoke about R14's diagnosis, and fires every doctor. LPN-B stated R14 was sick and tried to get R14 to comply with diabetic medications. LPN-B stated R14 had the nurse practitioner (NP) as a provider, but NP would not prescribe R14 medications if they do not see R14. R14 needed to see a doctor every 60 to 90 days, and 3/5/24 was the last time NP saw R14. R14 was agreeing to take their insulin and have blood sugar checks as R14 was on a [NAME] commitment but then stopped when R14 believed the insulin made their feet mushy and cold. R14 was sent to the hospital when R14 stopped taking insulin, and the hospital sent R14 back to the facility and stated R14's [NAME] was not for insulin and only psychiatric medications and concerns. R14 stopped taking their insulin and blood sugars after they returned from the emergency room. LPN-B stated NP was aware of the insulin and blood sugar refusals. During observation on 5/2/24 at 8:19 a.m., R14 was sitting in the main dining area with beverages and breakfast. R14 was asked if their blood sugar could be checked, and R14 declined and stated the DON should have told you. During interview on 5/2/24 at 9:15 a.m., the NP stated they followed R14 every three months for compliance and started to see R14 around November 2023. The NP was aware R14 went back and forth with providers and would generally have residents choose which provider they wanted to visit. NP was at facility on Tuesdays and would attempt to see R14 three times per month. NP stated they send their after-visit notes to the facility's medical records employee. NP stated staff would either call them or place a note in their communication book if there were concerns with residents. NP stated staff should make them aware of refusals after a couple days and hadn't been notified R14 was not taking insulin or checking blood sugars. NP believed R14 had an order to send R14 to the hospital if they would not take their insulin, and R14 had a psychiatric issue which affected their health. NP stated they should have been notified to assist to develop a plan for R14's refusals. NP stated R14 was at risk for hyperglycemia, diabetic coma, and many systemic failures. NP reviewed their last visit note in March 2024, which did not note R14's insulin and blood sugar refusals. NP stated R14 had not been to the hospital since they started following R14 and would expect to be notified if R14 went to the hospital. NP reviewed R14's emergency room visit from February 2023 and stated they should know some of those things that are happening. During interview on 5/2/24 at 3:25 p.m., the DON expected staff to notify providers about changes with residents, such as medication and other refusals, as soon as possible. Not notifying the provider timely could affect residents' wellbeing, since residents were on their medications for a reason. During another interview on 5/2/24 at 5:54 p.m., the DON stated R14 did not have a primary provider at this time, since R14 tried to establish with one provider and then went to another. DON expected staff to speak with the medical director (MD) as back up when residents were between providers. DON believed MD was aware of R14 but had not consulted with R14. During follow-up interview on 5/2/24 at 6:14 p.m., the DON stated R14 did not give consent to be seen by anyone from Hennepin Health Care, which the MD was affiliated with. During interview on 5/2/24 at 6:35 p.m., the MD was not aware of R14's consistent refusals of blood sugars and insulin and the multiple changes of providers. MD stated they would want to be notified of situations such as this to assist in finding a primary provider for the resident and figure out a solution for R14's medication refusals, such as suggestions for oral diabetic management. MD stated they did not know how severe R14's diabetes was but possible complications from chronically not taking diabetic medications were hyperglycemia, diabetic ketoacidosis (DKA; a complication of diabetes in which acids build up in the blood to levels which can be life-threatening), and hyperglycemic coma. The facility's policy Medication Refusal by Resident dated August 2023, directed staff to report to the ordering physician when medications refused for more than three days. The facility's policy Acute Change in Condition- Emergency Procedure dated August 2023, directed call the doctor if resident exhibited a sudden decrease in ability to care for self and if resident had a change in mental status or level of consciousness. Staff were to call the on-call doctor if unable to reach the primary physician. If the on-call doctor was not available, staff were to call the medical director. If the resident was in acute distress or lost consciousness, staff were to call 911.

Based on interview and document review, the facility failed to ensure 2 of 2 residents (R47 and R 53)'s grievances were documented, responded to and resolved in a timely manner. Findings include: R47's 2/23/24 quarterly Minimum Data Set (MDS) assessment identified his cognition was intact, and he had behaviors which included hallucinations, delusions, and verbal behavior directed toward others. He had diagnoses which included Schizophrenia, major depressive disorder, dependent personality disorder, and obsessive compulsive disorder (OCD). R47 was independent with activities of daily living (ADLs), but needed redirection and cueing to correct daily routines. R47's current undated care plan identified target behaviors of hallucinations, thought blocking delusions, paranoia and disorganized thinking. Interventions included validation when he expressed delusional content, Associated Clinic of psychology (ACP) services weekly and as needed (PRN), 1:1 visits to allow R47 to vent his feelings. Medications as ordered, with monitoring for side effects and effectiveness. Observation/interview on 4/29/24 at 3:20 p.m. with R47 as he sat in a wheel chair facing the wall with the curtain divider pulled between the two beds. R47 verbalized acceptance to being interviewed, reported he was not concerned that his room mate was in the room, and was offered to use a different location. R47 began answering questions and reported he had no issues with other residents, felt safe, and had not been abused in any way. He then reported he was done and did not want to answer any more questions, laid back on his bed and closed his eyes. R53's 2/9/24 quarterly MDS identified his cognition was intact, he was independent with ADLS and had behaviors identified as hallucinations, delusions, and self isolation due to pain. He had diagnosis of Complex Regional pain syndrome (a chronic condition that causes severe, debilitating pain in an arm, hand, leg or foot after an injury), major depressive disorder, low back pain, anorexia, prediabetes, and history of suicidal ideations with no current plan. R53 was able to direct his own care and chose if he wanted to move around in the facility or remain in his room based on his level of pain. R53's current undated care plan identified psychotropic medication usage with Interdisciplinary Team (IDT) monitoring for effectiveness and any side effects to be completed quarterly and PRN. R53 reported he had an intrathecal pain pump (a surgically implanted device that delivers medication into the spinal fluid to treat chronic pain or spasticity). The device was managed by his pain clinic who provided maintenance and refilled the device. Observation/Interview on 4/29/24 at 3:40 p.m., with R53 who was lying on his bed with the divider curtain closed around his bed. The TV was on and R53 lowered volume and agreed to interview. During interview the TV on R53's side of the room, changed channels and the volume increased. R53's TV remote was lying on the bed beside him, and he was observed not touching the control. R53 reported this happened all the time, especially if R47 was upset with him and would change channels or adjust the volume with his control. R53 reported R47 liked to follow where ever he went and identified he had even recorded a previous incident when R47 was yelling and made allegation that R53 had beat on him. R53 reported he had asked R47 to clean up after himself in the bathroom after smearing BM all over the the toilet seat, and R47 had become upset and started yelling. He reported he had never touched R47 and would not do so. He stated he was fearful he would be in trouble due to R47 making allegations. R53 reported he had informed multiple staff (unable to identify who he had spoken with), about his concerns and had requested a room change, but no one had ever gotten back to him, or offered to file a grievance or report about his concerns. R53 also stated due to his physical condition he liked the room cooler, and R47 was always complaining the room was too cold. The temperature was observed set a 74 degrees, and R53 reported he had actually turned the thermostats up, to 74 but R47 was still not satisfied, and complained the room was to cold. Interview on 4/30/24 at 1:47 p.m. with LPN-B reported she was aware of the requirement for reporting of any abuse, or mistreatment and also the grievance process. She reported she was not aware of the verbal issues between R47 and R53 and would investigate further. She reported she was aware there had been some concern about cleanliness of the shared bathroom but the facility had hired a new cleaning service and she thought it would be better. LPN- reported she would also update the social worker and director of nursing of the concerns, but was not aware of any grievance forms completed by staff or residents. Interview on 4/30/24 at 2:47 p.m. with the licensed social worker (LICSW) reported resident room assignments were made dependent on bed availability and if any room changes were indicated. The LICSW reported if problems/concerns developed between room mates it was discussed at the interdisciplinary meeting (IDT) and work to make changes as they were able. She further reported it was difficult due to the number of residents and number of beds available. She reported she was aware of some conflict between R47 and R53, but had not provided a grievance form or offered to assist in completing one. Interview on 5/1/24 at 1:00 p.m., interview with R 53 reported licensed practical nurse (LPN)-B had come and spoke with him and either he or his room mate were going to be separated and he was glad about that. Stated following lunch he had placed his call light cord over the wall unit to enable him to reach it, and R47 had grabbed it and thrown it on the floor. He reported he told R47 he was not able to get it if it was on the floor. R53 reported when he went downstairs for his medication he had asked the nurse passing meds to talk with R47 about the call light and she had done so. R53 reported R47 had left the call light alone after that, but had been continuously complaining the room was too cold. Review of the 4/29/24 at 10:37 a.m., Progress notes identified R53 had talked about issues with his roommate, reported he followed him when he left his room, put on the same TV station and then turn up the volume. R53 reported he tried to ignore him, but R53 reported he thought R47 did those things just to aggravate him. R53 reported he liked his room and didn't want to move so he just tolerated R47. Interview on 5/1/24 at 1:30 p.m. with the director of nursing (DON) reported she was aware the facility had a grievance policy, but was not aware of any grievances or concerns voiced between R47 and R53. She was not able to provide either a log of grievances or a policy which had been requested and was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure allegations of potential abuse were reported to the administrator and State Agency (SA) immediately, but not later than 2 hours after the allegation is made, for 1 of 1 residents (R45) reviewed for resident-to-resident verbal altercation. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication dated 7/7/23, indicated R28 had loose associations and was being treated with medications for active delusional symptoms. R28's CAA for psychosocial well-being dated 7/7/23, indicated he had a long-standing diagnosis of schizophrenia and had been treated over the years for his symptoms, which had impacted his communication. The CAA indicated other disciplines were working with R28 for improvement with staff interventions in place to address his psychosocial well-being. R28's care plan dated 10/27/20, indicated tangential speech that did not make sense as evidence by R28 responding to internal stimuli and becoming paranoid over the TV/radio and believing he is being harassed. Interventions identified by the care plan included providing medications as ordered, redirection and cueing. The care plan also indicated R28 had verbally abusive behaviors and identified that he was short-tempered with staff peers, and strangers. The care plan identified behaviors such as cussing and yelling at other residents in R28's way. The care plan listed interventions of contacting a mobile crisis unit, administering medications as ordered, and updating his psychiatrist and case manager of behaviors. A progress note dated 3/27/24, indicated the interdisciplinary team (IDT) met to discuss R28's behaviors after peers complaints related to inappropriate comments and yelling to other residents. The progress note indicated staff needed to make attempts to redirect R28 when he was yelling or screaming at other residents. The progress note lacked documentation of any specific incident or if a grievance was offered or filed in relation to R28's behaviors. A progress note dated 4/3/24, indicated R28 had been very abusive towards staffs and other residents. He was at some point found using the 'N' word in the dining area. The progress note lacked indication of a grievance being offered or filed. A social service MDS progress note dated 4/3/24, indicated R28 had a history of aggressive behaviors towards other residents. The progress note indicated during a nurse interview, R28 was reported to be at his baseline and continued verbal aggression towards staff and residents. Furthermore, the progress note indicated during a nursing assistant (NA) interview R28 had been verbally aggressive towards certain residents. On 4/30/24 at 8:52 a.m., R28 was not available for interview. On 4/30/24 at 9:14 a.m., R28 was not available for interview. R45's admission MDS dated [DATE], indicated intact cognition with adequate hearing, the ability to make herself understood and to understand others. MDS indicated no hallucinations or delusions and no behavioral symptoms directed towards self or others. R45's diagnoses included anxiety, bipolar disorder, and post-traumatic stress disorder (PTSD, or a disorder that can bring back memories of a traumatic experience accompanied by intense emotional and physical reactions). R45's care plan lacked documentation of a focus, goal, and interventions to keep her safe from the potential for abuse, neglect and/or exploitation. A review of R45's progress notes did not reveal any documented complaints by R45. During interview on 4/29/24 at 4:53 p.m., R45 stated there was another resident who was verbally confrontational with her. R45 stated one resident, R28, made racist and sexist comments towards her. R45 stated R28 called her a black cunt bitch, and had used racial slurs, such as the N word, when referring to her and other residents of color. R45 stated she felt R28 was directing what he was saying towards her and other residents because of the racial and sexist connotations. She stated his words felt disrespectful and abusive. R45 stated she reported R28 to staff and felt they gave the name calling a go-pass and brushed it under the rug. She stated no staff had follow up with her, offered to file a grievance, or provided a phone number for her to make a formal complaint. R45 stated she brought this up on multiple occasions, including at her first care conference. She stated she felt hurt by R28's comments and it felt like a disservice to her. Additionally, she stated it did not feel fair that staff knew about the situation and had not done anything to protect her or the other residents. A care conference progress note dated 3/27/24, lacked documentation of complaints or reported behaviors by R45. During interview on 4/29/24 at 6:36 p.m., the administrator denied being aware of any complaints from R45 but stated that may be due to his short-term presence in the facility. The administrator stated if staff heard something like that, they would report it. The administrator stated R28 was always grumbling about something to everyone. He's just a grumpy old man. A review of Aspen Complaints/Incidents Tracking System (ACTS) on 4/30/24 at approximately 11:00 a.m., did not reveal reported events regarding R45's complaints. R45 declined further interview on 5/1/24 at 11:17 a.m., and on 5/2/24 at 11:29 a.m. During interview on 4/30/24 at 1:30 p.m., the administrator stated some issues needed to be reported within 24 hours and other issues where there was no physical harm or altercation could be reported within five days. The administrator stated during a recent standup meeting, the team discussed that if in doubt, it would be better to over-report than to not report. The administrator verified other staff, including the director of nursing (DON), were aware of the incident prior to 4/29/24. The administrator stated the facility should take R45's complaints seriously, but after collaboration with the IDT, did not feel the resident-to-resident verbal altercation was reportable. The administrator stated LPN-B talked to R45 and provided reassurance and apologized. When asked to describe the investigation process, the administrator stated there was not a formal process until the team collaborated and decided if the incident was reportable or not. If the incident was deemed reportable, then the investigation would become more of a formal process. The administrator stated staff were really good about monitoring for potential or actual reported allegations of abuse by reviewing incidents from each resident throughout the shift and either reporting them or bringing them up during standup meetings. The administrator stated the DON was responsible for supervising and monitoring bedside care delivery. During interview on 4/30/24 at 2:15 p.m., activities staff (AS)-A verified becoming aware of R45's complaint about R28's verbal behaviors during her care conference. AS-A stated R45's complaint was what prompted the IDT meeting to address R28's behaviors and interventions. AS-A stated what was discussed would be shared under the communications tab in Point Click Care (PCC) and all staff should be checking that daily. Additionally, AS-A stated the information from the IDT meeting was shared during daily standup meetings and managers were responsible for sharing that information to their shift. AS-A stated the incident was addressed with R45 and R28's interventions were documented in his care plan. AS-A stated it was difficult to determine if R45's behavior changed after the incident since she was a newer admission to the facility. AS-A stated R28's baseline behavior was sitting in a general area and, making slurs about whoever is passing by. AS-A stated if a problem is brought to staff's attention, the first step is to get the full report either from a progress note or from a verbal report. AS-A stated most of the time it goes to social services (SS), who would determine if it was reportable. If the incident was reportable, SS would make the report. AS-A stated the most recent abuse identification, prevention, and reporting requirement training was completed last January. During interview on 4/30/24 at 2:52 p.m., NA-A stated R45 reported R28 made unprovoked racist comments towards her about a month ago and it really had her down. NA-A stated the incident was reported to the charge nurse on duty. NA-A was unaware of recent abuse training, but stated, if you see something, say something so things don't escalate beyond that. During interview on 4/30/24 at 3:26 p.m., LPN-B verified being aware of the incident and stated, I became aware of the situation because she came and told me after it happened. LPN-B stated, I did what I was supposed to do, and stated the incident was reported to SS during that morning's standup meeting. LPN-B stated if there were concerns for abuse, staff should never worry about being wrong and need to report incidents. LPN-B stated for instances with physical contact, a report needed to be made within 24 hours. During interview on 5/1/24 at 9:43 a.m., SS-A stated if there was serious injury, an event would need to be reported immediately or within an hour. If no serious injury occurred, it should be reported within 24 hours. SS-A stated the investigative process included gathering details, talking to the administrator and DON, and moving forward to report the event if it was deemed reportable. SS-A verified being aware of the incident involving R28 and R45 during risk management after R45's care conference. SS-A stated interventions were aimed at R28's behaviors and how staff should be attentive to him. SS-A stated R45's complaint was not documented in the care conference note nor was it brought up as a resident-specific complaint. SS-A stated R45's complaint was not reported because it was brought up as more as a general concern and not a resident-specific complaint. During interview on 5/1/24 at 1:17 p.m., LPN-A stated after gathering the details of a resident's complaint or concern, I would get social services involved. LPN-A stated most residents come to staff directly with concerns. During off-hours, if a resident had a complaint or concern, LPN-A stated the expectation was to document the issue in a progress note or in the communications tab in PCC under that specific resident. If the issue was urgent, LPN-A stated staff were expected to contact the on-call manager. If a resident complained about another resident making offensive comments, LPN-A stated, I would probably speak to both of them to determine what was going on, document that and then get SS involved. LPN-A stated incidents involving physical aggression needed to be reported within 24 hours but was unsure about other types of reportable events. During interview on 5/2/24 at 12:26 p.m., the DON stated when a resident had a complaint, staff should first determine if it involved a safety issue that needed to be addressed immediately. If not, the DON stated a grievance form could be filled out. The DON stated, when the grievance form is filled out, it can be discussed amongst the departments involved and we can resolve it. The DON stated the expectation was for staff to document what the situation was and what interventions were provided. The DON stated the key was to make sure the resident felt reassured even after reporting an incident, staff should ensure the resident received the help they needed and followed up. A facility policy titled Vulnerable Adult Information last updated 6/23/17, indicated the facility's objective was to assure protection of each resident from possible maltreatment. The policy indicated any situation where you have reason to believe a vulnerable adult is being or has been mistreated is a situation to report. Furthermore, the policy identified with any suspicion of a vulnerable adult incident a staff member shall inform their supervisor and/or charge nurse, the director of resident services, director of nursing, MDS coordinator, and/or therapeutic recreation director. Additionally, the policy directed staff to call [PHONE NUMBER] to make a verbal report. The policy also indicated staff should immediately make the initial report at the SA website and to the administrator. A facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/21/23, identified abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy indicated instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse and mantal abuse including abuse facilitated or enabled through the use of technology. Furthermore, the policy defined verbal abuse as the use or oral, written or gestured language that willfully includes disparaging and derogatory terms to resident and families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy indicated the purpose was to ensure all residents that live at the Birchwood Care Home (BCH) and Grand Avenue Rest Home (GARH) are protected from any and all abuse, neglect, misappropriate of resident property, exploitation, and harm in accordance with federal law and state statute that they maintain the highest practical physical, mental and psychosocial well-being of each resident. The policy indicated it was the policy of BCH and GARH that all reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy advised the designated facility personnel will begin the investigation immediately. For an investigation of abuse, when an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include the following key elements: a. Who was involved? b. resident statements - for non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to interaction and document findings. c. Resident's roommate statements, if possible. d. Involved staff and witness statements of events. e. A description of the resident's behavior and environment at the time of the incident. f. Injuries present. g. Observation of resident and staff behaviors during the investigation. h. Environmental considerations. The policy indicated the resident(s) will be protected from the alleged offender(s) and immediately upon receiving a report of abuse, neglect and/or harm, the administrator (or designee) will coordinate delivery of appropriate medical and/or psychological care as well as any attention needed to provide for the safety of other residents. The policy indicated the guidelines were to immediately remove the resident from the situation, examine and interview the resident to ensure proper documentation of any injury. If the resident could be at risk in the same environment, the policy indicated staff should evaluate the situation and consider some options including a room change, roommate change and/or risks of resident self-abuse. The policy indicated the resident and/or representative should be notified of the completion of the investigation and whether the incident was substantiated. Information would be provided according to the agency policy and guidelines. The policy identified that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source misappropriate of resident property) are reported per federal and state law and the facility will ensure that all alleged violations involving abuse are reported immediately. Employees will report the above examples immediately to their supervisor or person in charge and reports would be made to the administrator and other individuals as identified, including state agency in accordance with state and federal law. The policy includes reporting timelines for what to report, to whom, and when to report. The policy guides any covered individual (including the owner, operator, employee, manager, and agency or contractor of the facility) to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the facility administrator and to the other officials in accordance with State law, including the State Survey Agency (SA) and the adult protective services where state law provides jurisdiction in long-term care facilities. The policy indicated staff must report all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure allegations of resident-to-resident verbal abuse were thoroughly investigated, and protection provided for 1 of 1 residents (R45) who were involved in a resident-to-resident verbal altercation by R28. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate impairment with tasks of daily life, fluctuating inattention behaviors, continuous disorganized thinking, and no altered level consciousness. R28's MDS indicated he was usually able to make himself understood and was able to understand others. MDS indicated R28 experienced hallucinations and delusions and displayed verbal behaviors directed towards others in addition to other behavioral symptoms not directed towards others. MDS indicated R28 did not have physical behavioral symptoms director towards others. R28's diagnoses included schizophrenia and anxiety. R28's Care Area Assessment (CAA) for communication dated 7/7/23, indicated R28 had loose associations and was being treated with medications for active delusional symptoms. R28's CAA for psychosocial well-being dated 7/7/23, indicated he had a long-standing diagnosis of schizophrenia and had been treated over the years for his symptoms, which had impacted his communication. The CAA indicated other disciplines were working with R28 for improvement with staff interventions in place to address his psychosocial well-being. R28's care plan dated 10/27/20, indicated tangential speech that did not make sense as evidence by R28 responding to internal stimuli and becoming paranoid over the TV/radio and believing he is being harassed. Interventions identified by the care plan included providing medications as ordered, redirection and cueing. The care plan also indicated R28 had verbally abusive behaviors and identified that he was short-tempered with staff peers, and strangers. The care plan identified behaviors such as cussing and yelling at other residents in R28's way. The care plan listed interventions of contacting a mobile crisis unit, administering medications as ordered, and updating his psychiatrist and case manager of behaviors. A progress note dated 3/27/24, indicated the interdisciplinary team (IDT) met to discuss R28's behaviors after peers complaints related to inappropriate comments and yelling to other residents. The progress note indicated staff needed to make attempts to redirect R28 when he was yelling or screaming at other residents. The progress note lacked documentation of any specific incident or if a grievance was offered or filed in relation to R28's behaviors. A progress note dated 4/3/24, indicated R28 had been very abusive towards staffs and other residents. He was at some point found using the 'N' word in the dining area. The progress note lacked indication of a grievance being offered or filed. A social service MDS progress note dated 4/3/24, indicated R28 had a history of aggressive behaviors towards other residents. The progress note indicated during a nurse interview, R28 was reported to be as his baseline and continued verbal aggression towards toward staff and residents. Furthermore, the progress note indicated during a nursing assistant (NA) interview R28 had been verbally aggressive towards certain residents. On 4/30/24 at 8:52 a.m., R28 was not available for interview. On 4/30/24 at 9:14 a.m., R28 was not available for interview. During observation on 4/30/24 at 3:03 p.m., R28 walked down the hallway towards the smoking lounge. He used the handrail as he walked and was talking to himself out loud. When approached, R28 was mumbling to himself and was unable to be understood. He continued walking and went out into the smoking lounge to smoke a cigarette. At 3:13 p.m., R28 remained in the smoking lounge with his head down. During observation on 5/1/24 at 2:13 p.m., R28 was standing at the nurse's station, yelling through the glass at staff, where are my goddamn cigarettes? Unidentified staff told R28 they did not have his cigarettes. The administrator walked out of his office and followed R28 as he walked away from the nurse's station and through the dining area to the recreation room. The administrator asked R28 if there was something he needed help with. R28 walked away from the recreation room and into the bathroom. At 2:23 p.m., R28 walked back through the dining room without further verbal behaviors. R45's admission MDS dated [DATE], indicated intact cognition with adequate hearing, the ability to make herself understood and to understand others. MDS indicated no hallucinations or delusions and no behavioral symptoms directed towards self or others. R45's diagnoses included anxiety, bipolar disorder, and post-traumatic stress disorder (PTSD, or a disorder that can bring back memories of a traumatic experience accompanied by intense emotional and physical reactions). R45's care plan lacked documentation of a focus, goal, and interventions to keep her safe from the potential for abuse, neglect and/or exploitation. A review of R45's progress notes did not reveal any documented complaints or reported grievances by R45. During interview on 4/29/24 at 4:53 p.m., R45 stated there was another resident who was verbally confrontational with her. R45 stated one resident, R28, made racist and sexist comments towards her. R45 stated R28 called her a black cunt bitch, and had used racial slurs, such as the N word, when referring to her and other residents of color. R45 stated she felt R28 was directing what he was saying towards her and other residents because of the racial and sexist connotations. She stated his words felt disrespectful and abusive. R45 stated she reported R28 to staff and felt they gave the name calling a go-pass and brushed it under the rug. She stated no staff had follow up with her, offered to file a grievance, or provided a phone number for her to make a formal complaint. R45 stated she brought this up on multiple occasions, including at her first care conference. She stated she felt hurt by R28's comments and it felt like a disservice to her. Additionally, she stated it did not feel fair that staff knew about the situation and had not done anything to protect her or the other residents. A care conference progress note dated 3/27/24, lacked documentation of complaints or reported behaviors by R45. During interview on 4/29/24 at 6:36 p.m., the administrator denied being aware of any complaints from R45 but stated that may be due his short-term presence in the facility. The administrator stated if staff heard something like that, they would report it. The administrator stated R28 was always grumbling about something to everyone. He's just a grumpy old man. During interview on 4/30/24 at 1:18 p.m., R45 stated she was nervous about having reported the incident. R45 stated she feared getting into trouble because she was newer to the facility. R45 stated licensed practical nurse (LPN)-B spoke with her earlier about the incident and felt like LPN-B was trying to smooth it over. R45 declined further interview on 5/1/24 at 11:17 a.m., and on 5/2/24 at 11:29 a.m. During interview on 4/30/24 at 1:30 p.m., the administrator stated some issues needed to be reported within 24 hours and other issues where there was no physical harm or altercation could be reported within five days. The administrator stated during a recent standup meeting, the team discussed that if in doubt, it would be better to over-report than to not report. The administrator verified other staff were aware of the incident involving R28 and R45 prior to 4/29/24. The administrator acknowledged the facility should take R45's allegations seriously, but stated after collaboration with the IDT, determined it was not reportable. The administrator stated LPN-B talked to R45 and provided reassurance and apologized. When asked to describe the investigation process, the administrator stated there was not a formal process until the team collaborated and decided if the incident was reportable or not. If the incident was deemed reportable, then the investigation would become more of a formal process. The administrator stated staff were really good about monitoring for potential or actual reported allegations of abuse by reviewing incidents from each resident throughout the shift and either reporting them or bringing them up during standup meetings. The administrator identified interventions to protect R45 as watching R28, and stated, we all just watch R28. If I hear or see R28 having any interaction with someone, I'm watching him and others. We have to constantly watch all of the residents. During interview on 4/30/24 at 2:15 p.m., activities staff (AS)-A verified becoming aware of R45's complaint about R28's verbal behaviors during her care conference. AS-A stated R45's complaint was what prompted the IDT meeting to address R28's behaviors and interventions. AS-A stated what was discussed would be shared under the communications tab in Point Click Care (PCC) and all staff should be checking that daily. Additionally, AS-A stated the information from the IDT meeting was shared during daily standup meetings and managers were responsible for sharing that information to their shift. AS-A stated the incident was addressed with R45 and R28's interventions were documented in his care plan. AS-A was unable to locate documentation of R45's allegations in her electronic health record (EHR). AS-A stated, R28 always escalates, and our decision was to verbally intervene but then he immediately went to the hospital, so we never got a chance to try out interventions. He just got back not too long ago so it might not seem to R45 like we've really done anything. AS-A stated it was difficult to determine if R45's behavior changed after the incident since she was a newer admission to the facility. AS-A stated R28's baseline behavior was sitting in a general area and, making slurs about whoever is passing by. AS-A stated if a problem is brought to staff's attention, the first step is to get the full report either from a progress note or from a verbal report. AS-A stated most of the time it goes to social services (SS), who would determine if it was reportable. If the incident was reportable, SS would make the report. AS-A stated the most recent abuse identification, prevention, and reporting requirement training was completed last January. During interview on 4/30/24 at 2:52 p.m., NA-A stated R45 reported R28 made unprovoked racist comments towards her about a month ago and it really had her down. NA-A stated the incident was reported to the charge nurse on duty, LPN-B. NA-A was unaware of recent abuse training, but stated, if you see something, say something so things don't escalate beyond that. During interview on 4/30/24 at 3:26 p.m., LPN-B verified being aware of the incident and stated, I became aware of the situation because she came and told me after it happened. LPN-B stated, I did what I was supposed to do, and stated the incident was communicated to SS during that morning's standup meeting. LPN-B verbalized be unsure if the incident was reported and stated, I just know that I told them. LPN-B stated if there were concerns for abuse, staff should never worry about being wrong and need to report incidents. LPN-B stated for instances with physical contact, a report needed to be made within 24 hours. LPN-B identified interventions to de-escalate R28's behaviors and stated, if we can't get him out of the area, we get other people out of the area to make sure everyone else is okay and safe. During interview on 5/1/24 at 9:43 a.m., SS-A stated if there was serious injury, an event would need to be reported immediately or within an hour. If no serious injury occurred, it should be reported within 24 hours. SS-A stated the investigative process included gathering details, talking to the administrator and DON, and moving forward to report the event if it was deemed reportable. SS-A verified being aware of the incident involving R28 and R45 during risk management after R45's care conference. SS-A stated interventions were aimed at R28's behaviors and how staff should be attentive to him. SS-A stated R45's complaint was not documented in the care conference note nor was it brought up as a resident-specific complaint. SS-A stated R45's complaint was not reported because it was brought up as more as a general concern and not a resident-specific complaint. During interview on 5/1/24 at 1:17 p.m., LPN-A stated for grievances or complaints, I would get social services involved. LPN-A stated most residents come to staff directly with concerns. During off-hours, if a resident had a complaint or concern, LPN-A stated the expectation was to document the issue in a progress note or in the communications tab in PCC under that specific resident. If the issue was urgent, LPN-A stated staff would be expected to contact the on-call manager. If a resident complained about another resident making offensive comments, LPN-A stated, I would probably speak to both of them to determine what was going on, document that and then get SS involved. LPN-A stated incidents involving physical aggression needed to be reported within 24 hours but was unsure about other types of reportable events. During interview on 5/2/24 at 12:26 p.m., the DON stated the grievance process was to get the complaint, fill out the grievance form and if it needed to be addressed immediately, we would want to address that immediately. The DON stated, when the grievance form is filled out, it can be discussed amongst the departments involved and we can resolve it. The DON stated the expectation was for staff to document what the situation was and what interventions were provided. The DON stated the key was to make sure the resident felt reassured even after reporting an incident, staff should ensure the resident received the help they needed and followed up. During interview on 5/2/24 at 3:25 p.m., SS-A stated there was an anonymous box in the hallway with papers that were always stocked for residents to make grievances or formal complaints. SS-A stated residents were reminded of this during resident council. SS-A stated residents can either file a grievance or speak to SS directly. SS-A stated when a grievance form was received, it was reviewed and distributed to the related department. SS-A stated the department manager was responsible for proposing a resolution and after review by the team, it was proposed to the resident for approval. If the resident felt the resolution was an appropriate solution to the problem, it would then go to the administrator for implementation. SS-A stated the process for anonymous grievances would be the same without the review process by the resident. SS-A stated if the grievance was related to an abuse claim, it would be discussed in IDT and brought to the administrator and DON to discuss the next actions. A facility policy titled Vulnerable Adult Information last updated 6/23/17, indicated the facility's objective was to assure protection of each resident from possible maltreatment. The policy indicated any situation where you have reason to believe a vulnerable adult is being or has been mistreated is a situation to report. Furthermore, the policy identified with any suspicion of a vulnerable adult incident a staff member shall inform their supervisor and/or charge nurse, the director of resident services, director of nursing, MDS coordinator, and/or therapeutic recreation director. Additionally, the policy directed staff to call [PHONE NUMBER] to make a verbal report. The policy also indicated staff should immediately make the initial report at the SA website and to the administrator. A facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/21/23, identified abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy indicated instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish and includes verbal abuse, sexual abuse, physical abuse and mantal abuse including abuse facilitated or enabled through the use of technology. Furthermore, the policy defined verbal abuse as the use or oral, written or gestured language that willfully includes disparaging and derogatory terms to resident and families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy indicated the purpose was to ensure all residents that live at the Birchwood Care Home (BCH) and Grand Avenue Rest Home (GARH) are protected from any and all abuse, neglect, misappropriate of resident property, exploitation, and harm in accordance with federal law and state statute that they maintain the highest practical physical, mental and psychosocial well-being of each resident. The policy indicated it was the policy of BCH and GARH that all reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to determine what happened. The policy advised the designated facility personnel will begin the investigation immediately. For an investigation of abuse, when an incident or suspected incident of abuse is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include the following key elements: a. Who was involved? b. resident statements - for non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to interaction and document findings. c. Resident's roommate statements, if possible. d. Involved staff and witness statements of events. e. A description of the resident's behavior and environment at the time of the incident. f. Injuries present. g. Observation of resident and staff behaviors during the investigation. h. Environmental considerations. The policy indicated the resident(s) will be protected from the alleged offender(s) and immediately upon receiving a report of abuse, neglect and/or harm, the administrator (or designee) will coordinate delivery of appropriate medical and/or psychological care as well as any attention needed to provide for the safety of other residents. The policy indicated the guidelines were to immediately remove the resident from the situation, examine and interview the resident to ensure proper documentation of any injury. If the resident could be at risk in the same environment, the policy indicated staff should evaluate the situation and consider some options including a room change, roommate change and/or risks of resident self-abuse. The policy indicated the resident and/or representative should be notified of the completion of the investigation and whether the incident was substantiated. Information would be provided according to the agency policy and guidelines. The policy identified that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source misappropriate of resident property) are reported per federal and state law and the facility will ensure that all alleged violations involving abuse are reported immediately. Employees will report the above examples immediately to their supervisor or person in charge and reports would be made to the administrator and other individuals as identified, including state agency in accordance with state and federal law. The policy includes reporting timelines for what to report, to whom, and when to report. The policy guides any covered individual (including the owner, operator, employee, manager, and agency or contractor of the facility) to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the facility administrator and to the other officials in accordance with State law, including the State Survey Agency (SA) and the adult protective services where state law provides jurisdiction in long-term care facilities. The policy indicated staff must report all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R14 R14's annual Minimum Data Set (MDS) dated [DATE], indicated R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had diagnoses of schizophrenia and depression. Further, the MDS under section I, I6100, lacked a check mark indicating R14 had post-traumatic stress disorder (PTSD). R14's quarterly MDS dated [DATE], indicated R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had diagnosis of schizophrenia. Further, the MDS under section I, I6100, lacked a check mark indicating R14 had PTSD. R14's cognition care plan related to psychosis and delusions and behavioral care plan related to delusions revised 12/8/19, indicated R14 had schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. R14's annual social service MDS documentation dated 8/18/23 at 3:01 p.m., indicated R14 had diagnoses of schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. A Nursing Home Visit Encounter with R14's nurse practitioner dated 3/5/24, indicated R14 had schizophrenia, PTSD, major depressive disorder, among other diagnoses. R14's Face Sheet indicated the following diagnoses: schizophrenia with a date of onset on 8/19/15, major depressive disorder with a date of onset on 8/19/15, PTSD with a date of onset on 8/19/15, among other diagnoses. During interview on 4/30/24 at 1:48 p.m., nursing assistant (NA)-A stated their charting identified triggers and behaviors for residents. NA-A reviewed R14's target behaviors were refusing insulin and carrying belongings. NA-A reviewed R14 had no information on triggers of trauma. NA-A stated R14 believed people were trying to do things to them like poison them. NA-A stated R14 was more comfortable with them now and allowed NA-A to help with cares when needed compared to when NA-A was a newer employee. During interview on 4/30/24 at 2:58 p.m., registered nurse (RN)-C stated staff gave each other report between shifts on resident behavior and interventions completed in response. Besides report, the medical record had a communications area where they could record such information. RN-C stated care plans showed behavior plans for residents. During same interview on 4/30/24 at 2:58 p.m., licensed practical nurse (LPN)-B stated they believed R14 was abused and spoke about someone stalking them and was frightened and jumpy at times thinking someone was watching them. LPN-B stated residents had care plans related to trauma if they were open enough to talk about it, or residents' care plans reflected staff observations. LPN-B said the social work or MDS nurse completed trauma-based assessments. During interview on 5/2/24 at 9:53 a.m., the social worker (SW)-A stated R57 had PTSD. SW-A reviewed the care plan and stated R14 did not have specific information related to PTSD like triggers. During interview on 5/2/24 at 10:43 a.m., RN-B stated they completed the MDS including section I and utilized the form Medical Diagnosis, in the electronic medical record (EMR) to determine diagnoses for the MDS and stated R14 had schizophrenia, PTSD, major depressive disorder, among others. RN-B further stated only the diagnoses being treated or had orders to treat, such as medications or treatments, were incorporated on the MDS and stated R14 had PTSD but was not being treated for it and further stated PTSD was something the facility could care plan, such as what the symptoms and triggers were. During interview on 5/2/24 at 3:05 p.m., the director of nursing stated they expected PTSD diagnosis to be included on the MDS and expected staff to look at all the notes for diagnoses and stated it was important to have an accurate MDS in order to know what they are treating and managing. A policy, Interdepartmental MDS Review, dated August 2023, indicated each resident's MDS would be completed on admission, quarterly, annually, and significant change using current, accurate documentation and assessments specific to that resident. The interdisciplinary team (IDT) would review and discuss each resident during the 7 days assessment period and provide information, documentation and assessments they have from the prospective of their area of expertise. Discussions and evaluations of each resident were done for the purpose of identifying possible areas of conflict of information and to ensure accuracy of the completion of the MDS. The IDT will review the reports prepared by the resident's physicians, house psychologist and all other sources available to determine what and how the information will be used in the MDS process. Further, nursing was responsible for completion of section I of the MDS plus care area assessments triggered. Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident's diagnosis of post traumatic stress disorder (PTSD) (a mental health condition triggered by a traumatic event) for 2 of 2 residents (R57, R14) reviewed for MDS accuracy. Findings include: The resident assessment instrument (RAI) manual version 3.0 indicated under section I, Active Diagnoses, the items in this section were intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. Section I in the RAI manual further indicated definitions of active diagnoses were physician documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7 day look back period. For the assessment, there are two look back periods: 1. Diagnosis identification is a 60 day look back period and 2. Diagnosis status: active or inactive is a 7 day look back period. The disease conditions in this section require a physician documented diagnosis or by a nurse practitioner, physician assistant, or clinical nurse specialist in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis, problem list, and other resources as available. If a diagnosis problem list is used, only diagnoses confirmed by the physician should be entered. Further, the RAI indicated once a diagnosis was identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7 day look back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7 day look back period as these would be considered inactive diagnoses. Further, the following information sources in the medical record for the past 7 days is checked to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. R57's admission MDS dated [DATE], indicated moderate cognitive impairment, had bipolar disorder, factitious disorder, and depression. Further, the MDS under section I, I6100, lacked a check mark indicating R57 had PTSD. R57's quarterly MDS dated [DATE], indicated R57 had intact cognition, had bipolar disorder, manic depression, and under section I, I6100, lacked a check mark indicating R57 had PTSD. R57's psychiatric evaluation and management note dated 12/9/23, indicated R57 had bipolar disorder, PTSD, factitious disorder, and unspecified neurocognitive disorder. R57's physician progress notes dated 12/10/23, from the hospital referral on page 33 of 103 indicated R57 had neurocognitive disorder, bipolar disorder, PTSD. The note further indicated R57 had bipolar disorder and PTSD with recent discharge and rehospitalization. R57's hospital progress notes dated 12/12/23, and signed by the physician on page 8 of 103, indicated R57 had bipolar disorder, PTSD, and factitious disorder. R57's Level II Preadmission Screening (PAS) for Persons with Mental Illness Determination for Nursing Facility admission form dated 12/27/23, indicated a physician recommended nursing facility level of care for R57. The form further indicated R57 had current mental health diagnoses of bipolar disorder and PTSD and was receiving psychiatry services. R57's Adult Crisis Assessment social worker note dated 3/22/24, indicated the assessment was requested to assess safety, provide diagnosis, and appropriate referral. Further, the note indicated a provisional diagnosis of PTSD based on the brief crisis assessment, as well as reported by R57, and a historical diagnosis per review of records. Additionally, the note indicated R57 endorsed, displayed, or was reported to have the following symptoms: isolating self, outbursts of anger, easily startled, trouble with sleep, low energy, body or muscles tense, being on guard or constantly alert, and feeling short of breath, excessive worry, feeling restless, poor concentration, increased irritability, racing thoughts, feeling on the verge of losing control, and feared not being able to move to a more safe place to live. R57's goals were to continue to see and talk with his psychiatrist and take prescribed medications. R57's care plan dated 3/25/24, indicated R57 was short tempered, easily annoyed, emotionally labile, argumentative, irritable and impulsive and had neurocognitive disorder, bipolar, and PTSD. R57's Associated Clinic of Psychology (ACP) noted dated 4/23/24, indicated R57 had bipolar disorder, and PTSD. R57's medication administration record (MAR) dated May 2024, indicated the following diagnoses: bipolar disorder, PTSD. R57's Face Sheet indicated the following diagnoses: bipolar disorder with a date of onset on 1/5/24, PTSD with a date of onset on 1/5/24, factitious disorder with a date of onset 1/5/24, and depression with a date of onset on 12/22/23. During interview on 5/2/24 at 10:43 a.m., registered nurse (RN)-B stated she completed the MDS including section I and stated she utilized the form Medical Diagnosis, in the electronic medical record (EMR) to determine diagnoses for the MDS and stated R57 had bipolar disorder, PTSD, and factitious disorder. RN-B further stated only the diagnoses that were being treated or had ordered to treat such as medications or treatments were incorporated on the MDS and stated R57 has PTSD, but was not being treated for it and further stated PTSD was something the facility could care plan such as what the symptoms were and further stated they were not aware what R57's trauma was, but would be important to know if there were triggers. During interview on 5/2/24 at 9:52 a.m., social worker (SW)-A stated R57 had PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to develop a comprehensive care plan for psychotropic medications for 1 of 5 residents (R56) reviewed for psychotropic medications. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 had intact cognition and experienced hallucinations. MDS indicated R56 had diagnoses of diabetes, depression, and a psychotic disorder other than schizophrenia. MDS indicated R56 received an antipsychotic on a routine basis and an antidepressant medication. R56's Care Area Assessment (CAA) dated 2/14/24, for psychotropic drug use indicated R56 had mental illness diagnoses and was being treated with long-term psychotropic medications. The CAA further indicated staff would follow the plan of care to maintain R56's current level of functioning for improvement with symptom relief. R56's physician orders included the following: - Olanzapine (Zyprexa) oral tablet 7.5 milligrams (mg), Give 1 tablet orally at bedtime to treat psychotic depressive illness, dated 2/8/24. - Mirtazapine (Remeron) oral tablet 15mg, Give 1 tablet by mouth at bedtime to treat depression, dated 2/8/24. R56's care plan dated 2/8/24, indicated he had antipsychotic use and had target symptoms but lacked documentation of what antipsychotic medication was being used and lacked resident-specific target symptoms or behaviors to monitor. Interventions included staff will use non-pharmacologic interventions but lacked documentation of resident-specific non-pharmacologic interventions. Furthermore, R56's care plan lacked documentation of his antidepressant use and resident-specific target symptoms related to antidepressant use as well as related interventions. The care plan identified R56 had suicidal ideation with hospitalization and identified interventions of providing 1:1 visits with resident as needed, assisting resident to make a No Harm Contract, visiting an in-house therapist, medications as ordered, and updating the provider of increased suicidal ideation and/or plans. The care plan also identified R56's psychotropic drug use but lacked resident-specific medications and lacked documentation of resident-specific target symptoms to monitor. During interview on 5/2/24 at 12:34 p.m., the director of nursing (DON) stated the social services department was responsible for updating the care plan with the behavioral aspect of psychotropic medications. The DON stated expectations for residents on psychotropic medications were to see target behaviors and interventions in the care plan. The DON verified R56's care plan lacked resident-specific symptoms and interventions. Additionally, the DON expected R56's antidepressant medication to be identified in his care plan but verified it was not. During interview on 5/2/24 at 3:33 p.m., social services (SS)-A stated the process for monitoring psychotropic medications and related symptoms and behaviors was to review notes to determine what the medications were and what the symptoms were. SS-A stated for a new admission, it might take some time to develop resident-specific non-pharmacologic interventions because it is an interdisciplinary approach, and the ideas could come from nursing staff, providers, or therapists. SS-A stated the expectation was resident-specific symptoms and interventions should be documented in a resident's care plan if they were taking psychotropic medications. SS-A verified R56's care plan lacked resident-specific interventions and stated, his care plan was not completed. A psychotropic drug use policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure appropriate interventions, as a result of multiple falls and comorbidities contributing to the risk of additional falls, were identified and implemented for 1 of 2 residents (R2) reviewed for accidents, hazards and supervision. Findings include: R2's Face Sheet form indicated the following diagnoses: paranoid schizophrenia, end stage renal disease, hypokalemia (low potassium), bilateral myopia (difficulty in focusing on objects that are far away), presbyopia (the loss of your eyes ability to focus on nearby objects), hypertension, and osteoarthritis. R2's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had hallucinations and delusions, did not reject care, had a cane or crutch and a walker, did not have impairment in range of motion, was independent with activities of daily living (ADLs), was occasionally incontinent of bladder, had two or more falls without injury since the previous assessment, took antipsychotics, antidepressants, diuretics, and antiplatelet medications. Additionally, the MDS indicated R2's vision was adequate with glasses or other visual appliances and used corrective lenses. R2's physician orders indicated the following order: • 11/29/23, ok to try four wheeled walker with bench needs to balance personal items and maybe a safer option. R2's care plan dated 3/28/24, indicated R2 was at risk for falling due to a history of falling, and medications. R2 fell downstairs and fractured his rib and fingers on 8/15/23, and on 12/13/23, R2 fell on the stairs due to the elevator out of service and R2 decided to use the stairs, on 1/8/24 R2 sat down and missed the chair and on 1/14/24 R2 fell in his room and was unable to explain what happened. Interventions included nursing to check orthostatic blood pressures, educate resident to slow down when walking on ice and watch walking carefully for safe foot placement, encourage resident to avoid icy sidewalks, encourage resident to stay in when icy and snowing. R2's nursing assistant caresheet indicated R2 was independent, anticipate needs, had dentures and check for a cup and required supervision to follow through. The caresheet lacked information how R2 ambulated, or making sure room was free from clutter and crowding. R2's Incident report dated 8/14/23, indicated R2 fell on the floor by the stairway because his shoe got stuck on the steps. Interdisciplinary team (IDT) met and interventions to be put in place to minimize risks of injury included R2 should use the elevator when going from floor to floor for safety. R2's Incident Audit report dated 12/10/23, indicated R2 fell utilizing the stairs when he lost his footing. R2's Fall report dated 12/10/23, indicated R2 was sitting on the main stairs inside the building at approximately 12:00 p.m. Additionally, the report indicated R2 did not have any injuries, and under the heading, Predisposing Environmental Factors, indicated Other, however no additional information was documented on the predisposing environmental factor. R2's Incident Audit report dated 1/8/24, indicated R2 went to sit down and missed the chair due to being in a hurry and IDT met and determined staff would continue with education on watching when R2 sat down to feel the chair was behind him and reminders to sit down slowly, staff to continue to encourage use of the elevator when moving from floor to floor. R2's Incident Audit report dated 1/14/24, indicated R2 was found on the floor between the bed and the dresser and did not know why he fell. Additionally, there was crowding under predisposing environmental factors and the note indicated there was a lot of stuff in R2's room between the bed and dresser. IDT met regarding the incident and R2's fall was likely related to increased potassium level and staff were to continue using the elevator and provide education on diet and foods to avoid. R2's progress note dated 12/15/23 at 1:56 p.m., indicated R2 had two falls in the past three months related to using the stairs when ambulating between floors and the first incident R2 was sent to the ER and found to have a fractured rib and fingers and was instructed to only use the elevator. R2 fell a second time using the stairs when the elevator was out of service and the second incident did not result in any injury. R2 was advised to only use the elevator and if it was out of service R2 should request staff to assist him. R2's progress note dated 1/14/24 at 11:02 a.m., indicated R2 was found lying on his right side leaning forward between his dresser and his bed and his glasses frame was broken but did not remember what happened or why he fell. R2's progress note dated 1/16/24 at 11:21 a.m., indicated R2 was admitted to the hospital for an elevated potassium and potassium levels were improving. R2's progress note dated 3/27/24 at 9:57 a.m., indicated R2 was at moderate risk for falls related to medications, falls, and incontinence. During observation on 4/30/24 at 2:21 p.m., R2's room was dark, there was a small path between the bed and television night stand. R2 had a chair with clothes on top of it along with a cane and a seated walker was located towards the middle bed. There was a water gallon on the floor towards the head of the bed and a bag located on the floor. R2 entered the room and ambulated into the bathroom without his walker. During interview on 5/1/24 at 11:36 a.m., nursing assistant (NA)-A stated she relied on information in the electronic medical record to know what cares a resident required along with just seeing a resident and if a resident asked for help. NA-A stated R2 did not refuse cares and stated the only time she recalled R2 refuse was when he was too tired to come down for breakfast. NA-A stated R2 was mostly independent and had fallen a couple of months ago and was alerted by R2's room mate that R2 had fallen. NA-A stated R2 was reaching for his cigarettes and fell on the side of his head and it happened in his room. NA-A stated the paramedics came and stated everything in R2's room is close together, stating the bed and the chair were close together and then had the walker and had to bend over to pick up his cigarettes and was a lot in that small of a space. During interview on 5/1/24 at 12:07 p.m., NA-A stated R2 was supposed to have a walker. During interview on 5/2/24 between 8:33 a.m., and 8:55 a.m., licensed practical nurse (LPN)-A stated she looked at the care plan or the nursing assistant worksheets to know what kind of cares a resident required. LPN-A stated when a resident falls, the emergency contact, director of nursing (DON), administrator, and provider is contacted and a risk management and progress note is completed. LPN-A stated the risk management report asks nursing the description of the environment and what could contribute and interventions started after the fall and injury. LPN-A further stated the care plan should be updated but was not a protocol discussed. LPN-A stated she recalled R2 falling and stated R2 had three risk management reports. LPN-A viewed the fall report on 1/14/24 and stated R2 fell between the bed and dresser and factors related was crowding with a lot of stuff in between the bed and dresser and no new interventions were added. At 8:55 a.m., LPN-A went up to R2's room and verified R2 had a bag and water, a box, books and various items located on the floor and R2's walker was located by the middle bed in the room, R2's bed was located by the door to the hall. LPN-A stated R2's walker was in reach and stated R2 was at risk for falls because his pathway between the bed and the chair was so cluttered. During interview on 5/2/24 at 3:19 p.m., the director of nursing (DON) stated the nurse assesses the resident after a fall and based on the situation would be sent and the physician, family, DON, administrator would be notified and the risk assessment would be completed and the root cause is determined and interventions are put in place. The DON further stated she expected the care plan be updated and implemented because it was important for resident safety and to prevent further occurrence. During interview on 5/2/24 at 3:31 p.m., registered nurse (RN)-B stated care plans were updated during a resident's assessment period with the MDS assessment. RN-B further stated fall risk scores were populated before a care conference and stated it did not look like the elevator reminder was added to the care plan and planned to do so and further stated it should be on the care plan to keep R2's room free from clutter and stated the crowding was never discussed and the room environment wasn't taken into account in the falls risk score. A policy, Fall Management Policy, dated 7/3/23, indicated the purpose of the policy was to ensure that the resident environment remains as free of accident hazards as possible and each resident is assessed for fall risk and have preventative measures in place that maintain the resident's highest level of independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. The MDS indicated a mood interview should be conducted for R14, but R14 did not respond when asked questions about mood and social isolation. The MDS indicated R14 had hallucinations, delusions, and had other behavioral symptoms not directed toward others such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming, etc. daily of the previous 7 days. The MDS indicated R14 did not reject cares, was independent with activities of daily living (ADLs) and had schizophrenia. R14's annual social service MDS documentation dated 8/18/23 at 3:01 p.m., indicated R14 had diagnoses of schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. A Nursing Home Visit Encounter with R14's nurse practitioner dated 3/5/24, indicated R14 had schizophrenia, PTSD, major depressive disorder, among other diagnoses. R14's Face Sheet dated 5/3/24, indicated R14 had post-traumatic stress disorder (PTSD; a mental health condition triggered by a traumatic event). R14's Care Area Assessment (CAA) dated 11/3/23, delirium triggered for inattention and disorganized thinking. The CAA identified the symptoms were not new and had abnormal blood sugar levels due to R14's refusal to take insulin. The CAA for cognitive loss also triggered due to refusal of cognitive assessment and staff indicating short and long-term memory loss, poor decision making, inattention, and disorganized thinking. The CAA indicated R14 received frequent reorientation, reassurance, reminders to help make sense of things, and redirection and cues for appropriate responses and better decisions. The CAA psychotropic drug use trigged for antipsychotic use. The CAA mentioned diagnoses of schizophrenia and major depressive disorder. The CAA behavioral symptoms triggered related to rejection of care and noted behavior as worse. The care area assessments did not mention PTSD. R14's cognition care plan related to psychosis and delusions revised 12/8/19, identified R14 had delusional beliefs their mother was abused by their father, was paranoid about thing getting stolen so carried all belongings with them, believed they had allergy to insulin, made accusations of theft by peers and/or staff, and had diagnoses of schizophrenia, PTSD, major depressive disorder and was actively delusional on a daily basis. R14's behavior care plan related to delusions revised 12/8/19, indicated R14 had paranoid delusions daily, made accusations of people being in their room during the night taking papers, belongings, and messing up or destroying locked cabinet drawers, and had diagnoses of schizophrenia, PTSD, and major depressive disorder. R14's medical record lacked evidence of an assessment for PTSD triggers. During interview on 4/30/24 at 1:48 p.m., nursing assistant (NA)-A stated their charting identified triggers and behaviors for residents. NA-A reviewed R14's target behaviors were refusing insulin and carrying belongings. NA-A reviewed R14 had no information on triggers of trauma. NA-A stated R14 believed people were trying to do things to them like poison them. NA-A stated R14 was more comfortable with them now and allowed NA-A to help with cares when needed compared to when NA-A was a newer employee. During interview on 4/30/24 at 2:58 p.m., registered nurse (RN)-C stated staff gave each other report between shifts on resident behavior and interventions completed in response. Besides report, the medical record had a communications area where they could record such information. RN-C stated care plans showed behavior plans for residents. During same interview on 4/30/24 at 2:58 p.m., licensed practical nurse (LPN)-B stated they believed R14 was abused and spoke about someone stalking them and was frightened and jumpy at times thinking someone was watching them. LPN-B stated residents had care plans related to trauma if they were open enough to talk about it, or residents' care plans reflected staff observations. LPN-B said the social work or MDS nurse completed trauma-based assessments. During interview on 5/2/24 at 9:53 a.m., social worker (SW)-A stated if a resident had a specific trauma, it was care planned and the facility would care plan for any triggers or flashbacks in order to try to avoid a trigger. SW-A reviewed R14's diagnoses and care plan. SW-A verified R14 had diagnosis of schizophrenia and had not had an assessment which identified and assessed their triggers for PTSD. SW-A stated staff were more focused on R14's hallucinations, delusions, and uncooperation with medications and other health management. During interview on 5/2/24 at 10:43 a.m., registered nurse (RN)-B stated R14 had PTSD and stated they did not do any assessments for PTSD and stated all of that was done via the provider and further stated they would possibly expect a resident with a history of PTSD to be assessed for triggers however it would not be within their scope. RN-B further stated it would be up to social services to add a care plan and would be important to have triggers or behaviors care planned. During interview on 5/2/24 at 10:56 a.m., the director of nursing stated she expected staff know residents' triggers. A policy, Trauma Informed Care, dated 12/20/22, indicated it was the policy of the facility that all residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with residents' preferences and experiences. Residents who display and or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Residents will be screened and assessed upon admission, quarterly and or significant change by social services department in order to identify any history of trauma and or PTSD which includes review of current records, resident and or resident representative interviews. IDT will document and care plan for any areas of trauma. This will include identification of the stressor past life trauma, potential actual triggers that may cause re-traumatization of the resident, experiences, preferences, and or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident. Based on interview and document review, the facility failed to comprehensively assess for and identify potential triggers to avoid re-traumatization for 2 of 2 residents (R57, R14) who had a history of trauma. Findings include: R57's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, had moderate depression symptoms, sometimes socially isolated, had verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed at others such as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds 1 to 3 days of the previous 7 days. The MDS indicated R57 had delusions and further, rejected care, was independent with most activities of daily living (ADLs) had bipolar disorder, and manic depression. R57's Medical Diagnosis form dated 1/5/24, indicated R57 had post traumatic stress disorder (PTSD) (a mental health condition triggered by a traumatic event). R57's psychiatric evaluation and management note dated 12/9/23, indicated R57 had bipolar disorder, PTSD, factitious disorder, and unspecified neurocognitive disorder. R57's physician progress notes dated 12/10/23, from the hospital referral on page 33 of 103 indicated R57 had neurocognitive disorder, bipolar disorder, PTSD. The note further indicated R57 had bipolar disorder and PTSD with recent discharge and rehospitalization. R57's hospital progress notes dated 12/12/23, and signed by the physician on page 8 of 103, indicated R57 had bipolar disorder, PTSD, and factitious disorder. R57's Level II Preadmission Screening (PAS) for Persons with Mental Illness Determination for Nursing Facility admission form dated 12/27/23, indicated a physician recommended nursing facility level of care for R57. The form further indicated R57 had current mental health diagnoses of bipolar disorder and PTSD and was receiving psychiatry services. R57's Adult Crisis Assessment social worker note dated 3/22/24, indicated the assessment was requested to assess safety, provide diagnosis, and appropriate referral. Further, the note indicated a provisional diagnosis of PTSD based on the brief crisis assessment, as well as reported by R57, and a historical diagnosis per review of records. Additionally, the note indicated R57 endorsed, displayed, or was reported to have the following symptoms: isolating self, outbursts of anger, easily startled, trouble with sleep, low energy, body or muscles tense, being on guard or constantly alert, and feeling short of breath, excessive worry, feeling restless, poor concentration, increased irritability, racing thoughts, feeling on the verge of losing control, and feared not being able to move to a more safe place to live. R57's goals were to continue to see and talk with his psychiatrist and take prescribed medications. R57's care plan dated 3/25/24 indicated R57 was short tempered, easily annoyed, emotionally labile, argumentative, irritable and impulsive and had diagnoses of PTSD, bipolar, and neurocognitive disorder and included interventions for an in house therapist to visit weekly, nursing would medicate per physician orders, and nursing to notify the psychiatrist with increased anger with self and or others. The care plan was reviewed and lacked information identifying R57's PTSD triggers. R57's medical record lacked evidence of an assessment for PTSD triggers. R57's care area assessment (CAA) dated 1/3/24, identified psychosocial wellbeing, mood, cognition, psychotropic drug use, behavioral symptoms, however lacked information regarding PTSD triggers. During interview on 4/29/24 between 4:04 p.m., and 4:16 p.m., R57 stated he felt overloaded with information regarding forms for going to another facility. Additionally, R57 stated he did not like the overhead intercom because it startled him and stated the noise emitted was a very loud beeping noise. During interview on 5/1/24 at 1:23 p.m., R57 stated he heard the city tornado alarm test going off this afternoon and it startled him. During interview on 5/2/24 at 9:06 a.m., maintenance (M)-A stated the overhead intercom system was loud and could startle people. M-A further stated the overhead intercom was loud for residents to hear it and verified it sounded louder because of the small space and stated it would help if the staff who used the intercom knew how to use the speaker because they push the button which makes a beeping noise which may startle somebody. M-A verified the speaker for the intercom was located two doors from the speaker. During interview on 5/2/24 at 9:52 a.m., social worker (SW)-A stated if a resident had a specific trauma, it was care planned and the facility would care plan for any triggers or flashbacks in order to try to avoid a trigger. SW-A further stated they used the associated clinic of psychology (ACP) weekly and further stated PTSD should be care planned and if a resident with PTSD startled easily would be interviewed to identify the triggers and care plan accordingly. SW-A verified R57 had PTSD and verified R57 has not had an assessment that identified and assessed triggers for his PTSD and verified it was up to the facility to assess him for PTSD and triggers. During interview on 5/2/24 at 10:43 a.m., registered nurse (RN)-B stated R57 had PTSD and bipolar disorder and stated she did not do any assessments for PTSD and stated all of that was done via the provider and further stated she would possibly expect a resident with a history of PTSD to be assessed for triggers however it would not be within her scope. RN-B further stated it would be up to social services to add a care plan and verified there was no specific care plan related to PTSD triggers and added they were not aware what the trauma was for R57 and stated it would be important if there were triggers or behaviors and added R57 was short tempered and stated the intercom was used to announce everything such as phone calls, medication times and stated it was used multiple times throughout the day. During interview on 5/2/24 at 10:56 a.m., the director of nursing stated she expected staff know R57's triggers to manage the situation. A policy, Trauma Informed Care, dated 12/20/22, indicated it was the policy of the facility that all residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with residents' preferences and experiences. Residents who display and or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Residents will be screened and assessed upon admission, quarterly and or significant change by social services department in order to identify any history of trauma and or PTSD which includes review of current records, resident and or resident representative interviews. IDT will document and care plan for any areas of trauma. This will include identification of the stressor past life trauma, potential actual triggers that may cause re-traumatization of the resident, experiences, preferences, and or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was adequate monitoring and provider notification for insulin parameters for 1 of 3 resident (R56) reviewed for unnecessary medications. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], indicated R56 had intact cognition, experienced hallucinations, had no delusions, exhibited no physical or verbal behaviors, and had no rejection of cares. The MDS also indicated R56 had diagnoses of type 2 diabetes, depression, and schizoaffective disorder (a disorder characterized by a combination of symptoms of schizophrenia, like hallucinations and delusions, and a mood disorder, like depression). R56's Care Area Assessment (CAA) for self-care and mobility dated 2/14/24, indicated he was able to perform activities of daily living (ADLs) independently but required some cues and reminders as he could loose focus related to having active false fixed perceptions that required staff supervision to ensure follow through. R56's physician's orders included the following: - Insulin Aspart subcutaneous solution pen-injector 100 unit/milliliter (mL); Inject per sliding scale subcutaneously three times a day to treat type 2 diabetes, dated 4/24/24. Sliding scale is as follows: 70 mg/dL - 149 mg/dL = 0 units 150 mg/dL - 199 mg/dL = 1 unit 200 mg/dL - 249 mg/dL = 2 units units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 - 399 = 5 units; 400+ = 6 units <400 6 units and call provider, If blood glucose is less than 70 mg/dL, hypoglycemia protocol - Don't give corrective dose for as needed (PRN), post-prandial or nocturnal glucose checks unless ordered. - Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL (Insulin Glargine) Inject 14 unit subcutaneously in the evening to treat type 2 diabetes, dated 03/1/2024. R56's care plan dated 2/13/24, indicated R56 had the potential for diabetic complications and identified a goal to have blood sugars remain below 100 milligrams/deciliter (mg/dL). The interventions included Metformin and Lantus medications as ordered, accuchecks (a way to assess blood sugar or glucose levels) as ordered, and to observe for signs and symptoms of high blood sugar (fatigue, frequent urination, headaches, increased thirst, weight loss, nausea, vomiting, diarrhea, tingling hands and feet, blurred vision) and low blood sugar (confusion, tachycardia, shaking, sweating, nervousness, anxiety, dizziness, and hunger). A review of R56's blood sugar readings in Point Click Care (PCC) revealed the following readings: - 442 mg/dL dated 4/28/24 at 19:24 (7:24 p.m.). - 579 mg/dL dated 4/25/24 16:55 (4:55 p.m.). A review of R56's progress notes lacked documentation of a provider update for these elevated blood sugar readings greater than 400 mg/dL, as orders indicated staff should call provider. During interview on 5/1/24 at 11:20 a.m., registered nurse (RN)-A stated for residents receiving insulin based on a provider-ordered sliding scale, the amount of insulin administered was dependent on the blood sugar. RN-A stated if the blood sugar was low, the resident may not require insulin and if the blood sugar was elevated, the resident may require more insulin. RN-A stated R56 was a recent admission, and his sliding scale insulin was a new order. RN-A reviewed R56's sliding scale insulin order and stated to know how much insulin to administer, R56 would first need to have his blood sugar checked. RN-A stated if R56's blood sugar was a reading of 400 mg/dL or higher, R56 would require 6 units of insulin and his provider would need to be updated. RN-A stated staff were expected to contact the provider at this blood sugar reading and could either update the provider while they were on site or through their triage nurses via telephone and document in the progress notes. RN-A verified R56 had elevated blood sugars greater than 400 mg/dL on 4/25/24 at 16:55 (4:55 p.m.) and 4/28/24 at 19: 24 (7:24 p.m.) in PCC. RN-A stated R56 should have received 6 units of insulin for these elevated blood sugar readings and most of the time, he will eat first before getting the blood sugar checked. I don't think there was a note put in. RN-A verified there was no progress note documentation of R56's provider being updated about his elevated blood sugars. During interview on 5/2/24 at 9:40 a.m., R56's advanced practical registered nurse, certified nurse practitioner (APRN, CNP) acknowledged being familiar with R56's care and began overseeing his care in February with his last visit being in April. The APRN, CNP expected to be notified of blood sugar readings of greater than 400 mg/dL and stated, We only see patients every three months, so I'd like to have that update. The APRN, CNP stated while understanding R56 might be eating prior to having his blood sugar checked, the expectation would be to continue to be notified per the orders so that the long-acting insulin dose was not adjusted. During interview on 5/2/24 at 12:34 p.m., the director of nursing (DON) stated staff were expected to follow orders and update the providers if a resident's blood sugar was above the parameter limit. The DON reviewed R56's blood sugars for 4/25/24 at 16:55 (4:55 p.m.) and 4/28/24 at 19: 24 (7:24 p.m.) in PCC and verified they were greater than 400 mg/dL and stated staff should have administered the insulin as ordered and called the provider. The DON stated the nurse that had not updated the provider during these instances had mentioned R56 ate before he got his blood sugar checked and the DON stated the nurse received coaching at the time about documentation and updating the provider per the orders. A request for medication monitoring policy was requested but not received. A request for diabetic management policy was requested but not received. A request for a change of status and/or notification of change policy was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 5 residents (R260, R46, R10) observed to receive medication. A total of (3) errors out of 25 opportunities were identified resulting in a 12% (percent) facility error rate. Findings include: R260's physician orders dated [DATE], included the following order: • mucus relief oral tablet extended release 12 hour 600 milligram (MG) (guaifenesin) give 600 mg by mouth two times a day for RSV, respiratory distress related to acute respiratory distress syndrome. There was no stop date on the order. During interview and observation on [DATE] from 7:20 a.m., to 7:32 a.m., registered nurse (RN)-A stated she would be helping to administer medications until the trained medication aide (TMA) arrived. At 7:20 a.m., RN-A prepared R260's medications, except for the mucus relief and stated she did not see the medication for mucus relief. At 7:30 a.m., RN-A gave R260 her medications with the exception of the mucus relief. At 7:32 a.m., RN-A verified she did not administer R260's mucus relief and stated there was not a stop date on the medication and would contact the pharmacy to reorder the medication. R46's physician orders dated [DATE], indicated the following order: • risperidone tablet 2 mg give 1 mg by mouth two times a day related to schizoaffective disorder, bipolar type. Give 1/2 of 2 mg tablet. During observation on [DATE] between 7:51 a.m., and 7:56 a.m., TMA-A prepared R46's medications and put a whole 2 mg risperidone tablet in the medication cup and gave the cup to R46 who gave the cup back and stated she took a half a tablet. At 7:56 a.m., TMA-A cut the 2 mg risperidone tablet in half and gave the half tablet to R46. R10's physician orders dated [DATE], indicated the following order: • oyster shell calcium/D tablet 500-5 mg-mcg (microgram) (calcium carb-cholecalciferol) give 1 tablet by mouth two times a day for calcium and vitamin D insufficiency with breakfast and dinner. During observation on [DATE] between 8:25 a.m., and 8:34 a.m., TMA-A prepared R10's medications. The stock calcium medication had an expiration date of 4/2024. TMA-A began to give R10 her medications when the TMA-A was asked what the expiration was and whether the medication was expired. TMA-A asked for R10's calcium back and stated it was expired and at 8:28 a.m., located R10's personal bottle of calcium and administered the calcium to R10. At 8:34 a.m., TMA stated when medications are administered you have to check for the right patient, right route, right medication, right dose, right time, and stated the medication expiration should be checked prior to administering medications and verified she did not check the expiration date until prompted. During interview on [DATE] at 11:05 a.m., the director of nursing (DON) stated medications should be ordered 5-7 days before the supply runs out and as soon as possible and stated R260's medications should have been ordered prior to running out. Additionally, the DON stated she expected staff follow the 5 rights of medication administration and stated medications needed to be checked for the expiration prior to administering. A policy, Ordering Medication From Pharmacy, dated [DATE], indicated each nurse/TMA med pass person will be responsible for pulling the label off an over the counter medication, cream or lotion, or injectable or medication that is not on automatic renewal, that has less than a five day supply of the medication left. If a medication is needed for the same day or the next morning, the nurse/TMA should write beside the label Need today please. A policy, Administering Medications, dated [DATE], indicated the facility staff administer medications in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering medications verifies the resident's identity before giving the resident his/her medications. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi dose container, the date opened is recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to accommodate dietary preferences for 1 of 1 resident (R57) reviewed for food. Findings include: The facility form, Alternate Meal Choices, available seven days a week, indicated if a resident did not like a meal on the menu, a request for an alternate meal: peanut butter and jelly sandwich, grilled cheese sandwich, meat and cheese sandwich, and chef salad could be submitted. The facility Week 4 at a Glance menu dated 4/28/24, through 5/4/24 indicated the following food items: • 4/28/24: the breakfast items indicated choice of cereal, egg bake, sweet roll, milk; the noon meal indicated fried chicken mashed potatoes, chicken gravy, cascade veggies, pie, and milk. The alternate food item was country fried steak and gravy. The evening meal indicated corn dogs, macaroni and cheese, baked beans, seasonal fresh fruit and milk and the alternate was taco salad. • 4/29/24: the breakfast items indicated choice of cereal, fried eggs, toast, margarine and jelly; the noon meal indicated goulash, carrots, mandarin oranges, bread stick and the alternate indicated turkey wrap. The evening meal indicated open hot beef sandwich, mashed potatoes, creamy coleslaw, mixed fruit, and the alternate was a hot do on a bun. • 4/30/24: the breakfast items included choice of cereal, sausage patty, waffles, maple syrup, milk; the noon meal indicated baked ham, fried potatoes, fruit, monster cookie cake, and milk, and the alternate was a tuna salad sandwich. The evening meal indicated summer chicken tortellini soup, crackers, chopped salad and dressing, breadstick, banana berry cup, milk and the alternate was lemon pepper cod. • 5/1/24: the breakfast items included choice of cereal, sausage gravy biscuit, milk; the noon meal indicated fruited turkey pasta salad, tomato slices, breadstick, French chocolate cheesecake, and milk, and the alternate was a sloppy joe on a bun. The evening meal indicated Italian sausage sandwich, tater tots, corn, mixed fruit, milk, and the alternate was an egg salad sandwich. • 5/2/24: the breakfast items included choice of cereal, boiled eggs, bacon, toast, margarine and jelly, and milk; the noon meal indicated smothered cube steak mashed potatoes, buttered peas, bread and margarine, fluffy strawberry dessert, milk and the alternate were baked pork chops. The evening meal indicated baked chicken drumstick, pasta salad, balsamic tomato cucumber salad, garlic toast, pears, cookie, and milk and the alternate were grilled cheese sandwiches. • 5/3/24: the breakfast items included choice of cereal, sausage link, French toast and syrup, milk and the noon meal indicated shrimp and chips, broccoli with cheese, cornbread and margarine, seasonal fresh fruit and milk and the alternate indicated pork tenderloin on a bun. The evening meal indicated Spanish beef and rice bake, seasonal vegetable bread margarine, butterscotch brownie and milk and the alternate indicated an egg salad sandwich. • 5/4/24: the breakfast items included choice of cereal, fried eggs, donut holes, and milk; and the noon meal indicated lemon Dijon pork chop, baked yam, green beans, bread and margarine, sherbet, and milk and the alternate were cottage cheese and fresh fruit plate and crackers. The evening meal indicated a deli sandwich, potato chips, peaches, cake roll, and milk and the alternate were a chef salads, rolls and margarine. R57's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, was independent with activities of daily living. R57's Medical Diagnosis form indicated the following diagnoses: bipolar disorder, post traumatic stress disorder, unspecified symptoms and signs involving cognitive functions and awareness, factitious disorder imposed on self, and depression. R57's physician's orders indicated the following order dated 12/26/23: regular diet, regular texture. R57's care plan dated 1/3/24, indicated R57 was at risk for nutritional problem related to a low protein intake related to vegetarian status. Interventions included encouraging three meals a day and weekly weights. R57 had the following weights documented: • 12/28/23, 138 pounds standing. • 2/4/24, 133.2 pounds standing. • 3/3/24, 132.2 pounds standing. • 4/6/24 131.8 pounds standing. R57's admission Nutritional MDS Assessment/Monthly form dated 1/3/24, indicated R57 did not skip meals, ate only certain foods because R57 stated he was a vegetarian. The assessment form further indicated dietary would work to accommodate for preferences. R57's quarterly Nutritional MDS Assessment/Monthly form dated 3/25/24, indicated R57 did not skip meals, ate only certain foods because R57 was a vegetarian and was noted to eat some meats. The assessment form further indicated R57 received a regular diet and dietary would work to accommodate for preferences though R57 ate some meats at mealtimes. R57's nursing progress note dated 12/28/23 at 10:30 p.m., indicated R57 did not eat supper because he was a vegetarian. R57's nursing progress note dated 12/29/23 at 2:06 p.m., indicated R57 did not want to eat the food at the facility and staff were arranging vegetarian meal options per resident preferences. R57's care conference note dated 1/17/24 at 11:38 a.m., indicated R57 was going to meet with the dietician on 1/17/24, to discuss vegetarian mean preference changes and R57's goal weight was 160 pounds and was 130 pounds as of 1/15/24. R57's progress note dated 2/16/24 at 10:13 a.m., indicated R57 requested to meet with the dietician to review his diet and concerns and stated he was a vegetarian and did not want to consume dairy products in addition to not having meats due to gas issues causing ongoing stomach pains and would eat eggs, peanut butter, beans, and rice and would try vegetarian burgers. R57's progress note dated 4/4/24 at 6:37 p.m., indicated R57 participated in a discussion about trying to make healthy choices and R57 stated it was super challenging to eat healthy at this facility. The note further indicated another member suggested R57 talk with the dietician again and R57 discussed being a vegetarian. R57's care conference note dated 4/10/24 at 11:09 a.m., indicated R57 did not attend the conference and was on a regular diet and R57's weight was 131.8 as of 4/6/24. The note further indicated R57 met with the dietician on 1/17/24 to discuss vegetarian mean preference changes. During interview on 4/29/24 at 3:51 p.m., R57 stated he went shopping on Amazon because he was a vegetarian and the facility had a lot of meats and was difficult for him to receive food for his diet. R57 further stated he ate peanut butter, but sometimes the facility ran out of it. During observation on 5/1/24 at 7:21 a.m., R57 had biscuits and gravy for breakfast and was eating at the table. During observation on 5/1/24 between 11:53 a.m., and 11:54 a.m., R57 came into the dining room and at 11:54 a.m., went to the window in the dining room by the kitchen and ordered his meal and was provided a brownie type dessert from the server and no other meal and a beverage. During interview and observation on 5/1/24 at 12:16 p.m., R57 finished his dessert and walked towards the elevator and stated he had cheesecake for lunch. During interview on 5/1/24 at 12:25 p.m., the dietary manager (DM)-C stated residents had turkey pasta salad and sliced tomatoes, bread, and cheesecake for lunch and stated they did not provide a vegetarian option and further stated they did not have any resident on vegetarian diets at the time. DM-C further stated residents had cards with their pictures on them and a blue card indicated a resident had a regular diet, a red card indicated a consistent carbohydrate diet. DM-C viewed R57's card and verified it only indicated R57 was on a regular diet. During interview on 5/1/24 at 1:32 p.m., the registered dietician (RD) stated she was a contracted dietician and completed all the assessments and followed up on anything that required interventions for special diets. RD stated if a resident was on a special diet she let staff including the DM know. RD stated R57 stated he was a vegetarian and stated R57 indicated the day prior he was comfortable with the foods he had been receiving. RD further stated residents were provided two options at meals and in addition the RD stated there were always available options but added she did not know whether this menu was always followed and stated she did not document a note from her conversation with R57 the day prior, but could add documentation. Additionally, RD stated they tried to keep veggie burgers, and peanut butter on the always available options. During interview on 5/1/24 at 2:32 p.m., dietary aide (DA)-A stated she knew what kind of diet a resident was on based on their cards. DA-A further stated menus were posted in the dining room and on each floor and stated if a resident requested, they could have a peanut butter and jelly or other sandwich, grilled cheese sandwich, meat and cheese sandwich and chef salad and pointed to a posted sign labeled, Alternate Meal Choices that indicated, If you don't like a meal on the menu, you can place your request for an alternate meal: peanut butter and jelly sandwich, grilled cheese sandwich, meat and cheese sandwich, chef salad. Additionally, the meal choices were available seven days a week. During observation on 5/1/24 at 2:38 p.m., the menu in the dining room indicated for lunch a fruited turkey pasta salad, tomato slices, breadstick, French chocolate cheesecake, milk and the alternate was a sloppy joe on a bun and the breakfast choice was cereal, choice of juice, sausage gravy biscuit and milk. During interview on 5/2/24 at 9:52 a.m., social worker (SW)-A stated R57 was very specific and did not want meat and bought his own peanut butter and expected staff to accommodate his diet preferences. During interview on 5/2/24 at 3:05 p.m., the director of nursing (DON) stated she expected staff to provide a vegetarian menu for patient centered care in order to meet R57's needs. A policy, Nutritional Assessment, dated August 2023, indicated all residents would have a nutritional assessment completed within 14 days of admission and would be updated annually. The food service supervisor would visit new residents to record food and beverage preference, food intolerance, past food habits and inform resident of food service programs and meal and nourishment times. The consulting dietician will review information obtained and complete nutritional assessment form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R360, R26) reviewed for vaccinations. Findings include: The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adults 19-[AGE] years old with chronic health conditions, such as diabetes mellitus, who received PCV13 (pneumococcal conjugate vaccine) should receive either one dose of PCV20 or one dose of PPSV23 (pneumococcal polysaccharide vaccine). The dose of PCV20 or PPSV23 should be administered at least one year after PCV13. Adults 19-[AGE] years old with chronic health conditions, such as diabetes mellitus, who received PPSV23 should receive either one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. R360's admission Minimum Data Set (MDS) dated [DATE], indicated R360 was [AGE] years old, had intact cognition and diagnosis of diabetes mellitus. Furthermore, R360's MDS indicated R360 was not up to date with pneumococcal vaccination and not offered the pneumococcal vaccine. R360's Minnesota Immunization Connection (MIIC) report undated, indicated R360 had received the Prevnar (PCV)13 on 9/13/19. Review of the current CDC pneumococcal vaccine recommendations 3/15/23, indicated R360 required one dose of PCV20 or PPSV23 at least one year after PCV13. R26's quarterly MDS dated [DATE], indicated R26 was [AGE] years old, had intact cognition and diagnoses of hypertension, renal insufficiency or failure and diabetes mellitus. Furthermore, R26's MDS indicated R26 was not up to date with pneumococcal vaccination and not offered the pneumococcal vaccine. R26's MIIC report undated, indicated R26 had received the PPSV23 on 10/7/3, 12/11/9, and 10/2/20. Review of the current CDC pneumococcal vaccine recommendations 3/15/23, indicated R26 required one dose of PCV20 or PCV15 at least one year after PPSV23. When interviewed on 5/2/24 at 12:20 p.m., registered nurse (RN)-A stated resident vaccinations were assess upon admission. Staff made sure the immunization records were up to date and called the hospital or wherever the resident was admitted from to obtain the most current immunization record. When interviewed on 5/2/24 at 12:37 p.m., RN-B, who was the infection preventionist, stated they accessed the MIIC to verify residents were up to date with vaccinations and asked residents if they wanted the pneumococcal vaccinations during their assessment interviews. RN-B checked yearly to ensure current residents were up to date with vaccines. RN-B stated if residents needed the pneumococcal vaccines they would receive from their provider or go to a pharmacy if safe to go out to community. When interviewed on 5/2/24 at 3:25 p.m., the director of nursing (DON) stated staff annually assessed which residents needed pneumococcal vaccinations following the CDC guidance. Ensuring residents were up to date on vaccines was important to minimize resident risks. The facility was asked for documentation of R360 and R26's pneumococcal vaccination offer and/or declination but did not receive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident call light cord was within reach from the shower floor for 1 of 1 multi-resident (R39, R14, R25, R32) bathroom reviewed for call light accessibility. Findings include: R39's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition, had hallucinations and delusions and no refusals of care. R39 was independent with activities of daily living (ADLs) but needed substantial and/or maximal assistance with showers/bathing. R39 had diagnoses which included schizophrenia and cataracts. R39's care plan printed 5/3/24, identified R39 was a low fall risk and directed staff to educate and remind R39 to use the call light and call for staff when weak. R14's quarterly MDS dated [DATE], identified R14 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R14 had hallucinations, delusions, inattention, disorganized thinking, and no rejections of care. R14 was independent with all ADLs, including showering. R14 had diagnoses of diabetes mellitus and schizophrenia. R14's care plan printed 5/3/24, identified R14 was a low fall risk. R25's quarterly MDS dated [DATE], identified R25 had short- and long-term memory problems and made moderately impaired decisions regarding tasks of daily life. R25 had hallucinations, delusions, inattention, disorganized thinking, and altered level of consciousness. R25 did not reject cares. R25 was independent with most ADLs but required substantial and/or maximal assistance with shower. R25 had diagnosis of schizophrenia. R25's care plan printed 5/2/24, identified R25 was at moderate risk for falls and indicated call light at bedside. R32's annual MDS dated [DATE], identified R32 had intact cognition, delusions, and no behaviors nor rejection of cares. R32 was independent with ADLs and had diagnoses of diabetes mellitus and schizophrenia. R32's care plan printed 5/2/24, identified R32 was a low fall risk. During observation and interview on 4/29/24 at 12:12 p.m., R39's bathroom had a call light cord and box by the toilet. A string was tied around the call light cord, and the string went above the door frame and back down to dangle by the shower. The string with a plastic piece at the end of it was looped a couple times and approximately four feet from the ground. The string by the shower was out of reach if a resident fell in the shower or was sitting in the shower chair. R39 stated they did not have assistance with showers. During observation and interview on 5/1/24 at 8:52 a.m., nursing assistant (NA)-A stated R39 was not very stable when first getting up in the morning and needed stand by assistance and reminders to use her walker. NA-A stated R39 showered in evening so unsure of how much assistance was usually given. NA-A stated the light outside room doors turned on when a resident had their call light on. NA-A either observed call lights on and went to assist, or a phone at the nurse's station also indicated a call light was on. NA-A stated call lights needed to be within reach, including in the bathroom and shower. NA-A observed the string by the shower and agreed the call light is high and should be lower like the other call lights they have seen. NA-A grabbed the string and pulled down. The part of the string tied around the call light by the toilet slid down the call light which lengthened the amount the NA-A had to pull until the string tightened enough to turn on the call light. NA-A agreed they had to pull the string excessively to turn on the call light. During interview on 5/2/24 at 12:20 p.m., registered nurse (RN)-A stated staff looked at assignment sheets and care plans to know how much assistance residents needed. R39 did not like assistance, but staff tried to assist R39 with showers. R14 did not allow staff to assist with showers, but staff reminded R14 to try to let staff assist. R32 was independent with ADLs, but staff stood by when R32 showered for safety. R25 needed assistance with showers. During interview on 5/2/24 at 3:25 p.m., the director of nursing (DON) stated call lights should be within reach of residents, which included when in shower and using toilet. The DON stated staff may not be able to respond to or be aware of an emergency if a resident could not reach or turn on their call light. The facility policy Call Lights dated 12/23, indicated the nursing station should be equipped to receive resident calls form the resident room, bath and bathrooms.

Based on observation, interview, and document review, the facility failed to ensure a multi-resident bathroom ceiling vent fan was cleaned for 4 of 4 residents (R39, R14, R25, R32) reviewed for cleanliness of environment. Findings include: During observation on 4/29/24 at 12:24 p.m., grayish white colored dust thickly covered 50 to 75% of a bathroom ceiling vent. The ceiling vent fan ran but no air flow felt. During interview on 5/1/24 at 9:16 a.m., the administrator (admin) expected maintenance and housekeeping to keep vents and fans clean as often as necessary. Admin stated usually maintenance cleaned high vents and fans, and housekeeping cleaned lower vents and fans. The facility recently changed housekeeping from in-house to a contracted company, so a cleaning schedule was being developed. During interview on 5/1/24 at 9:22 a.m., the assistant director of maintenance (M)-B stated they cleaned vents and fans when dust was observed or when residents came and told them. M-B stated they tried to check rooms twice a month but sometimes didn't happen. M-B stated they had a log for tracking cleaning and would have to find it. During interview on 5/1/24 at 9:51 a.m., the head of maintenance (M)-A stated vents and fans should be cleaned every month. M-A stated they had an old checklist but needed to clean it up and create a checklist sheet for the whole year. M-A observed the bathroom ceiling vent fan and stated maintenance needed to clean it. M-A stated dirty vents and fan caused elements to fly around the air and were important to keep clean to improve air flow and equipment performance. The facility's Room Order Cleaning Procedure dated 8/23, directed staff to follow room order guideline and check general appearance of unit and did not mention to check and clean vents and fans.

Based on interview and document review, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 60 residents which resided in the facility. Findings include: The facility's QAPI meeting minutes for the past 12 months were requested, however not received. Documentation and evidence of the facility's ongoing performance improvement projects (PIPs) was requested, however not received. Documentation and evidence of a recent performance improvement plan (PIP) was requested, however was not received. When interviewed on 5/2/24 at 5:10 p.m., the administrator stated the facility held quarterly QAPI meetings but due to being interim, he was unable to access the shared network where he believed the previous administrator saved the previous meeting minutes. The administrator stated the facility was also involved in PIPs but was unable to locate documentation of the projects during interview. The facility's QAPI plan dated 4/2024, indicated the QAPI committee, comprised of all department managers, the administrator, director of nursing, infection control and prevention officer, medical director, consulting pharmacist, and quality coordinator, would meet quarterly. The QAPI plan indicated QAPI activities and outcomes would be on the agenda of every staff meeting, and the committee would review data, suggestions, and input to prioritize opportunities for improvement. The facility's QAPI plan indicated the committee would solicit individuals from the organization to conduct PIPs and would monitor their progress. Additionally, the QAPI plan indicated the facility used a Plan-Do-Study-Act model to test actions and recognize and address unintended consequences of planned changes when working to prevent future events and promote sustained improvement.

Based on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that was effective in identifying and responding to quality deficiencies, and developing procedures for feedback, data collection and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas. This deficient practice had the potential to affect all 60 residents currently residing in the facility. Findings include: Quality tracking data was requested from the facility but was not provided. During interview on 5/7/24 at 7:24 p.m., the administrator stated, I think the last administrator had meetings, but was unsure where the meeting minutes were located. The administrator also stated he believed the facility had a PIP but was unable to locate any information regarding the project. A facility policy titled QAPI Plan - 2024 dated 4/2024, indicated the facility implement PIPs to improve processes, systems, outcomes, and satisfaction. The QAPI plan indicated the facility would conduct PIPs to revise and improve care or services in areas identified as needing attention. The QAPI plan indicated topics for PIPs were identified during quarterly review of data and input from data sources (Centers for Medicare and Medicaid Services (CMS) quality measures, falls, medication errors, rehospitalization rates, resident satisfaction, abuse, neglect, and maltreatment reports, complaints, resident council and family council, satisfaction surveys, and suggestion boxes). The plan indicated it would look at issues, concerns, and areas that need improvement as well as areas that will improve quality of life and quality of care and services for the residents. The plan also indicated PIPs would include high-risk, high-volume, or problem-prone areas that affected health outcomes and quality of care and areas that affected staff. Additionally, the plan indicated other considerations would include existing standards or guidelines, measures that could be used to monitor progress, quality measures publicly reported on Nursing Home Compare, goal areas from the Advancing Excellence in America's Nursing Homes Campaign, and projects that require system or environmental changes, and those affecting staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 53 of 58 residents with personal funds accounts (including R5, R6, R8, R11 and R12) deposited with the facility, had access to the personal funds after hours and on weekends. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 3/21/24 at 8:41 a.m., R5 stated he could only get money out of his account twice a month. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. On 3/21/24 at 8:44 a.m., R6 stated he could only pull money out of his account Monday through Friday from 8:00 a.m. until 10:00 a.m. R6 stated if the banking office was closed, he couldn't get his money. R8's admission MDS dated [DATE], indicated R8 was cognitively intact. On 3/21/24 at 8:54 a.m., R8 stated he would be able to take money from his account during banking hours from 8:00 a.m. until 10:00 a.m. but not after that time frame. R11's quarterly MDS dated [DATE], indicated R11 was cognitively intact. On 3/21/24 at 9:04 a.m., R11 stated he was not able to get money from his account after 10:00 a.m. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact. On 3/21/24 at 9:07 a.m., R12 stated she could get money from her account between 8:00 a.m. and 10:00 a.m. in the morning during weekdays, but not on the weekends. On 3/21/24 at 10:01 a.m., trained medication assistant (TMA)-A stated if residents came to her and asked for money, she would tell them the business office was open Monday through Friday from 8:00 a.m. to 10:00 a.m. TMA-A stated she would not be able to give them any money. TMA-A stated there was $20 available at the nurse's station for residents if needed. On 3/21/24 at 10:04 a.m., licensed practical nurse (LPN)-A stated there was $20 at the nurse's station if residents requested money after hours and on weekends. On 3/21/24 at 11:56 a.m., R23 stated she could take money out of her account Monday through Friday during the hours of 8:00 a.m. until 10:00 a.m. On 3/21/24 at 11:58 a.m., R24 stated she could get money from her account from 8:00 a.m. until 10:00 a.m., but not after hours or on the weekends. On 3/21/24 at 12:52 p.m., the administrator stated he was not aware residents had concerns not having access to their personal funds accounts. The administrator stated residents should have access to their money 24 hours a day, seven days a week. The administrator stated the facility has not informed residents they can go to the nurse's station and get money from their accounts, because there would be a line all of the time with residents wanting to withdraw their money. On 3/21/24 at 2:46 p.m., business office staff (BO)-A stated he was not aware of any cash fund at the nurse's station, but administration was working on setting that up. BO-A stated residents had a paper where they could sign up to be able to take money out on the weekends, but they had to do this by Friday of that week. BO-A stated the funds would then be left at the nurse's station for that weekend. BO-A stated if ten residents were to go to the nurse's desk on the weekend and ask for $10, they would not be able to get that money until Monday. On 3/22/24 at 12:21 p.m., the business office door had a sign which indicated, Open from 8:00 a.m. to 10:00 a.m. On 3/22/24 at 12:24 p.m., the nurse's station had $20 cash in a locked draw. A policy related to resident trust accounts was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to reconcile resident personal fund accounts for 53 of 58 residents (including R5, R6, R8, R11, and R12). In addition, the facility failed to provide quarterly statements for resident personal fund accounts for 53 of 58 residents reviewed for personal fund accounts. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 3/21/24 at 8:41 a.m., R5 stated he had not received a quarterly statement for his personal fund account. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact. On 3/21/24 at 8:44 a.m., R6 stated he had not received a quarterly statement for his personal fund account. R8's admission MDS dated [DATE], indicated R8 was cognitively intact. On 3/21/24 at 8:54 a.m., R8 stated he had not received a quarterly statement for his personal fund account. R11's quarterly MDS dated [DATE], indicated R11 was cognitively intact. On 3/21/24 at 9:04 a.m., R11 stated he he had not received a quarterly statement for his personal fund account. R12's quarterly MDS dated [DATE], indicated R12 was cognitively intact. On 3/21/24 at 9:07 a.m., R12 stated she had not received a quarterly statement for her personal fund account. The facility computerized Trust Transaction History dated 3/21/24, indicated a balance of $74,000.06 in the residents' trust fund bank account. The First Bank and Trust Savings Account statement dated 3/21/24, indicated a balance of $56,359.21. The First Bank and Trust Checking Account statement dated 3/21/24, indicated a balance of $900.72. According to all calculations, the computerized Trust Transaction History indicated a $74,000.06 balance in the resident's personal funds accounts. The First bank and Trusts savings and checking accounts totaled $57,259.93. The current amount of cash within the safe and cash box at the facility was $3,266.35., indicating a discrepancy of $13,473.78 which was unaccounted for. On 3/21/24 at 12:52 p.m., the administrator stated he was not aware of any discrepancies in the resident trust. The administrator stated he had access to both the computerized Trust Transaction History and the bank documents. The administrator stated, Everything is on the up and up here. On 3/21/24 at 1:34 p.m., the chief financial officer (CFO) stated she was unaware of any pending or missing deposits to the resident personal fund accounts. The CFO stated she was not aware of a $13,000+ dollars difference in the accounts, and she was unable to give any explanation. On 3/21/24 at 2:13 p.m., the administrator stated he had not looked at the Trust Transaction History and the bank statements together. The administrator stated he had not had concerns to make him feel like he needed to look at them. The administrator stated he did not know where the money went, and he was not aware of the last time the Trust Transaction History and the bank accounts were reconciled. The administrator stated he thought the CFO was responsible to reconcile the accounts. On 3/21/24 at 2:46 p.m., business office staff (BO)-A stated he does not have access to the bank accounts, so he is not able to reconcile the Trust Transaction History and the bank accounts. BO-A stated the CFO and owner reconcile the accounts and was not aware if quarterly statements were given to residents. On 3/21/24 at 2:56 p.m., the administrator stated residents have not been getting quarterly statements on their personal funds accounts, but they would be starting 4/1/24. On 3/22/24 at 9:09 a.m., the owner of the facility stated the Trust Transaction History and the bank accounts had not been reconciled in several months. The owner stated he was under the impression it was being done by the CFO monthly, which is what he would have expected to be done. Policies related to quarterly statements and reconciliation of accounts were requested and not provided.

Based on interview and document review, the facility's current administration failed to ensure proper oversight for the facility's financial operations. This practice resulted in resident personal funds accounts being unaccounted for. This had the potential to affect all 58 residents who resided in the facility at the time of the survey. Findings include: The facility computerized Trust Transaction History dated 3/21/24, indicated a balance of $74,000.06 in the residents' trust fund bank account. The First Bank and Trust Savings Account statement dated 3/21/24, indicated a balance of $56,359.21. The First Bank and Trust Checking Account statement dated 3/21/24, indicated a balance of $900.72. According to all calculations, the computerized Trust Transaction History indicated a $74,000.06 balance in the resident's personal funds accounts. The First bank and Trusts savings and checking accounts totaled $57,259.93. The current amount of cash within the safe and cash box at the facility was $3,266.35., indicating a discrepancy of $13,473.78 which was unaccounted for. On 3/21/24 at 12:52 p.m., the administrator stated he was not aware of any discrepancies in the resident personal funds accounts. The administrator stated he had access to the computerized Trust Transaction History and the bank documents. The administrator stated, Everything is on the up and up here. On 3/21/24 at 1:34 p.m., the chief financial officer (CFO) stated she was unaware of any pending or missing deposits to the resident personal fund accounts. The CFO stated she was not aware of a $13,000+ dollars difference in the accounts, and she was unable to give any explanation. On 3/21/24 at 2:13 p.m., the administrator stated he had not looked at the Trust Transaction History and the bank statements together. The administrator stated he had not had concerns to make him feel like he needed to look at them. The administrator stated he did not know where the money went, and he was not aware of the last time the Trust Transaction History and the bank accounts were reconciled. The administrator stated he thought the CFO was responsible to reconcile the accounts. On 3/21/24 at 2:46 p.m., business office staff (BO)-A stated he did not have access to the bank accounts, so he was not able to reconcile the Trust Transaction History and the bank accounts. BO-A stated the CFO and owner reconcile the accounts. On 3/22/24 at 9:09 a.m., the owner of the facility stated the Trust Transaction History and the bank accounts had not been reconciled in several months. A policy related to administration oversite expectations was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to implement interventions to prevent elopement, failed to follow safety plan for leaving the premises, and failed to timely report missing person in accordance with care plan and facility policy for 1 of 1 resident (R1) who had a history of multiple elopements related to audible hallucinations. Findings include: During interview on 3/13/24 at 2:20 p.m., R1 stated he enjoyed being able to leave the facility to take walks, use public transportation, go to restaurants, and visiting with his mother. He managed his own money and had a bus card. R1 recalled running away from the facility this week and was not planning on coming back. R1 explained there was two ways he would leave the facility and indicated it was dependent on the voices he heard in his head. The first way was taking his phone, going to the nurses station to sign out, and get his GPS tracker. The other way was when the voices gave him the desire to escape or the need to runaway. He would intentionally not bring his GPS tracker because he did not want staff to know he was running away, and there was nothing stopping him from leaving. R1 stated when he heard those voices he felt claustrophobic, felt like his skin was crawling, and it was almost like an attack and could feel my heart pounding. R1 stated the desire to escape came every couple of months. R1 endorsed smoking cigarettes and the frequency varied. During interview on 3/13/24 at 3:04 p.m., licensed practical nurse LPN-(A) reported R1 had an ongoing history of elopement, however the facility initiated a tracker system with global positioning system (GPS) in which R1 had been compliant with the last couple of months. LPN-A reported R1's voices have been a lot worse recently and the voices tell R1 to do things; the facility was trying to figure out why. LPN-A explained R1 heard voices all the time, however some of the voices were mean and intense; these command voices gave R1 more negative direction by telling him to do things which were uncharacteristic such as take off clothing and leaving without telling anyone. LPN-A indicated when R1 was hearing the command voices that's when he would escape from the facility. LPN-A was able to distinguish when R1 heard the negative voices because his eyes would become big and buggy, he tended to pace more, and would ask for more cigarettes.When R1 would demonstrate these behaviors she implemented more frequent checks on his whereabouts. R1's face sheet identified R1 had diagnoses that included schizophrenia, schizoaffective disorder, other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations and other psychoactive substance dependence. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition was not assessed. R1 had inattention behaviors that fluctuate and changed in severity, in addition to hallucinations. R1 did not display physical, verbal or other behavioral symptoms directed at others and did not have a behavior of wondering. R1's ability to leave facility safely assessment dated [DATE], identified R1 had a history of elopement due to negative voices telling him to leave. He had displayed unsafe behaviors in the community when leaving due to his voices. R1 desires to go out into the community unsupervised and has an order in place to leave unsupervised. Disposition identified R1 was deemed safe to leave facility unescorted. R1 knows to check in with the nurse before leaving. R1 will keep tracker in his pocket when leaving the facility unsupervised. R1's Safety in the Community Evaluation dated 10/26/23, identified R1 displayed clear understanding of safe behavior in the community at the time of assessment. Resident is safe to go out into the community unsupervised while utilizing safety interventions. R1's care plan dated 11/8/23, identified behavior of wandering and was at risk for elopement. The following history was included in R1's care plan: -On 8/12/23, staff discovered R1 was not in building during hourly checks, not at his moms, hospitals contacted, police report done. R1 returned at 2:00 a.m. 8/13/23/23, was not drinking and physically okay. R1 had been walking. He reports sometimes feels cooped up because of the hourly checks and safety measures in place related to the incident that occurred on 2/12/23. -On 9/1/23 R1 left facility around 5:00 a.m., he was not answering phone or at moms house, missing person report was done and social service director (SSD) was contacted. On 9/2/23 at 8:30 a.m. R1 was afraid to return to the facility. R1 did not want to get locked up, he returned unharmed by self from St. [NAME] at 11:45 on 9/2/23. A tracker device was not available, tracking device was now available. R1's care plan also informed and directed staff of the following: -R1 currently uses a GPS tracker to monitor whereabouts. R1 was to obtain the tracker from charge nurse and charge nurse turns it on, Then R1 confirms he has his cell phone on as well. -Facility staff are to provide ACP (associated clinic of psychology) therapist weekly/biweekly, provide medications per Dr/psychiatrist order, Staff are to call his phone if he does not return when he states. -Staff will follow facility policy regarding MISSING PERSON/WANDERING RESIDENT if resident does not return per statement. -Staff will monitor residents whereabouts hourly and document on hourly monitoring sheets. -Staff will use the following guidelines when he wants to leave the facility: Ask him if he is hearing voices tell him to leave, take clothes off etc. , ask if he is having any anxiety and/or thinking about drinking alcohol. Note his general appearance, speech, facial expressions, etc. to see if anything is out of the ordinary. Give him the tracking device and activate it. Make sure he has his cell phone with him and it is charged and the ringer is on. Ask him when he will be returning. Inform him to call facility if he plans on being gone longer then planned. He has to return to the facility BEFORE dark. Have him use the sign out book. When he returns he needs to return the device to the nurse and sign back in. R1's progress note dated 3/9/24 identified at 5:15 p.m., writer noticed R1 wasn't in his room or anywhere in the building. Writer gave him some time to see if he would return from where he was, but he did not. At 5:30 writer called his cell phone and left a voicemail asking him to call and let us know where he was and left phone number. Writer then called his mom to see if he was there, and she said, he wasn't. Writer checked the sign-out book and he had not written anything in it from today. He had not taken the tracking device. Writer decided to give him some more time in case he came back on his own. He did not. Writer notified the director of nursing (DON) social worker and administrator. Writer called 911 and filed a missing persons report and officers came out and go over the details. Writer did a vulnerable adult report online and submitted it. At 12:50 a.m. Sunday [3/10/24] morning, resident reported on his own. When writer asked him what happened or was it voices that told him to leave? He said I just was gonna run away. Writer asked if he had a place he was going to run and he said no. Next writer asked why he decided to return and he said, because it was so cold outside. Although, staff identified R1 was not in the building on 3/9/24, at 5:15 p.m. the police report dated 3/9/24, identified the facility had not reported R1 missing until 10:07 p.m. which was not in accordance with the care plan that directed to follow Missing Person Policy. During interview on 3/13/24 at 4:24 p.m., registered nurse (RN)-A indicated she was familiar with R1 however, was not aware of any behavioral triggers R1 displayed when he heard command voices and described him as having a flat affect (without emotion or stoic). RN-A reported she worked the evening shift on 3/9/24. R1 went out of the facility without staff knowing around 5:15 p.m. and returned at 12:50 a.m. on 3/10/24. RN-A explained while R1 was out of the facility she had called the police, his mother, and administration. When R1 returned he had told RN-A his reason for leaving was he wanted to run away and he came back to the facility because he was cold. RN-A stated she increased R1's safety checks from every two hours to every one hour. R1's progress note dated 3/11/24 at 1:47 p.m. identified social services met with R1. Discussed leaving the facility on 3/9/24 without talking to staff. He stated his voices told him to leave, he stated he was getting afraid of all the people around him and having severe ideation about running. He stated it didn't cross his mind to get the tracking device. Will have therapeutic recreation make a sign for his room with a reminder to get the tracking device when he was having a hard time. R1's progress note dated 3/11/24, at 9:05 p.m. included staff noted the resident to be missing at 8:30 p.m., last seen between 5:30 p.m. and 6:15 p.m. per trained medication aid (TMA). Call placed to 911 as a missing person, gave description, stated that they'll try to locate him. The DON, social worker and ADMIN notified. Will continue to wait any report from the police or the resident to show up. Secondary note dated 3/11/24 at 9:24 p.m. identified R1 had just walked in stated the crazy thoughts are telling me to leave and can't leave me alone, had to leave for a minute, I feel better now. R1 reminded to take his tracker next time he leaves the facility or at least to let staff know. During interview an 3/14/24 at 1:55 p.m., Minneapolis police department representative MPDR-(A) reported nothing was submitted by the facility on 3/11/24 and the last contact was on 3/9/24. However, a report was received by Minneapolis police on 3/20/24, that identified facility staff member contacted police on 3/11/24 at 8:46 p.m. (between 2.5-3.25 hours since he was last seen) and R1 was located at 9:14 p.m. During interview on 3/14/24 at 10:13 a.m., trained medical aid TMA-(A) indicated on 3/11/24, she provided R1 with his medications at 3:30 p.m. and when she provided medications she was supposed monitor for behavioral symptoms. TMA-A stated she would ask R1 questions like how are you today?, is everything good?, or anything bothering you? but R1 did not typically express a lot. TMA-A did not articulate the questions outlined in the care plan. TMA-A stated R1 had never told her he was hearing the command voices and was not aware of R1's triggers and/or behaviors exhibited when R1 heard command voices. TMA-A stated the first time she had observed anything abnormal in R1's behaviors was on 3/11/24 around 5:30 p.m. He was outside walking away from the facility at a fast pace, his eyes were big, opened wide, and bulging which was abnormal. TMA-A had asked R1 where was he going and told him he needed his tracker, but R1 said No, I wil be right back I promise. TMA-A reported R1 was on 2-hour safety checks, did not have any safety concerns for R1 and felt he would come right back. TMA-A indicated she notified another facility staff member around 6:00 p.m. (could not recall who). TMA-A stated around 8:00 p.m. she tried to find R1 however he was missing. During interview on 3/14/24 at 12:06 p.m. nursing assistant NA-(A) indicated she worked with R1 on 3/11/24; she had worked the evening shift. NA-A stated it was her responsibility to check R1's location every hour and document it on his tracking log. NA-A recalled on 3/11/24 at 5:00 p.m., R1 was in the dining room and at 5:08 p.m. R1 was outside smoking. NA-A then went to break. NA-A stated she had returned from break around 5:20 p., did not see R1 but found his cell phone on top of his bed. NA-A recalled documenting out on the tracking log and immediately notifying the nurse. NA-A reported R1 was back in the facility at 9:16 p.m. During interview on 3/15/24 at 11:37 p.m., registered nurse RN-B indicated according to R1's safety monitoring plan, R1 was supposed to be back in the facility before nightfall when it was dark outside because he was a vulnerable adult. During observation on 3/14/23 at 10:35 a.m., R1 entered nursing station area and licensed practical nurse LPN-(A) asked to R1 you're going out for a while? R1 responded yeah. Once tracker was set up LPN-A instructed R1 to put the tracker in his pocket. LPN-A and R1 discussed medication changes, however no further questions were asked to ascertain R1's mental state and about his outing (such as when he was returning). R1 was observed to be standing in a stance like position whith his hands in his pocket. At start of conversation R1 was noted to be staring [NAME] ahead and not blinking or making eye contact and eyes appeared large. When discussing medication changes R1's eye pattern changed and was observed to have rapid eyes movements back and forth with his head down. Additionally, staff member did not make sure R1 had his cell phone with him, it was charged, and the ringer was on. During interview on 3/14/24 at 10:43 a.m., LPN-A reported the behavioral monitoring which was completed during the observation was visual. LPN-A looked at his eyes and voice appeared okay and calm and not pressured. If R1 were to have wild eyes, frightened, or like he was completely distracted and his mind was somewhere else, it would have been different, and more questions were to be asked. LPN-A did not identify concerns with R1's eye patterns. During interview on 3/14/24 at 11:41 a.m., social service director SSD-(A) reported R1 had a history of command voices and elopements in the facility and it was her job to monitor any changes and what the changes were. R1's care plan directed nursing staff to monitor his behaviors, whereabouts, and ask him several questions prior to him being able to leave. SSD-A indicated when R1 had an increase in voices he would leave the facility without telling staff. SSD-A reported R1 did not have any visable differences when R1 heard command voices, however had never witnessed R1 be in the moment of needing to run and escape. All facility staff were to follow the care plan, the behavior monitoring plan, and assess/monitor behaviors multiple times a day. SSD-A was unaware of any triggers for R1. During interview on 3/15/24 at 9:15 a.m., director of nursing (DON) identified R1 missing on 3/11/24 should have been reported to the police. During interview on 3/15/24 at 9:15 a.m. director of nursing (DON) indicated she was noified of R1 missing on 3/11/24 at 7:00 p.m. and staff should have immediatly initaited the missing person protocol when it was identified R1 left the facility without the tracker. Facility staff should be following the resident safety monitoring plan, the care plans, and hourly checks. Facility policy titled Missing Resident Reporting Procedure undated, identified the purpose is to promote a safe environment for all residents and respond appropriately when a resident is missing or overdue back from outside the facility. When a resident is considered missing: -From the hours of 7 am until dark we consider a resident missing if the resident has not returned within 2 hours of the expected return time. -After dark, we consider a resident missing after 1 hour following the expected return time. -If a resident has left the facility without signing out, use the time that you discover them out of the facility as the time to start the 2-4 hour timer. -If a resident has not returned by the expected time but has been in communication with staff, they are not considered to be missing. Staff are to update a new return time and the whereabouts of the resident and documented by putting in a progress note and updating the sign-out sheet. What to do when a resident is missing: -Elopement/wander binder is located at Nursing station 1) verify the resident did not come back to the facility but failed to sign in. 2) announce code white over loudspeaker 3) staff meet at nursing station for further assignment- check inside and outside the facility and surrounding neighborhood. 4)Inform administrator, social services and DON 5) Try to locate the resident and an update on expected return time. a. Try calling the phone number listed on face-sheet or sign out sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure appropriate services and treatment that included medication management and monitoring and failed to ensure coordination of care between mental health care providers to ensure the highest level of mental and psychosocial well being for 1 of 3 residents (R1) who had a diagnosis of schizophrenia with audible hallucinations and a court order for medication management to control symptoms of psychosis. Findings include: R1's court document dated 5/5/22 identified R1 does not have the ability to understand and use information about his mental illness, its symptoms, and treatment. Neuroleptic medications are currently prescribed for respondent (R1) by his treatment provider. They are prescribed to relieve his psychotic symptoms, including command hallucinations and paranoia. The documents included a [NAME] order (court order that gives the court the power to order administration of medication for committed person who is unwilling to take prescribed psychiatric medications). The order included, Respondent (R1) does not take prescribed neuroleptic medication voluntarily. Respondents (R1) treating physician attempted to discuss the diagnosis and proposed treatment plan including the use of neuroleptic medication with respondent. However, responded does not have sufficient insight to understand the consequences of not taking the prescribed medications, with the result that he stops taking the prescribed medications and then decompensates. The use of neuroleptic medication will relieve the interference cause by the mental illness and allow respondent (R1) to derive increased benefit from psychosocial therapy. Respondent (R1) is not now competent and lacks the capacity to give or withhold consent for the use of neuroleptic medication. R1's face sheet identified R1 had diagnoses that included schizophrenia, schizoaffective disorder, other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder with hallucinations and other psychoactive substance dependence. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition was not assessed. R1 had inattention behaviors that fluctuate and changed in severity, in addition to hallucinations. R1 did not display physical, verbal or other behavioral symptoms directed at others and did not have a behavior of wondering. R1's care plan dated 9/20/22, identified cognition, psychosis hallucinations. Resident hears command voices that tell him to do various things. He will obey commands if he doesn't take a PRN (as needed) medication to lighten the symptoms. When R1 was having hallucinations, staff are to follow interventions which included: Medications per Psychiatrist/Doctor order. Nursing will update medical doctor (MD) about any reports of increased hallucinations. Staff will ask questions to bring resident back to reality, 1) Are you having whispers, intense, or screaming voices in your head? 2) what are the voices tell you? Remind him that is not okay to take off his clothing and that he is not going to hell if he does not throw away his clothes. Staff will attempt to re-direct when hallucinations are bothering other residents. Staff will offer reality-based support and reassurance to resident when he is experiencing hallucinations. R1's [NAME] order dated 12/15/23, identified order of the court filed April 17th 2023 authorized to use neuroleptic medications: Invega, Thorazine, Zyprexa and/or Haldol was granted. R1's treatment team requested his [NAME] order be amended to include the neuroleptic medication Seroquel and remove Haldol. R1's self-administration of medications dated 1/26/24, identified R1 was unable to identify what their medications were, was unable to tell what each medication was for, unable to tell what the most common side effect for each of their medications. R1 had not demonstrated that he/she understood their medications, what they were and why they are taking them and may not self-administer when on therapeutic leave or day pass. R1 physician orders included the neuroleptic or antipsychotic medications identified in R1's [NAME] order however, did not include an as needed medication for when R1 had episodes of acute psychosis or increased command voices. -Order dated 11/24/21, directed facility staff to ask R1 if hearing voices anxiety, psychosis, agitation give 1 unit by mouth three times a day for anxiety related to other psychoactive substance dependence, uncomplicated. Give PRN if indicated. -Order dated 8/14/23, identified R1 required Quetiapine Fumarate (Seroquel) oral tablet 50 milligram (MG) (antipsychotic medication) give 1 tablet by mouth three times a day for anxiety related to schizoaffective disorder, unspecified. -Order dated 2/27/24, identified R1 required Quetiapine Fumarate oral tablet 100 milligram (mg) (quetiapine fumarate) give 100 MG orally as needed (PRN) for insomnia at bedtime. R1's record did not identify a diagnosis of insomnia nor identify R1 had problems sleeping. R1's behavior monitoring Point of Care (POC) documentation which asked Did the resident experience hallucinations were reviewed in conjunction with medication administration records (MAR) between 3/1/24 and 3/15/24 which prompted a response three times daily for Ask if hearing voices, anxiety, psychosis, agitation and progress notes between 2/13/24 through 3/14/24. The review indicated inconsistent documentation between POC and MAR, without further description of the behavior/hallucination/psychosis documented, and without further assessment and/or interventions when the documented responses identified the presents of the aforementioned. R1's MAR between 3/1/24 and 3/11/24, had recorded entries of NO for all three entries except for the evening on 3/9/24 in which the box was left blank. Responses of YES were documented on 3/12/24, for the morning and noon, and NO for the evening. On 3/13/24, the response was documented and YES. R1's POC documentation included one recorded entry per day which was documented primarily in the morning or mid afternoon. In response to the hallucination question; YES was documented on all days except for 3/1/24, 3/2/24, and 3/3/24. R1's progress note dated 2/13/24 identified R1 was seen by associated clinic of psychology (ACP) and was encouraged to use the PRN medication as needed and inform staff of this need. The note did not include the name of the PRN medication. R1's ACP visit note dated 2/20/24, included R1 continued to experience emotional and behavioral symptoms that affect functioning. R1 reports his auditory hallucinations remain stable and the interventions in place are helpful. R1's sleep, mood and appetite are stable. The treatment plan included ACP to remain part of treatment plan. R1's progress note dated 2/23/24 at 1:30 p.m., identified R1 left the facility to visit family member at 7:30 a.m. and planned to return to the facility the next morning. Prior to leaving R1 denied exacerbation of hallucinations and denied suicidal ideations. He was provided with his medications. R1's ACP note dated 2/27/24, included R1 continued to experience emotional symptoms that affect functioning. R1 reports his mood, sleep, and appetite all remain stable. R1 reports his auditory hallucinations remain stable and he continues to use interventions including walks and music. R1 was reminded of his PRN medication and to alert staff if auditory hallucinations increase. Treatment included: ACP to remain part of treatment plan. The note did not include the name of the PRN medication. R1's progress note dated 2/27/24, at 5:22 p.m. psychiatric medical doctor (MD) indicated R1 had an appointment with multiple medication changes that included Sertraline (antidepressant) increased to 150 mg daily, Thorazine 50 mg three times a day and 150 mg at bedtime, seroquel 50 mg three times a day plus 100 mg as needed for insomnia. In review of R1's record it was not evident R1's psychotropic medication changes were continuously monitored for effectiveness. R1's associated clinic of psychology (ACP) note dated 3/5/24, identified progress toward treatment goals and continued medical necessity. Continued services are needed to maintain and improve the client's current level of functioning. Client continues to exhibit behavioral and emotional symptoms that affect functioning. R1 was reminded by treating provider of R1's PRN medication and to alert staff if auditory hallucinations increase. The name of the PRN medication was not mentioned. During interview on 3/13/24 at 2:20 p.m., R1 stated he enjoyed being able to leave the facility to take walks, use public transportation, go to restaurants, and visiting with his mother. He managed his own money and had a bus card. R1 recalled running away from the facility this week and was not planning on coming back. R1 explained there was two ways he would leave the facility and indicated it was dependent on the voices he heard in his head. The first way was taking his phone, going to the nurses station to sign out, and get his GPS tracker. The other way was when the voices gave him the desire to escape or the need to runaway. He would intentionally not bring his GPS tracker because he did not want staff to know he was running away, and there was nothing stopping him from leaving. R1 stated when he heard those voices he felt claustrophobic, felt like his skin was crawling, and it was almost like an attack and could feel my heart pounding. R1 stated the desire to escape came every couple of months. R1's progress note dated 3/9/24 at 9:13 p.m. indicated at 5:15 p.m. R1 was not anywhere in the building, had not signed out, a missing person report was filed, and R1 had not returned until 12:50 a.m. on 3/10/24. R1 reported to facility staff I just was gonna run away. and only returned because it was cold outside. R1 was administered his 8:00 p.m. medications and was given PRN (name of med was not included nor reason/symptomology it was given for) Writer reminded him that he can go to myself or another nurse ect. if he feels like running away again or if the voices start telling him to leave and tell us about what's going on so that we cn give him a PRN or whatever it is that he might need. He said he would. R1's medication administration records reviewed between 3/1/24 through 3/15/24, identified R1 received PRN dose of Seroquel 100 MG orally as needed for insomnia at bedtime on 3/10/24 at 12:51 a.m. R1's record did not identify the indication for which the Seroquel was given and/or the effectiveness for which it was administered. R1's progress note dated 3/11/24, at 9:05 p.m. included staff noted the resident to be missing at 8:30 p.m., last seen between 5:30 p.m. and 6:15 p.m. per trained medication aid (TMA). Secondary note dated 3/11/24 at 9:24 p.m. identified R1 had just walked in stated the crazy thoughts are telling me to leave and can't leave me alone, had to leave for a minute, I feel better now. R1 reminded to take his tracker next time he leaves the facility or at least to let staff know. During interview on 3/14/24 at 10:13 a.m., trained medical aid TMA-(A) indicated on 3/11/24, she provided R1 with his medications at 3:30 p.m. and when she provided medications she was supposed monitor for behavioral symptoms. TMA-A stated she would ask R1 questions like how are you today?, is everything good?, or anything bothering you? but R1 did not typically express a lot. TMA-A did not articulate the questions outlined in the care plan. TMA-A stated R1 had never told her he was hearing the command voices and was not aware of R1's triggers and/or behaviors exhibited when R1 heard command voices. TMA-A stated the first time she had observed anything abnormal in R1's behaviors was on 3/11/24 around 5:30 p.m. He was outside walking away from the facility at a fast pace, his eyes were big, opened wide, and bulging which was abnormal. During interview on 3/13/24 at 3:04 p.m., licensed practical nurse LPN-(A) reported R1 had an ongoing history of elopement. LPN-A reported R1's voices have been a lot worse recently and the voices tell R1 to do things; the facility was trying to figure out why. LPN-A explained R1 heard voices all the time, however some of the voices were mean and intense; these command voices gave R1 more negative direction by telling him to do things which were uncharacteristic such as take off clothing and leaving without telling anyone. LPN-A indicated when R1 was hearing the command voices that's when he would escape from the facility. LPN-A was able to distinguish when R1 heard the negative voices because his eyes would become big and buggy, he tended to pace more, and would ask for more cigarettes. When R1 would demonstrate these behaviors she implemented more frequent checks on his whereabouts. R1's care team tried to keep R1's medication ridged as R1 decompensates very quickly. LPN-A was unaware of any sleep concerns with R1. During subsequent interview on 3/14/24 at 8:45 a.m., LPN-A reported the staff were supposed to have a PRN medication to give to R1 if they identified increased behavioral symptoms and/or command voices, however the medication (Seroquel) that would be used was specifically ordered insomnia at bedtime with no other behavioral symptoms identified for which it could be given for and therefore could not and has not been given during those episodes. LPN-A indicated she had communicated the concern with the psychiatrist (did not identify a date) with no change to the order given. LPN-A explained R1's psychiatrist made large medication changes on 2/27/24, but did not give any direction on how to monitor for the effectiveness or when to follow-up with the results. During interview on 3/13/24 at 4:24 p.m., registered nurse (RN)-A indicated she was familiar with R1 however, was not aware of any behavioral triggers R1 displayed when he heard command voices and described him as having a flat affect (without emotion or stoic). During interview on 3/14/24 at 8:17 a.m., licensed graduate social worker LGSW-(A) reported to provide services through ACP (associated clinic of psychology) and had been R1's provider since may of 2023. LGSW-A had discussed with R1 and encouraged R1 to inform staff when the voices were stating to occur rather than when the voices were at their highest. LGSW-A reported R1 had a PRN medication available to assist with the increased voices but R1 needed to ask staff for medication when the voices were getting worse so that R1 received the PRN medication in time. LGSW-A was unaware R1's medications had changed on 2/27/24 and medications were not managed by ACP but through the primary provider. During subsequent interview on 3/14/24 at 3:34 p.m., LGSW-A reviewed R1's orders and identified the physician had ordered R1's PRN mediation for insomnia at night. LGSW-A reported R1 had never reported poor sleep and had always reported to LGSW-A he had been sleeping well. LGSW-A was not aware of any other mental health care provider was involved with R1's care. LGSW was under the impression R1 had a PRN medication available for when his negative auditory hallucinations increased and staff could prevent R1 from becoming manic. During interview on 3/15/24 at 8:48 a.m., R1's primary physician nurse practitioner NP-(A) stated she had not been notified of R1 leaving the facility without staff awareness and was not aware of the presence of command voices. NP-A indicated the command voices and management would be up to psychiatry. Psychology and psychiatry NP-A was not aware of any concerns with R1's sleep. During interview on 3/14/24 at 3:08 p.m., medical doctor MD-(A) reported to be R1's psychiatrist since Halloween of 2023. MD-A was unaware R1 was being provided ACP services and was unsure if it would be appropriate due to R1's need for a highly specialized provider due to R1's disorders. MD-A indicated he had not been aware of R1's complete behavioral history as a result of the command voices including when R1 had been found with no clothes on outside in cold temperatures last winter (2023). Since MD-A has been treating R1, he did not believe the command voices have led R1 to self-harm. MD-A further indicated R1's command voices could be harmful and cause emotional distress. MD-A endorsed there were medications changes on 2/27/24, including the addition of a PRN dose of Seroquel for resistant insomnia and anxiety. MD-A indicated the PRN dose was prescribed based on R1's concerns of difficulty sleeping and anxiety as the facility did not record or provide sleep logs. MD-A reported auditory hallucinations for R1 can be improved by medication and there was almost not a moment R1 should not be untouched by the frequent doses. MD-A did not address and/or instruct which of R1's medications could be administered PRN to control or manage R1's acute exacerbations of psychosis secondary to R1's command voices. During interview on 3/14/24 at 4:31 Administrator and DON indicated R1 typiclly left the facility unescorted to psychiatry appointments and R1 would bring a after visit summery (AVS) from the appointment and hand deliver it to the nursing team at the facility. The document then gets uploaded into R1's electronic medical record. If facility nurses have questions or concerns, they have the ability to call R1's psychiatry care team, however all communication should be documented on a referral communication form and that would also be uploaded into R1's medical record. R1's psychology appointments were in house and if the provider had any concerns she would collaborate directly with the nursing team at the facility at the time. Administrator and DON reported R1's psychiatrist had not communicated R1 had feelings of being overwhelmed in his space or in his room. DON was not sure if R1's psychiatrist and care team members through ACP had any collaboration or communication between themselves. DON had not reached out to R1's psychiatrist as had not been aware of any issues that needed to be communicated. DON was unaware of any sleeping concerns for R1 and there was no concerns communicated to the doctor regarding sleep. The only option for medication on board to manage an acute exacerbation of the identified behavior was the Quetiapine Fumarate but that was specifically ordered as needed for sleep at bedtime. There was no medication to offer if and when the negative voices/behavior was identified during the day. Staff were to follow R1's safety monitoring plan to keep R1 safe as well as follow the missing person protocol. Policy and procedures for medication administration and behavioral health was requested and not received. Facility assessment tool dated 7/11/23 identified the facility to be able to manage residents with Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions with an acuity number of 60 residents. Specific care or practices include Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

Based on document review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were reported to the state agency (SA) within the mandated 2 hour time frame, and in accordance with established policies and procedures for 2 of 6 facility reported incidents investigated during the survey. Findings include: The facility ABUSE, NEGLECT AND EXPLOITATION PREVENTION POLICY, updated on 06/23/21, directed, The residents of Birchwood Care Home have the right to be free from abuse, neglect and/or corporal punishment of any type by anyone. The policy directed, immediately after an incident occurs for alleged violations of maltreatment .the Administrator, the Director of Nursing (DON), and the Director of Resident Services (DRS) must be contacted. Review of the incident report submitted by the facility to the SA on 05/24/23 at 10:43 a.m., indicated the administrator, DON, and DRS were not contacted by licensed practical nurse (LPN)-A immediately after the incident occurred, nor was a report generated per policy. The incident involved one resident's (R45) hands made contact with another resident's (R3) chest due to a medication administration place-in-line argument. No injuries to either resident occurred but physical contact was made. The report indicated the facility acted the following morning after the administration was informed of the prior evening's incident. The initial report was sent, the investigation was completed, and the five-day report was completed and submitted within the correct time frame. The Agency Director was informed of LPN-A's neglect to follow protocol. An interview with LPN-A on 06/07/23 at 2:26 p.m., revealed that she had been informed of the incident that night by a staff member. The staff member told LPN-A that a progress note had been written. LPN-A stated she did not call anyone to inform them of the incident. Review of reporting and investigation documents for incident submitted to the SA by the facility revealed the facility informed the SA on 3/7/23 at 7:51 p.m., when the incident occurred at 11:25 a.m. that day. The incident involved a resident (R109), who was seen on video standing with his back to the camera in the smoking area of the facility. Review of the video revealed that the offender was not seen making contact. Further review of the video revealed the head of the offended (R1) was seen to go backwards. The initial reporting was done past the regulated two-hour deadline. The facility then investigated the incident and submitted the five-day report in the designated time frames. An interview with the Social Worker on 06/07/2023 at 10:43 a.m., revealed she was aware of the two-hour reporting deadline but didn't know why this incident wasn't reported when it should have been. She didn't realize it had been late until it was pointed out to her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed follow provider orders to provide adequate supervision for 1 of 3 (R1) reviewed for the ability to leave the facility unsupervised to prevent accidents. Findings include: R1's provider order dated 7/7/22 indicated R1 may not leave the facility unsupervised. R1's medication administration record (MAR) dated 7/7/22, identified R1 may not leave facility unsupervised. R1's care plan dated 7/7/22, identified R1 was a vulnerable adult and at risk for abuse, neglect, and exploitation. R1's Minimum Data Set (MDS) dated [DATE], identified R1 as experiencing hallucinations, delusions, and moderately impaired cognition. When R1 received antipsychotic, antianxiety, and antidepression medication no wandering behaviors were observed. R1 did not need assistance with activities of daily living (ADLS). R1's medical diagnoses included depression, anxiety, adult maltreatment, and acute cerebrovascular insufficiency (decreased blood flow to the brain causing damage.) In addition, R1 was assessed as a high fall risk. R1's care plan dated 10/14/22, identified R1 had moderate impaired cognition. R1's progress note dated 11/30/22, identified R1 had fallen on the street. A truck driver stopped to help R1 get up, and the staff assisted her back to the facility. R1 told the staff she was going out to get some fresh air. Staff reminded her to stay at the facility and not to cross the street. R1's Resident's ability to leave facility safely assessment dated [DATE], identified R1 was impulsive. In addition, R1 had a drop foot, requiring a leg brace to walk. Currently R1's leg brace was broken. R1 could walk without the brace, but she was very slow. The assessment identified the current medical provider's order for supervision when R1 left the building was no longer needed, and the staff would consult with R1's medical provider to discontinue the order. In addition, the interdepartmental team (IDT) encouraged R1 not to leave the facility unless she was supervised, identified where she was going and how long she would be gone. R1's Safety in the community evaluation dated 11/3/22, identified she understood the importance of letting the staff know when she planned to leave the building. R1's progress note dated 12/2/22, identified R1 was observed walking away from the facility and then picked up by an unknown woman driving a car. R1's progress note dated 12/2/22, identified other residents alerted the facility nursing staff when R1 had fallen across the street from the facility. Two strangers attempted to get R1 up when the nursing staff arrived at the scene with a wheelchair. R1's clothing was soaking wet, no injury reported, and facility staff transferred her back to the facility. R1 told the staff she was sorry she left the facility and would not do it again. R1's care plan dated 1/23/23, identified R1 was very vulnerable and had a history of people taking advantage of her. R1 required constant redirection related to her hallucinations and poor attention skills. In addition, R1 made poor decisions, had a mild developmental disability and a history of not being able to find her way back to the facility without the assistance of staff, strangers, or law enforcement. R1's care plan dated 1/23/23, identified R1 left the facility without supervision on 7/11/22, 7/30/22, 8/6/22, 10/13/22, 12/2/22, 12/30/22, 1/10/23, 1/14/23, and 1/15/23. At that time R1 told the staff she left the facility to have sex or get good weed. R1's progress note dated 12/29/22, identified R1's medical provider's nurse inquired about the recent request to discontinue R1's order preventing her from leaving the facility unaccompanied. The nurse indicated she would update the medical provider. R1's progress note dated 12/30/22, identified R1 left the facility without supervision around 7:00 p.m. The St. [NAME] Homeless Shelter called the nursing staff when R1 arrived at their location. Birchwood's interim social worker picked up R1 and drove her back to the facility. R1 told the staff she went to St. [NAME] because it's where the good weed is. R1 promised the staff she would never leave the facility again without supervision. R1's progress note dated 1/10/23, identified a bartender from a wine bar called the facility staff because R1 was worried about the current icy conditions and needed transportation back to the facility. R1 had purchased snacks and alcohol while she was there. The police were called to help R1 return to Birchwood Care Center, but they were unable to help related to the number of high volumes of priority calls they had in their queue. R1's progress note dated 1/14/23, identified R1 had left the building around 3:00 p.m. While R1 was away a stranger at a grocery store called the facility for R1 so she could be picked up. The nursing staff arranged for a taxi to pick R1 up. Once the taxi driver arrived at the store, R1 was no longer there. Later the nursing staff received a phone call from a stranger who told them they were driving R1 back to the facility. R1 arrived at the facility at 5:35 p.m. R1's progress note dated 1/15/23, at 1:11 p.m. identified R1 left the facility between 12:00 p.m. and 1:00 p.m. The nursing staff conducted a building search and walked around the neighborhood looking for R1, but they were unable to find her. R1's progress note dated 1/15/23, at 4:32 p.m. identified the administrator was notified R1 was last seen at 11:00 a.m. and she instructed the staff to wait until 8:00 p.m. for her to return. R1's progress note dated 1/15/23, at 8:37 p.m. identified the nursing staff made a missing person's report with the police department and reported the incident to the Office of Health Facility Complaints. R1's progress note dated 1/15/23, at 9:22 p.m. identified the facility notified the police about R1's disappearance. Shortly after they made the report a hospital called the staff and told them R1 was brought to the hospital by the police for a possible cold exposure injury. In addition, the hospital explained the St. [NAME] police department found R1 on a park bench in St. [NAME]. R1 told the police she went to St. [NAME] with friends to score some good weed. R1 stated her friends left her to panhandle and she did not want to go with them, so she remained in the park. No injuries were reported. R1's progress note dated 1/16/23, at 12:57 a.m. identified R1 returned to Birchwood Care Center. R1's progress note dated 1/18/23, at 11:52 a.m. identified staff instructed R1 they are no longer able to keep her safe at Birchwood Care Center. R1 pleaded with the staff she would never leave again unsupervised. In addition, R1 was notified of the plan to transfer her to a new facility with a locked memory care unit, and to find a court ordered legal guardian to make her future medical decisions. During interview on 1/26/23, at 11:23 a.m. R1 Stated she left the facility last Friday and took a bus to Saint [NAME]. R1 stated the bus stop is just across the street from Birchwood Care Center. R1 stated even though she had fallen and was robbed in the past, she was not afraid to leave the facility by herself. R1 carried a photo ID and wore a wrist band with the facility's contact information. R1 stated she is happy at Birchwood Care Center and had made several friends. R1 stated she likes to go to Saint [NAME] because she knows people at the St. [NAME] homeless shelter and feels safe there. During interview on 1/26/23, at 12:32 p.m. treatment medical assistant (TMA)-A stated it was the resident's right to leave the facility on their own, unless the medical provider's order stated, may not leave the facility unsupervised. TMA-A stated currently the facility had three residents who would leave the facility on their own without supervision. To ensure those residents were safe, the staff conducted hourly safety checks. Because of R1's behavior she required the staff to check on her every 30 minutes. If staff observe these residents leaving the facility, they were required to remind them to stay in the building and notify the social worker. TMA-A stated one-time last summer R1 told the staff she was going to walk to the gas station to get a fountain drink. She was reminded to stay at the facility but R1 said I'm going and walked away. TMA-A added on the way to the gas station R1 fell in the middle of the street and required assistance to get up. During interview on 1/26/23, at 1:45 p.m. the director of nursing (DON) stated R1's medical provider's order identified she was unable to leave the facility without supervision. DON stated R1 left the facility multiple times without letting the staff know where she was going or when she would return. The DON stated in the past R1 would leave the facility with her boyfriend, but they are no longer dating. The DON stated R1 would leave the building and upon her return she would promise never to do it again. The DON stated each time she would believe her and felt the facility could keep her safe. The DON stated when they received a new resident the medical provider would review the facility's order set to choose the appropriate orders for their resident. One of those choices was an order stating if the resident could leave the facility independently. The DON stated most physicians are picking the option requiring a [NAME] even though only a court appointed guardian or judge had the legal authority to do so. In addition, the DON stated R1 usually returned within 4-5 hours after leaving the facility. The DON stated the facility's policy identified staff were required to wait until midnight before filing a missing person's report to the police. In this case, the team decided to wait until 8:00 p.m. before they made a missing person's report. Additionally, the DON stated they did not consider R1's absence as wandering or an elopement because she had a purpose when she left and was her own decision maker. Since 1/15/23, the facility found a legal guardian, and future placement to keep R1 safe. During interview on 1/26/23, at 1:12 p.m. the case manager (CM)-A stated she was appointed by the court system to monitor R1. CM-A stated R1 was very impulsive and unable to accurately identify her surroundings and safety. CM-A stated in the past while R1 resided at the Saint [NAME] homeless shelter she was financially and sexually exploited. To complicate matters, R1's history of cerebrovascular accident (stroke) caused her to have frequent falls and memory loss. On 1/15/23, R1 left the facility and was found on a park bench in St. [NAME] by the police. She was taken to the hospital to be assessed for cold exposure. CM-A agrees with the facility's plan of action to obtain a legal guardian, and transfer R1 to a locked memory care unit for her own safety. The Facility Assessment Tool dated 11/26/19, a Safety in the Community Assessment is to be completed during admission, annually, and PRN, then documented in residents care plan those who are not allowed to leave the facility independently. The facility's Missing Person and Wandering Resident policy dated 5/2/7, states that when a resident's location is unknown, staff would search the building and surrounding area. If not found staff would contact family or friends to find out if they knew where the resident was. Staff would notify the administrator, the DON, and the social worker. In addition, the facility would report to the local police department and file a missing person's report.