**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and document review, the facility failed to follow R1's Physician Orders for Life-Sustaining Treatment (POLST) do not attempt resuscitation (DNR), do not intubate, and to allow natural death for 1 of 3 residents (R1) when R1 became unresponsive after a fall and licensed practical nurse (LPN)-A initiated cardiopulmonary resuscitation (CPR). The immediate jeopardy began on [DATE] when R1 became unresponsive after a fall, licensed practical nurse (LPN)-A initiated cardiopulmonary resuscitation (CPR), and was identified on [DATE]. The campus administrator, director of nursing, and nurse manager of facility staff were notified of the immediate jeopardy at 3:20 p.m. on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated he was a DNR. R1's progress note dated [DATE] at 10:17 a.m., indicated R1 was found on the floor by a nursing assistant (NA) at 6:07 a.m. R1 became unresponsive while staff were cleaning him up after a bowel movement. His skin color changed, and he stopped talking to them. CPR was initiated. The ambulance staff continued lifesaving efforts and transported R1 to the hospital. Facility investigation interview with LPN-A note dated [DATE], indicated when R1 became unresponsive she left the room to update the officer on duty (OD) and retrieve R1's medical chart. She indicated while holding the POLST document her finger covered up the check mark for the DNR option. She interpreted his code status as a full code and initiated CPR. During an interview on [DATE] at 1:42 p.m., LPN-B stated she would go to the computer to look up the resident's code status or read the POLST located in their chart at the nursing station. During an interview on [DATE] at 3:10 p.m., LPN-C stated she would look for the POLST in the resident's chart and make sure it was signed. The label on the chart spine would be white if they were a full code. During an interview on [DATE] at 3:17 p.m., LPN -D stated she would go to the chart to find the code status documented on the POLST. During an interview on [DATE] at 3:25 p.m., registered nurse (RN)-A stated she would expect the nurses to look for the CPR status on the POLST. The second nurse arriving during a cardiac arrest would verify the code status. Interview on [DATE] at 2:14 p.m. family member (FM)-A stated his father had Alzheimer's disease, and he was the appointed healthcare representative. R1 had been a DNR since admission to the facility on [DATE]. He received a phone call on [DATE], notifying him his father was pulseless, and staff were doing CPR. He thought to himself why are they doing CPR, but he didn't say anything to the staff and just wanted to get to the facility. On the way to the facility, he received a phone call from the hospital. He was told they were only able to get his pulse back for a few minutes before his heart stopped again. They wanted to stop CPR. FM-A told them they should have never started CPR because his father was a DNR. Interview on [DATE] at 10:47 a.m. LPN-A stated while they were cleaning him up after a bowel movement, he became unresponsive, and his color changed. She left the room to call the OD and to look up his code status. She still had her gloves on, and she only saw attempt resuscitation. She started CPR when she returned to the room. The next day staff told her she read the POLST wrong. She looked again and saw the check mark for Do not resuscitate. Since she had training on how to read a POLST. She now knows the chart spine label is colored white for a full code and blue for a DNR. In addition, the POLST was located inside the chart. The facility policy Medical Emergency Protocol dated [DATE], indicated the nurse would first identify absence of breathing and circulation. Before starting CPR, the resident's code status would be reviewed in the electronic medical record, or the POLST found in the residents chart. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and he deficient practice corrected on [DATE] after the facility implemented a systemic plan that included the following actions: 1. Health unit coordinator (HUC), nurse manager, and registered nurses would check all resident's charts to ensure POLST matched the electronic medical record banner and the charts spine color. 2. Staff were educated on emergency protocols. a. Where to check code status.b. Two people verify the POLST. 3. Completed audits with staff and verified the training. 4. Completed monthly Code drills where staff would read the POLST and correctly identify if a full code or DNR. 5. Ongoing audit schedule to evaluate staff knowledge regarding the POLST and where to find the code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident was free from a significant medication error for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an Immediate Jeopardy (IJ) citation when licensed practical nurse, (LPN)-A administered morphine, a narcotic medication, 20 times the amount that was ordered by the provider. The immediate jeopardy began on 4/11/25 p.m. when LPN-A administered 20 times the amount of liquid morphine to R1 and was identified on 4/17/25. The director or nursing (DON) and the Administrator were notified of the immediate jeopardy at 3:03 p.m. on 4/17/25. The immediate jeopardy was removed on 4/17/25, and the deficient practice corrected on 4/14/25, prior to the start of the survey and was therefore was issued at past noncompliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's primary diagnosis was cerebral vascular accident (stroke). Other diagnoses included: diabetes, dementia and atrial fibrillation. R1's Brief Inventory of Mental Status (BIMs) assessment was not conducted as R1 was rarely/never understood. R1 was dependent upon staff for toileting and personal hygiene, dressing, transferring and rolling from side to side in bed. MDH has the MDS printed from ASPEN. R1's progress note dated 4/11/25 at 11:00 p.m. indicated R1's blood pressure (BP) was 158/61, (normal 100/60 - 120/80), pulse (P) was 73 normal (60-100) oxygen saturation (SpO2) was 86% to 91% (normal 90% - 100%). Oxygen levels were fluctuating, the nurse practitioner (NP) was called. The NP advised 2-4 liters (L)of oxygen. If oxygen levels did not improve R1 was to be sent to the hospital. R1's oxygen remained below 88% and his family declined hospitalization. The NP ordered 5 milligrams (mg) of Morphine every hour as needed. R1's order dated 4/11/25 indicated R1 was to take morphine 5 mg (20 mg/1 ml) oral every hour as needed for shortness of breath. R1's individual narcotic record dated 4/11/25, indicated morphine 20 mg/1 ml. Give 5 mg every hour as needed. The quantity of liquid morphine prior to administration was 15 ml and after administration at 11:45 p.m. was 10 ml, indicating R1 received 5 ml (add 100 mg) and not 5 mg as ordered. R1's progress note dated 4/12/25 at 1:49 a.m., indicated a medication error morphine 5 ml given instead of ordered dose of morphine 5 mg. The NP was notified. R1's BP was 160/74, P 74, R 26, and SpO2 93% on 2 L NC. NP advised to hold the morphine for the next few hours and monitor R1. R1's progress note dated 4/12/25 at 3:00 a.m., indicated death at 2:50 a.m. R1 was unresponsive, and vitals had ceased at 2:50 a.m., pupils were fixed, and no pulse was found. Upon interview on 4/17/25 at 10:20 a.m., registered nurse (RN)-A stated the nurse, referring to LPN-A, failed to follow the five rights of medication administration (right medication, right dose, right route, right time and right patient). LPN-A failed to check the correct dose. In addition, she did not verify the dose with another nurse per facility policy. The nurse manager on duty found the medication error around 12:30 a.m. on 4/12/25 in the system because the order had not been verified with another nurse. RN-A immediately reached out to LPN-A to verify the medication error and notified the NP for new orders. RN-A stated all staff had been retrained following the incident. Upon interview on 4/17/25 at 11:01 the NP stated on 4/11/25 he was informed that R1 was having difficulty eating, breathing and was agitated. He ordered R1 to have oxygen and if his breathing did not improve to send him to the hospital. R1's family did not want him sent to the hospital, so the NP ordered liquid morphine 5 mg (20 mg/1 ml). He ordered the morphine in liquid form because that was available in the emergency medication kit. At around 12:30 a.m. he was notified that R1 received an incorrect dose of morphine. The NP gave the orders to hold the morphine and monitor R1 frequently. The NP was under the impression R1 received 20 mg of morphine and was not told until the following day that R1 instead received 100 mg of morphine. The NP stated he was not certain if the overdose caused R1's death. He stated the Medical Examiner will make that determination. Upon interview on 4/17/25 at 1:42 p.m. RN-B stated she worked as the facility manager the night of 4/11/25. She was given report by the outgoing manager RN-C that R1 had a change in condition, the NP was notified and had placed an order for oxygen and morphine. RN-B stated she received the hard copy verbal order of the morphine. She checked the order to ensure there were two signatures on the order. She got the medication out of the emergency (e)-kit and delivered it to LPN-A around 11:30 p.m. RN-B handed the medication vial to LPN-A and another LPN staff member signed the managers book that the medication was delivered. RN-B left the unit and went to complete other assignments. At approximately 12:30 p.m. RN-B noticed R1's morphine order had not been confirmed in R1's electronic chart (e-chart). She was concerned because medications were not to be given until two nurses had confirmed the ordered dose in the e-chart. RN-B went to the unit and asked LPN-A why she had not administered R1's morphine. LPN-A told RN-B she had administered the morphine at 11:45 p.m. RN-B noticed that LPN-A had written down 5 ml administered. RN-B asked LPN-A how much morphine R1 received, and LPN-A told her 5 ml. RN-B stated she knew it was the wrong dose and calculated the error. RN-B's calculation indicated R1 received 20 mg of morphine. RN-B called the NP and reported R1 had been given 20 mg of morphine instead of 5 mg. The NP ordered staff to hold the morphine and to monitor R1. RN-B told the family, who was in R1's room that R1 had been given 20 mg of morphine instead of 5 mg and the facility would be holding the morphine and monitoring R1 frequently. The family still wanted R1 to stay at the facility and not be sent to the hospital. RN-B brought in cots for the family to spend the night with R1. At approximately 2:15 a.m. RN-B received a call from LPN-A stating R1's oxygen saturations were trending down in the 70's. RN-B elevated R1's head of bed and got him a face mask for the oxygen instead of the nasal cannula. At approximately 2:40 a.m. LPN-A told RN-B that she thought she may have given R1 more than 20 mg of Morphine. RN-B looked at the morphine bottle again and what LPN-A had given and realized she had given him 100 mg of Morphine instead of the 20 mg they had thought prior. RN-B paged the NP, as she was paging him, she was told R1 had passed away. After confirming R1's passing and consoling the family, RN-B met with the family and told them R1 received more morphine than they originally thought he received, it was 100 mg of morphine at 11:45 p.m. and 20 mg was previous reported to the family. RN-B stated the facility provided training to all licensed staff following the error. Upon interview on 4/17/25 at 6:22 p.m., family member (FM)-A stated she had spoken with RN-A a few days prior to R1's death regarding R1's change in condition. FM-A was told R1 required more assistance with feeding and was sleeping more. A plan was made that R1 would stay at the facility and not be hospitalized if he declined further. On 4/11/, FM-A and FM-B were with R1 at dinner time and assisted with his feeding. They left the facility around 7:00 p.m. At approximately 10:00 p.m. FM-A received a call from the facility stating R1 was agitated, and his oxygen saturations were under 90% and they wanted to send R1 to the hospital. FM-A stated not to send him to the hospital that she and FM-B were on their way to the facility to see him. They arrived at the facility around 10:30 p.m. R1 was anxious, pulling at his blankets and his breathing seemed more labored. R1 was wearing oxygen when they arrived, however his saturations continued to be below 90%. RN-C told FM-A that the NP ordered some morphine to relax R1 and assist with the breathing. FM-A was agreeable. At 11:45 p.m. LPN-A administered the morphine to R1. LPN-A had to awaken R1 to administer the morphine. R1 stayed awake and was breathing harder, sounded like sleep apnea although he was awake FM-A asked staff to please leave the O2 monitor on R1, which they did. R1's saturations continued to drop. At approximately 12:30 p.m. LPN-A told the family she had accidentally given R1 20 mg of morphine instead of 5 mg, that the NP had been notified, and the staff would be monitoring R1 frequently. At approximately 12:40 p.m. RN-B entered the room and explained the medication error to the family again. RN-B recommended the family spend the night and brought in cots to sleep on. FM-A stated over the next few hours R1 became worse, his saturations continued to drop, he was agitated and then he went into a coma state where his pupils looked to be pinpoint. He still had a pulse at 1:50 a.m. At approximately 2:00 a.m. FM-A stated R1 started the death rattle which was confirmed by RN-B. RN-B told FM-A she thought R1 was dying and to notify the rest of the family. After R1's passing at 2:50 a.m. RN-B told the family R1 had received 100 mg of morphine. Attempts to contact LPN-A were unsuccessful. A facility protocol titled Medication Administration Protocol with a revision date of 4/2025 indicated: Medication/Treatment Administration Procedure: A. Perform hand hygiene. B. Unlock medication cart. C. Open resident's electronic health record (HER) and choose eMAR. D. Identify medication/treatment to be administered. E. Check for resident allergy. F. Locate medication card/container and compare the label with the eMAR directions. 1. Check the label for: a) Right resident b) Right drug - check label description for color and shape c) Right dosage d) Right route e) Right time In addition: Special instructions: a) Liquid narcotic medication: two nurses must verify the amount to be given. Liquid narcotic medication requiring a dosage calculation must be transcribed in PCC order in ml and verified at time of transcription by two nurses. A facility policy titled Medication Administration with a revision date of 12/4/2024 indicated: Staff administering medication must ensure the correct medication is administered in the correct dose, in accordance with the manufacturer's specifications or provider's order, to the correct person via the correct route in the correct dosage form and at the correct time. Medication incidents that result in certain types of medication errors for the resident (Such as the wrong person, drug, dose, route, frequency, lack of clinical justification, or charting omissions) must be documented and reported by staff to nursing leadership as applicable. Following survey the DON sent the policy and protocol which were in the investigative file. The IJ that began on 4/11/25, was corrected on 4/14/25. The IJ was issued at past noncompliance due to the actions the facility implemented prior to survey, including: The facility identified the error on 4/11/25 and completed a thorough investigation identifying the root cause that LPN-A did not follow the medication right or right dose and did not verify the dose with another nurse. LPN-A was placed on a leave pending the investigation on 4/14/25. All nursing staff were educated on the medication order transcription process, order confirmation process, ensuring orders are confirmed and appear on the electronic medication record prior to administration, double noting of liquid narcotics to ensure correct dosing on order and in the narcotic book. This was completed on 4/14/25. IDT meeting was held to discuss the use of liquid narcotics in the facility vs. sublingual morphine to propose the change to the pharmacy for emergency medication kit use on 4/14/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide adequate supervision and interventions to prevent elopement of 1 of 1 resident (R1). This resulted in an immediate jeopardy (IJ) for R1 who eloped after being left alone in an unsupervised area. Findings include: The IJ began in 5/7/23, when R1 eloped from the facility and was found in the parking lot by a staff member who was on break and recognized R1. R1 was trying to get into cars in the parking lot, and stated he wanted to find his wife. R1 was wearing his WanderGuard (monitoring device with an alarm to alert staff when a resident attempts to leave a safe area) when he was found. The administrator and director of nursing (DON) were notified of the IJ on 5/15/23 at 4:12 p.m. The facility implemented corrective action to prevent reoccurrence by 5/12/23, so F689 was issued at past non-compliance. R1's Face Sheet printed 5/15/23, indicated R1's diagnoses included Alzheimer's Disease, delusional disorders, hypertension (high blood pressure), and chronic kidney disease. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, delusions, ambulatory and wandering behavior four to six days of the seven-day look-back assessment period. R1's baseline care plan dated 11/15/19, indicated, I am at risk for elopement due to my history at MVH [Minnesota Veteran's Home] and prior facilities. R1's care plan dated 11/18/21, indicated R1's photo was posted behind the reception desk at the front entrance for, Staff to know [identify in case of elopement]. R1's care plan dated 2/15/22, indicated R1 was at risk of elopement related to impaired memory, impaired cognition and safety judgment, and a history of attempts at elopement. The care plan indicated on 11/15/22, R1 required frequent checks due to his ability to turn off the wander guard, and on 3/20/23, indicated R1 required supervision to go off the unit. A facility report to the State Agency (SA) dated 5/7/23, indicated on 5/7/23 at approximately 11:50 a.m., R1 ambulated off the unit into the elevator bay area, setting off the WanderGuard alarm, to which staff responded. R1 stated he wanted to sit in the area to look out the window. Human services technician (HST)-A left R1 sitting in the area and went back to the unit. At approximately 12:00 p.m., staff looked for R1 for lunch, and did not find R1 in the elevator bay by the window where he was last seen. A search of the unit was initiated without finding R1. At approximately 12:20 p.m., the registered nurse (RN) on the unit received a call from the front desk indicated R1 was observed in the parking lot attempting to open car doors and stated he was looking for his car. On 5/15/23 at 11:57 a.m., RN-B was interviewed and stated she interviewed HST-A after the incident and found HST-A was not familiar with R1's plan of care, and thought because R1 was mobile and verbal, it was okay to leave him in the area alone. RN-B stated R1 made it down the elevator and out the front door. RN-B stated the expectation was staff would review the plan of care prior to performing care on the unit. On 05/15/23 at 12:16 p.m., RN-A stated R1 had a WanderGuard that triggered an alarm when R1 was close to the door. RN-A joined the room-to-room search for R1 when RN-A returned from break. When RN-A was getting ready to call the Officer of the Day, a front desk staff called the unit to indicate R1 was found outside. On 05/15/23 at 1:40 p.m., HST-A stated she heard the WanderGuard bell ring and found R1 sitting in a chair in the elevator bay outside the unit. R1 was mobile, but said he would stay there, so HST-A left R1 and returned to the unit. HST-A stated staff could not find R1 for lunch, so HST-A went back to get R1 from the elevator bay area, and R1 was not there, so HST-A told other floor staff that she could not find R1. HST-A and other floor staff performed a room-to-room search on the unit. HST-A stated someone from the floor called the front desk to inquire if R1 was in the area, but the front desk staff had not seen R1. As the search of the unit continued, the unit received a call indicating licensed practical nurse (LPN)-A found R1 in the parking lot and returned R1 to the unit. On 05/15/23 at 2:35 p.m., the director of nursing (DON) stated R1 had a WanderGuard, and had not tried to leave the unit recently. The DON stated the risk of R1 being off the unit unsupervised was for injury related to a fall or dehydration. The DON further stated staff checked R1's WanderGuard device every shift for placement and functionality, and knew it worked when the device illuminated a blinking red light. The Elopement/ Missing Resident Policy dated 10/20/20, indicated elopement is verified when a resident who has been determined to be cognitively impaired as evidenced by quantifiable measures on the Cognitive Performance Test and/or Risk Assessment leaves a defined area/ environment (as determined by care plan) unsupervised, undetected, unobserved, without staff knowledge of departure. The facility implemented corrective action to prevent reoccurrence on 5/9/23. The facility reviewed the Elopement/ Missing Person policy and implemented re-training for R1's unit staff on the Elopement/ Missing Resident policy which was completed 5/12/23. RN-B stated she performed audits to ensure staff tested the wander guard unit for placement and functionality each shift. RN-B's reviewed R1's care plan and initiated an additional level of supervision on 5/9/23, for R1 to have line-of-sight supervision when he chose to sit in the elevator bay. This was verified through staff interviews on 5/15/23.