Oakland Park Communities, Inc.

During interview on 12/30/25, at 2:20 p.m. the unit manager (UM)-B stated when the facility received a call from the hospital that they were going to admit a resident, they would ask the family for a bed hold.

The facility did not always get the call from the hospital or would get the call after hours and then it would be done the next day.

Bed holds were usually done on the phone verbally and then would be documented and scanned into the resident's chart. UM-B was not sure why a bed hold notice had not been completed for R12.

When interviewed on 12/30/25, at 3:53 p.m. the director of nursing (DON) stated she had been unable to find a signed or verbal bed hold completed for R12. A bed hold should be obtained when a resident was sent to the emergency room or hospital, and staff should have them sign one before they left the facility in case they were admitted to the hospital. If it was not obtained before a resident left the facility and the facility received notification the resident would be admitted to the hospital, the charge nurse was to call the family and obtain a verbal bed hold. A bed hold should have been obtained for R12; however, it had been missed.

During telephone interview on 12/31/25, at 8:55 a.m. family member (FM)-C stated they had never discussed a bed hold or signed a bed hold when R12 was admitted to the hospital. R12 was able to return to the facility and her same room without any concerns or issues.

The family knew R12's bed would be held at the facility because it was paid up for the month but had never been informed of the facility's bed hold policy.

The facility's Bed Hold and Return for Hospital/Therapeutic Leave policy dated 7/2017, identified the facility would provide written information to the resident and/or representative about the facility's bed hold policy on admission and before a resident was transferred to the hospital or went on therapeutic leave. In case of an emergency transfer, the resident/representative would be provided with written bed hold notice within 24 hours after the transfer.

The facility would hold a resident's bed for 18 consecutive days for a hospital leave. No charge would be made for those 18 days, regardless of payer source.

245592 12/31/2025

Oakland Park Communities, Inc. 123 Baken Street Thief River Falls, MN 56701

at passerby, hey get in here, come back here. R18's voice became louder and angrier, until staff went

other resident and asked if he could have her food.

The unidentified female resident stated no, you ate

to his plate and reached for his cup of liquid to drink.

When interviewed on 12/30/25, at 5:50 p.m. the director of nursing (DON) stated R18 did not tolerate the Zoloft decrease very well and things escalated quickly.

With in the two weeks, staff were seeing behaviors and attributed it to the GDR on his Zoloft as well as he had been started on a steroid.

Right after the medication adjustments they had started to see an escalation of his behaviors.

They discussed resident incidents, behaviors, changes of condition in their daily interdisciplinary team meetings and had also done an environmental analysis at the same time.

The facility had noted they had a handful of residents that were exhibiting sundowning type of behaviors with increase agitation.

Staff had reported it was difficult to control the dining room at supper time because of the sundowning behaviors some residents were exhibiting. IDT had implemented a few things that also improved R18's behaviors and aggression.

Staff implemented a low stimulation environment in the common area between 2:00 and 4:00 p.m., housekeeping typically vacuumed the common area around 4:00 p.m. so they stopped that as well. We dimmed the lights, use of essential oils and tried to not have all the residents congregated in that one common area when waiting for supper.

The facility had even turned the issue into a quality improvement project to track the interventions and progress with the escalation of resident behaviors in the evenings.

During interview on 12/31/25, at 10:00 a.m. the DON stated she received an incident report on resident-to-resident incidents.

The facility looked at if there were injury or mental anguish or changes in the victim to determine if an incident was reportable.

The DON discussed the incident with the nurse working at the time it occurred and visit with the victim to assess for trauma.

After every incident a new interventions was implemented.

Usually the interventions were documented in the resident's care plan and are in the internal risk reports as well.

Interventions were also put on the aide care sheets and as a memo in the nurse aide report and the nurse report book.

New incidents and interventions were also passed on in shift report.

The facility made it a practice to always do some kind of new intervention following an incident.

They had put interventions in place for R18 for being around other residents, encouraging him to be active in activities.

When R18 was having a bad day, staff were to bring him to his room or a quiet area, as well as the environmental changes they had done to help calm residents in the evenings.

The DON thought R18's care plan had been revised on 12/5/25, but it did not include resident to resident altercations or the environmental interventions implemented.

When R18 was like that, having a bad day, staff knew him well enough to know when he was building.

Staff knew to move him to a different area when he was more agitated or restless.

The staff also knew that R18 did not respond well to the younger girls assisting him with care, so they tried to pair him with older staff members for care.

Was not specific in R18's plan of care but staff knew R18 and when he had escalating behaviors. A policy for care plans was requested, however was not received.

245592 12/31/2025

Oakland Park Communities, Inc. 123 Baken Street Thief River Falls, MN 56701

Review of the culture on file identified the culture had not been finalized until 12/17/25, the day after R23 was seen by her physician on rounds.

When interviewed on 12/30/25, at 11:18 a.m. the director of nursing (DON) stated the unit managers were expected to follow up on urinalysis and culture results and ensure the appropriate antibiotics were ordered.

The DON would have thought UM-B would have followed up on R23's urine culture as that was her expectation and if not sensitive to follow up with the resident's primary provider.

The infection control nurse then collected the data and did a summary on the review of antibiotics.

The facility's Antibiotic Stewardship policy with last review date 2/2025, identified the nurse would utilize the Loeb Minimum Criteria protocols to determine if it was necessary to treat with antibiotics or if adjustments in therapy needed to be made.

Physicians would be notified of results of diagnostic tests to ensure residents were taking the appropriate antibiotic of if the antibiotic needed to be discontinued or changed.

245592 12/31/2025

Oakland Park Communities, Inc. 123 Baken Street Thief River Falls, MN 56701

Control (CDC) education regarding the potential risks and benefits for vaccinations being offered

immunizations.Findings include:R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 was admitted to the facility on [DATE], was [AGE] years old, had moderate cognitive impairment, and had a diagnosis of heart failure. R21's immunization record dated 12/31/25, identified R1 had a historical record R1 had received the pneumovax vaccination on 10/23/02.

However, R21's medical record failed to identify R21 or R21's representative was provided the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal.

During an interview on 12/31/25 at 10:38 a.m., the interim director of nursing (IDON) stated a resident's immunization stated was reviewed upon admit and on a yearly basis.

Documentation of is entered when immunizations were reviewed, education give, and if accepted or declined.

There was no documentation in R21's medical that R21 or R21's representative had received education related to the pneumonia vaccine or if was offered.The facility's Pneumococcal Vaccine policy dated 11/2024, identified the facility would provide education related immunization and document administration or refusal of immunization.