Every finding on record at Friendship Haven, Inc

Based on record review, observation, policy review and staff interviews the facility failed to ensure staff appropriately and safely transported a resident in a wheelchair with the resident's feet on the wheelchair foot pedals for two of seven residents that required use of a wheelchair for transport (Resident #26 and Resident #109). The facility reported a census of 110 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had diagnoses of dementia and muscle weakness. The resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. The MDS indicated the resident used a wheelchair and required partial to moderate assistance for wheeling at least 150 feet in a corridor or similar space. The Care Plan edited 5/28/26 revealed the resident had impaired decision making related to dementia. The resident also had a risk for falls related to decreased safety awareness. During observation on 8/17/26 at 12:15 PM, Staff E, Resident Companion, pushed Resident #26 at least 150 feet in a wheelchair from the dining room, down the hall, across a common area and back to the dining room without ensuring Resident #26's feet were placed on the wheelchair foot pedals. The wheelchair foot pedals were attached to the wheelchair but the foot pedals were in the up position. At the time, Resident #26 had shoes on and his feet shuffled back and forth on the floor as Staff E pushed the wheelchair. The resident's foot also dragged on the floor as Staff E pushed and turned the wheelchair to go through the common area. 2. The MDS assessment dated [DATE] revealed Resident #109 had a diagnosis of dementia. The resident had a BIMS of 8, indicating moderately impaired cognition. The MDS indicated the resident used a wheelchair. The Care Plan revised 7/28/26 revealed Resident #109 had a risk for falls and got weak and dizzy at times when his blood levels were low. The Care Plan revealed the resident required use of a wheelchair for longer distances and as needed. During observation on 8/17/26 at 12:24 PM, Staff E pushed Resident #109 in a wheelchair from the dining room to the hallway approximately 10-12 feet. Staff E then stopped, placed the foot pedals on the wheelchair, told the resident to put his feet on the pedals and then proceeded to push Resident #109 down the hall to his room. On 8/19/26 at 8:57 AM, the Administrator sent an email that the facility did not have a policy for transporting a resident in a wheelchair.In an interview on 8/20/26 at 8:31 AM, Staff J, Unit Manager, reported she expected foot pedals placed whenever staff pushed a resident in a wheelchair. Staff J reported she provided education to Staff E this week regarding the need to ensure wheelchair foot pedals in place whenever staff transported a resident in a wheelchair. In an interview on 8/20/26 at 9:30 AM, the Assistant Director of Nursing reported she expected the wheelchair foot pedals placed whenever staff pushed a resident in a wheelchair.

Based on record review, observations, staff interviews, policy review and manufacturer's instructions the facility failed to assure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 31 opportunities resulting in an error rate of 6.45 % (Residents #113 and #124). The facility reported a census of 110 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #113 had diagnosis of Type 2 diabetes (a chronic condition where the body resists or cannot use insulin well or does not make enough insulin). The MDS documented the resident took insulin.The Medication Administration Record (MAR) for Resident #113 listed Lantus insulin 18 units subcutaneously (SQ) scheduled at 12:00 PM daily was administered on 8/18/26 by Staff C, Registered Nurse (RN). During observation on 8/18/26 at 12:50 PM, Staff C, RN, attached a needle on the end of a Lantus insulin autoinjector pen. Staff C held the pen horizontally, turned the dial on the end of the pen to 1, then pushed the button on the end of the pen. Staff C then dialed the pen to 18. Staff C removed the cap on the pen, placed the pen by the resident's left lower abdomen, pushed the button on the end of the pen and held the pen in place for under 5 seconds. Staff C then removed the needle/pen from the insertion site.In an interview, Staff C reported she primed the pen with 1 because she did not like to waste insulin. The Lantus manufacturer instructions revised 5/2025 revealed the following procedural steps when gave an insulin injection: a. Remove the pen cap.b. Wipe the pen tip (rubber seal) with an alcohol swab. c. Screw a needle onto the pen. d. Remove the outer cap of the needle.e. Turn the dose selector to 2.f. Hold the pen with the needle pointed up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help get the most accurate dose. g. Press the injection button all the way in and check to see that insulin comes out of the needle. If no insulin comes out, repeat the test up to three times. The needle may be blocked if no insulin came out. Change the needle and repeat the safety test again. h. Turn the dose selector to the number of units needed. i. Clean the site with alcohol. j. Push the needle into the skin. k.Press the injection button all the way in. Keep the injection button held in and when you see 0 in the dose window, slowly count to 10 to ensure the full dose administered. l. Release the button and remove the needle from the skin. 2. The Electronic Health Record Face Sheet for Resident #124 revealed a diagnosis of Type 2 diabetes. The Care Plan created 8/11/26 revealed Resident #124 had an alteration in metabolic function related to diabetes. The Care Plan directed staff to administer insulin as ordered. The MAR dated 8/1/25 to 8/19/26 revealed Resident #124 had an order for Novolog insulin flexpen 12 units plus a correction (sliding) scale of 12 units for a blood sugar reading greater than 351. The MAR revealed Staff D, Licensed Practical Nurse (LPN), documented Novolog insulin 24 units SQ administered to the RLQ (right lower quadrant) on 8/18/26 for the 11:00 AM dose. During observation on 8/18/26 at 11:14 AM, Staff D, LPN, reported Resident #124's blood sugar level was 419. Staff D checked the computer and reported Resident #124 had an order for 12 units of Novolog insulin plus 12 units of Novolog insulin per sliding scale for a blood sugar reading of 419. Staff D reported she planned to administer a total of 24 units. Staff D obtained Resident #124's Novolog flexpen from a locked medication drawer. Staff D removed the cap and attached a needle on the end of the pen. Staff D then turned the dial on the flexpen to 2, held the pen horizontally, and pushed the button on the end of the flexpen. Staff D then turned the dial on the end of the pen to 24 (units). Staff D inserted the Novolog flexpen needle into the resident's right lower abdomen, pushed the button on the end of the pen and then removed the flexpen needle from the insertion site within 5 seconds. The Novolog manufacturer instructions revised 2/2023 revealed the following procedural steps whenever used a Novolog flexpen: a. Pull the pen cap offb. Wipe the rubber stopper with an alcohol swabc. Pull the protective tab from the disposable needle and screw the needle tightly onto the flexpen. d. Remove the outer needle cap. e. Before each injection, a small amount of air may collect in the cartridge. Prime the pen to avoid injecting air and to ensure proper dosing. f. To prime the pen, turn the dose selector knob to 2 units. Hold the pen with the needle pointed up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in. A drop of insulin should appear at the needle tip. Repeat steps up to 6 times until insulin is seen at the tip of the needle. g. To administer the insulin: Turn the dose knob to select the number of units (of insulin) needed to inject. Choose an injection site and inject the needle SQ under the skin of the stomach area, buttocks, upper legs or upper arms. Push the dose knob all the way in and continue to hold the dose knob in for at least 6 seconds before removing the needle to ensure the full dose of insulin administered. A Medication Administration policy reviewed 7/2026, revealed it was the facility's policy that residents received their medication in accordance with established policies. The policy did not address insulin administration. On 8/19/26 at 9:59 AM, the Administrator sent an email to the surveyor that the facility did not have a policy specifically for insulin or the insulin flexpen.In an interview on 8/20/26 at 9:30 AM, the Assistant Director of Nursing reported she expected staff to follow the manufacturer instructions for insulin flexpen use and insulin administration.

Based on record review, observations, staff interviews, policy review and manufacturer's instructions the facility failed to prime an insulin pen properly and failed to administer insulin per the manufacturer instructions to ensure the ordered insulin dose was fully administered for two of two residents observed for insulin administration (Resident #113 and #124). The facility reported a census of 110 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #113 had diagnosis of Type 2 diabetes (a chronic condition where the body resists or cannot use insulin well or does not make enough insulin). The MDS documented the resident took insulin seven of seven days during the look-back period. The Care Plan revised 7/28/26 revealed the resident had diabetes and took Lantus insulin. The Care Plan directed staff to administer insulin as ordered. The Physician Order Report dated 8/2026 revealed Lantus Solostar 100 units per milliliter (ml) inject 18 units subcutaneously (SQ) daily. The Medication Administration Record (MAR) for Resident #113 listed Lantus insulin 18 units SQ scheduled at 12:00 PM daily was administered on 8/18/26 by Staff C, Registered Nurse (RN). During observation on 8/18/26 at 12:50 PM, Staff C, RN, attached a needle on the end of a Lantus insulin autoinjector pen. Staff C held the pen horizontally, turned the dial on the end of the pen to 1, then pushed the button on the end of the pen. Staff C then dialed the pen to 18. Staff C removed the cap on the pen, placed the pen by the resident's left lower abdomen, pushed the button on the end of the pen and held the pen in place for under 5 seconds. Staff C then removed the pen from the insertion site.In an interview, Staff C reported she primed the pen with 1 because she did not like to waste insulin. The Lantus manufacturer instructions revised 5/2025 revealed the following procedural steps when gave an insulin injection: a. Remove the pen cap.b. Wipe the pen tip (rubber seal) with an alcohol swab. c. Screw a needle onto the pen. d. Remove the outer cap of the needle.e. Turn the dose selector to 2.f. Hold the pen with the needle pointed up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. If no insulin comes out, repeat the test up to three times. The needle may be blocked if no insulin came out. Change the needle and repeat the safety test again. g. Turn the dose selector to the number of units needed. h. Clean the site with alcohol. i. Push the needle into the skin. j. Press the injection button all the way in. Keep the injection button held in and when you see 0 in the dose window, slowly count to 10 to ensure the full dose administered. k. Release the button and remove the needle from the skin. 2. The Electronic Health Record Face Sheet for Resident #124 revealed a diagnosis of Type 2 diabetes. The Care Plan created 8/11/26 revealed Resident #124 had alteration in metabolic function related to diabetes. The Care Plan directed staff to administer insulin as ordered. The Physician Order Report for Resident #124 dated 8/2026 included an order for Novolog (insulin) flexpen 100 units/ml (3 ml) with meals started on 8/17/26. The order included to administer Novolog 12 units plus a correction (sliding) scale of 12 units SQ for a blood sugar reading greater than 351. The MAR dated 8/1/25 to 8/19/26 revealed an order for Novolog insulin flexpen 12 units plus a correction scale of 12 units for a blood sugar reading greater than 351. The MAR revealed Staff D, Licensed Practical Nurse (LPN), documented Novolog insulin 24 units SQ administered to the RLQ (right lower quadrant) for the 11:00 AM dose on 8/18/26. During observation on 8/18/26 at 11:14 AM, Staff D, LPN, reported Resident #124's blood sugar level was 419. Staff D checked the computer and reported Resident #124 had an order for 12 units of Novolog insulin plus 12 units of Novolog insulin per sliding scale for a blood sugar reading of 419, and she would give a total of 24 units. Staff D obtained Resident #124's Novolog flexpen from a locked medication drawer. Staff D removed the cap and attached a needle on the end of the pen. Staff D then turned the dial on the flexpen to 2, held the pen horizontally and pushed the button on the end of the flexpen. Staff D turned the dial on the end of the pen to 24 (units). Staff D inserted the Novolog flexpen needle into the resident's right lower abdomen, pushed the button on the end of the pen, then removed the flexpen needle from the insertion site within 5 seconds. The Novolog manufacturer instructions revised 2/2023 revealed the following procedural steps whenever used a Novolog flexpen: a. Pull the pen cap offb. Wipe the rubber stopper with an alcohol swabc. Pull the protective tab from the disposable needle and screw the needle tightly onto the flexpen. d. Remove the outer needle cap. e. Before each injection, a small amount of air may collect in the cartridge. Prime the pen to avoid injecting air and to ensure proper dosing. f. To prime the pen, turn the dose selector knob to 2 units. Hold the pen with the needle pointed up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in. A drop of insulin should appear at the needle tip. Repeat the steps up to 6 times until insulin is seen at the tip of the needle. g. To administer the insulin: Turn the dose knob to select the number of units (of insulin) needed to inject. Choose an injection site and inject the needle SQ under the skin of the stomach area, buttocks, upper legs or upper arms. Push the dose knob all the way in and continue to hold the dose knob in for at least 6 seconds before removing the needle to ensure the full dose of insulin administered. A Medication Administration policy reviewed 7/2026, revealed it was the facility's policy that residents received their medication in accordance with established policies. The policy did not address insulin administration. An email from the Administrator 8/19/26 at 9:59 AM revealed the facility did not have a policy for the insulin flexpen. In an interview on 8/20/26 at 8:31 AM, Staff J, Unit Manager, reported the process for insulin pen preparation and administration: dial the pen to 2 to prime the needle/pen, then dial the pen to the ordered dose. Staff J reported she usually dialed the pen to the ordered dose and added 2 to prime the pen, and then administered the insulin. Staff J reported that the needle/pen held in place for a count of 10 in order to ensure the medication dose was administered. The reason for priming the needle / pen was to make sure the needle and pen worked correctly. In an interview on 8/20/26 at 9:30 AM the Assistant Director of Nursing reported the process for insulin pen priming and administration: Prime the insulin flexpen with 2 units to get the air out of the needle, dial the pen to the dose needed, administer the insulin and hold the pen for a count of 10 in order to ensure the full dose of insulin administered, then remove the needle/pen from the site.

Based on observations, staff interview, and policy review, the facility failed to obtain food temperatures prior to serving to residents to ensure appropriate cooking temperatures were reached for 1 of 1 meal services observed. The facility reported a census of 110. Findings include: During a continuous lunch observation on 8/17/26 at 12:15 PM, Staff A, Certified Nursing Assistant (CNA) was given a bowl of soup and instructed to heat it up in the microwave for a resident. The microwave was located in the nursing unit's kitchenette area and not in the kitchen area itself. The soup was in the microwave for less than a minute when Staff A removed and served it to the resident. Staff A did not obtain a temperature of the soup before serving. During the same observation period, Staff B, Homemaker, prepared a hamburger as requested by a resident. Staff B did not obtain a temperature of the cooked hamburger prior to serving it to the resident. In an interview on 8/18/26 at 2:10 PM, the Certified Dietary Manger, CDM, explained food temperatures must be obtained prior to serving to residents. This includes any food prepared in the nursing units' kitchen.The policy Food Safety Requirements, reviewed August 2025, noted the following: 1. Foods shall be prepared as directed until the recommended temperature for the specific food is reached. Staff should refer to the current Food and Drug Administration and facility policy to the food temperatures as needed 2.Ready-to-eat food that require heating before consumption much be heated to at least 135 degree

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents reviewed (Resident #1 and #88). The facility reported a census of 110 residents.Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition. The MDS identified Resident #1 required substantial/maximal assistance with toileting hygiene. Resident #1's MDS included diagnoses of hypertension, pneumonia, diabetes mellitus, non-alzheimer's dementia. The Care Plan with a target date of 10/15/26 documented Resident #1 had continence issues and was taking an antibiotic nightly for recurrent urinary tract infections. The care plan directed staff to assist with changing clothing and with incontinence cares as needed. On 8/19/26 at 9:25 AM, observed Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA complete incontinence care with Resident #1. Staff H and Staff I completed hand hygiene and put gloves on. Both CNAs assisted Resident #1 to a standing position in front of the recliner using the mechanical stand. Staff I pulled Resident #1's pants down, removed the soiled incontinence brief and discarded it. Staff H handed incontinence wipes to Staff I and Staff I completed the incontinence care. Staff H handed Staff I a new incontinence brief and Staff I applied the brief while wearing the same gloves used for incontinence care. Staff I pulled up Resident #1's pants while wearing the same dirty gloves. Staff I proceeded to assist Resident #1 to a seated position in the recliner using/touching the mechanical stand, and then released the harness belt while continuing to wear the same pair of dirty gloves. Staff I then removed her gloves, discarded them and did not perform any hand hygiene. Staff I then went to the closet to get a new shirt and assisted Resident #1 with putting the new shirt on. On 8/19/26 at 11:20 AM, Staff I, CNA acknowledged she did not change gloves when going from a dirty to clean task. On 8/19/26 at 1:40 PM, the Assistant Director of Nursing (ADON) agreed she would expect gloves to be changed between dirty and clean tasks and hand hygiene to be complete when gloves were removed. On 8/19/26 at 2:11 PM, the Administrator reported that the facility did not have a specific policy about hand hygiene and gloving but thought it was covered within the standard precautions policy. The facility policy titled Standard Precautions Infection Control reviewed July 2026 documented it was the policy that all staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services. All staff shall adhere to Standard Precautions to prevent the spread of infection. During the care of resident care services, avoid unnecessary touching of surfaces near the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #88 showed the Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented diagnosis of cancer, hypertension, and anxiety disorder. On 8/20/26 at 7:15 a.m., observed Staff G, Registered Nurse (RN), provided wound care for Resident #88, who was seated in a recliner with his left lower extremity elevated. Staff G gathered supplies, applied gloves, and removed the existing dressing. Each wound site was cleansed with soap and water using 4x4 gauze and dried. Staff G applied Vaseline using sterile cotton-tipped applicators, covered the wounds with 4x4 gauze, and wrapped the foot and ankle with kerlix. During the procedure, the kerlix roll fell to the floor; a Certified Nursing Assistant (CNA) retrieved the roll and handed it to Staff G, who proceeded to use the contaminated material to wrap the resident's foot and ankle. Staff G secured and dated the dressing, cleared the supplies, and performed hand hygiene. Staff G failed to change gloves between removing the soiled dressing and applying the new dressing. On 8/20/26 at 7:30 a.m., Staff F, CNA, was observed providing catheter care for Resident #88, who was seated in a recliner. Staff F applied Enhanced Barrier Precautions (EBP) and prepared supplies. Staff F assisted Resident #88 to a standing position, removed the soiled brief, and assisted the resident back to a seated position on the recliner cushion without a barrier in place. Staff F then removed the resident's pajama pants, performed hand hygiene, and secured a catheter leg bag to the resident's left leg. Staff F performed hand hygiene and applied new gloves before putting a clean brief and pants on the resident. Staff F then assisted the resident to stand and provided perineal care. Staff F performed hand hygiene, applied new gloves, and pulled up the resident's brief and pants before assisting the resident back to a seated position on the cushion without sanitizing it. During an interview on 8/20/26 at 11:15 a.m., the Assistant Director of Nursing (ADON) confirmed the expectation for staff to perform a glove change after removing a soiled dressing and before applying a new one. The ADON further stated that a barrier should be placed before a resident is seated on a cushion, and noted that the facility practice is to swap, launder, and replace the cushion as needed. Per facility policy named Preventive Skin Care Policy dated 8/14/25 revealed it is the policy of the facility to assess skin and provide preventative measures to ensure that residents not develop pressure sores while in the facility. All residents will be assessed for risk of skin breakdown within 24 hours of admission, quarterly, and upon any significant change in condition. 1. To prevent and control infections, the following precautions should be implemented when changing a dressing: a. Follow established Standard Precautions; b. Complete hand hygiene thoroughly before beginning the procedure; c. Assure that all necessary equipment and supplies are clean prior to use; d. Change dressings using aseptic technique and clean equipment; e. If gloves touch the soiled dressing, remove the gloves, wash hands and put on new gloves; f. If soiling of clothing is likely, a gown should be worn; g. Dispose of all soiled bandages, dressings, gloves, etc. in Biohazard bags. Do not leave soiled or used items in the resident's room. Per facility policy named Infection Prevention and Control Program dated 4/1/24 revealed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 5. Resident-Care Equipment and Instruments/Devices: a. Procedures have been established for containing, transporting, and handling resident-care equipment and instruments/devices that may be contaminated with blood or body fluids. Personnel are trained in the use of these procedures.

Based on clinical record reviews and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #3) for falls. The facility reported a census of 114 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS identified Resident #3 required partial to moderate assistance for all transfers. The MDS included diagnoses of cerebrovascular accident (stroke), multiple sclerosis (MS), disorientation and repeated falls. The Care Plan with a start date of 10/9/25 revealed Resident #3 had impaired functional status and required assistance of one staff member for all transfers. The Fall Risk Assessment Form revealed a score of 16 indicating Resident #3 was at high risk for falls. The Incident Report (IR) titled Fall Scene Investigation Report dated 1/17/25 at 5:44 PM documented Resident #3 had a fall in her room with no apparent injuries. According to the IR, Staff A, Certified Nursing Assistant (CNA) reported Resident #3 got weak during a transfer and was lowered to the floor. Resident #3 had a fever, cough and tested positive for COVID during fall assessment. The IR documented a gait assistive device was not used at the time of the fall.On 1/21/26 at 1:10 PM, Staff A, CNA reported Resident #3's call light was on, she went to the room and observed Resident #3 was slouched down in her recliner. Staff A said she offered Resident #3 help to sit up. She said usually Resident #3 could sit up by herself. Staff A said you could tell something was off with Resident #3. Staff A said she noticed Resident #3's pants were very wet and she offered to take her to the bathroom. She said she tried to stand Resident #3 up and she felt uneasy and needed to sit back down. She said when Resident #3 was ready, she stood her up again then started to turn her to get into the motorized scooter. Staff A said she was lightly touching/guiding Resident #3's hips, then her legs gave out and she lowered her to the floor. Staff A reported she did not have a gait belt on Resident #3 during the transfer. She said Resident #3 did not hit the floor hard when she was lowered. When asked how she was lowered to the floor, Staff A said she had her arms under Resident #3's arms. She said she made sure that her legs did not get twisted and she did not hit her head on the foot board of her bed. When asked if Resident #3 was supposed to have a gait belt on during transfers, she said yes. She said at the time of the fall she did not know that. She said she had seen other staff members transfer Resident #3 without using a gait belt. Staff A said when she called the nurse to the room due to the fall, the nurse told her to make sure she always had a gait belt on Resident #3. Staff A said she received a phone call from Staff B, CNA/Neighborhood Lead on 1/21/26 asking her about Resident #3's fall. She said Staff B educated her that all residents who require assistance of one with transfers need to have a gait belt on during a transfer. On 1/21/26 at 1:29 PM, the Administrator reported the facility did not have a gait belt policy. She reported the facility had a gait belt acknowledgement form that was signed during orientation.On 1/21/26 at 1:40 PM, Staff B, CNA/Neighborhood Lead reported it was an expectation for any resident who required assistance of one or two staff members to have a gait belt on during a transfer. Staff B reported she was going to complete a verbal write up for Staff A, CNA for not using the gait belt. The facility form titled Gait Belt Acknowledgement Form signed by Staff A, CNA on 9/13/25 documented the gait belt when worn around the waist may assist team members by allowing a secure hold onto the resident. The gait belt reduces the potential risk of resident and/or employee injury from falls. Nursing personnel (certified and/or licensed) on duty will have access to a gait belt to assist in the performance of transfers and/or ambulation. A facility form titled Employee Counseling report documented Staff A, CNA received a verbal written warning on 1/21/26 for not utilizing a gait belt with a resident during a transfer on 1/17/26. On 1/21/26 at 1:54 PM, the Administrator reported she would expect residents who require staff assistance to use a gait belt during transfers unless it was contraindicated by the care plan or a behavior.

Based on clinical record review, facility investigation, facility policy/procedures, and staff interviews the facility failed to provide a supportive and safe environment for 1 of 3 residents reviewed (Resident #1). On 8/3/25, the facility staff learned of a Certified Nurse Aide (CNA) being accused of taking a photograph of Resident #1. After learning of this allegation, the facility staff allowed the CNA to work with Resident #1 and all other residents for an entire 8 hour shift. The facility identified a census of 122 residents.Findings include: The Minimum Data Set (MDS) dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 4 for which indicated severely impaired decision making abilities, displayed physical (hitting, kicking, pushing, scratching, grabbing abusing other sexually) and verbal (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (scratching self, public sexual acts, screaming, disruptive sounds) for which occurred daily. The MDS also documented the resident required substantial to maximal assistance with showering/bathing, upper body dressing and dependent with lower body dressing and toileting hygiene, and diagnosis for which included anemia (condition in which the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen throughout the body), coronary artery disease (reduction of blood flow to the heart muscle due to build up of plaque), hypertension (condition in which the force of the blood against the artery walls is too high), Traumatic Brain Injury (injury to the brain caused by an external force), depression and Bi-polar disease. The Care Plan dated 7/1/25, documented Resident #1 had impaired functional status: bed mobility, transfers, toileting, locomotion, eating, grooming, personal hygiene and bathing. Interventions include: 2-person assist with bed mobility, 2-person assist with transfers and EZ lift (a device designed to allow clients to change from sitting to standing posture or vice versa, by wrapping this patient lift sling around clients waist). 1-person assist to help dress upper body and wash face and brush teeth and total assistance with bathing. The Interdisciplinary Notes dated 8/4/25 at 1:02 p.m., documented, Human Resource employee made Administrator aware of social media picture of an employee and this resident at approximately 8:00 a.m., on 8/4/25. Self report completed and information submitted to DIAL (Department of Inspections and Appeals and Licensing) immediately. Family and Primary Care Provider notified. Resident unaware and unable to recall event. Internal investigation initiated. No injuries or adverse events to resident. The Incident Summary dated 8/4/25 at 8:44 a.m., documented a text message sent to Human Resource cellphone by Staff A, homemaker of Journey's neighborhood, regarding a concerning photo she had screenshot on social media (Snapchat) which included a long term care resident, and Staff C, Certified Nursing Assistant (CNA). In photo, caregiver Staff C and Resident #1 are in a split frame side by side, resident is in side lying position with a tie-dyed t shirt on and a purple and green tie blanket, likely lying in her bed with exposed peri area. Review of the Employee Timesheet with a run dated 9/9/25 at 1:15 p.m., revealed Staff C, CNA worked on 8/3/25 from 1:52 p.m., to 10:07 p.m. Observation on 9/8/25 at 2:00 p.m., Resident #1 was lying in bed on her back with a yellow and black blanket over her and wearing a pink sweatshirt. Interview on 9/8/25 at 2:00 p.m., Resident #1 was not able to recall and remember a photograph being taken and would giggle during the interview. Interview on 9/9/25 at 11:30 a.m., Staff B, Registered Nurse (RN) at the facility and also CNA instructor, stated she had CNA students at the facility 8/1/25-8/3/25 and on 8/3/25 at about 2:00 pm it had been brought to her attention a picture had been sent to one of the students in the CNA class of a resident and another CNA at the facility. Staff B stated she recognized both people in the photo. Staff B stated took my students into a room and explained to them that social media and taking pictures was not allowed while they were in the facility and that the perception of others in the facility could cause harm/danger, she explained that it is not appropriate that pictures be taken of any of the residents and sent. Staff B stated did not call any facility staff. Staff B said she was in teacher mode and not in nurse mode, and was more worried about what we were going to do as a college then a facility. Staff B stated I know that I should of called someone from the facility and sent Staff C home, but I messed up on that part. Staff B stated I did not realize until facility called me on 8/4/25 and explained that since I was still a prn employee of the facility that I needed to have called someone on the administrative side and sent Staff C home and separated from other residents at the facility. Interview on 9/9/25 at 4:45 p.m., the facility Administrator acknowledged that Staff C, CNA worked on 8/3/25 from 1:52 p.m. to 10:07 p.m. The Dependent Adult Abuse Policy dated 3/25, documented the policy is that all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident medical symptoms. This includes prohibiting staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment including cameras, smart phones, and other electronic devices to take, keep, distribute photographs and/or recordings on social media or through multimedia messages. The facility terminated the employee and all team members were re-educated on the facility Social Media Agreement on 8/4/25. Campus Leadership and department email sent, as well as utilized their mass communication software text them all to send messages to all employees. Delivery confirmation received. A text is going to all team member, please remind everyone you work with of the following and post at huddle boards, nurse desks, or anywhere else your team members congregate for shared information. Employees may not post any pictures of residents, their personal belongings, or any part of their living space to the employees personal social media outlets or maintain any such pictures on their personal devices. This will result in discipline, up to and including termination.

Based on clinical record review, facility policy/procedure, employee time card, and staff interviews, the facility failed to protect vulnerable residents from an alleged abuser. On 8/3/25 at 1:30 p.m., facility staff were aware of a photograph that was taken of 1 of 3 residents reviewed (Resident #1). Facility staff allowed the alleged abuser to work their entire shift on 8/3/25 and allowed the alledged abuser to work with Resident #1 and all other vulnerable residents and failed to notify the facility administration of the allegation. The facility identifed a census of 122 residents. Finding include:The Minimum Data Set (MDS) dated [DATE], documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 9 for which indicated moderately impaired decision making abilities, displayed physical (hitting, kicking, pushing, scratching, grabbing others) and verbal (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed towards others (scratching self, screaming, disruptive sounds) for which occurred daily. The MDS documented the resident required substantial to maximum assistance with showering/bathing, upper body dressing and dependent with lower body dressing, toileting and personal hygiene. The MDS documented diagnosis which included anemia (condition in which the blood does not have enough healthy red blood cells and hemoglobin to carry oxygen throughout the body), hypertension (condition in which the force of the blood against the artery wall is too high) and Traumatic Brain Injury ( injury to the brain caused by an external force), depression and bi-polar disease. The Care Plan dated 7/1/25, had focus area of Resident #1 had impaired functional status related to bed mobility, transfers, toileting, locomotion, eating, grooming, personal hygiene and bathing. Interventions include: 2 person assist with bed mobility, 2-person assist with transfers and EZ lift ( a device designed to allow clients to change from sitting to standing posture or vice versa, by wrapping this patient lift sling around clients waist), 1-person assist to help with upper body dressing and wash face and brush teeth and total assistance with bathing. The Interdisciplinary Notes dated 8/4/25 at 1:02 p.m., documented, Human Resource employee made Administrator aware of social media picture of employee and this resident at approximately 8:00 a.m., on 8/4/25. Self report completed and information submitted to DIAL (Department of Inspections and Appeals and Licensing) immediately. Family and Primary Care Provider notified. Resident unaware and unable to recall the event. Internal investigation initiated. No injuries or adverse events to resident. The Incident Summary Report dated 8/4/25 at 8:44 a.m., documented, a text message sent to Human Resource cell phone by Staff A, (homemaker) of Journeys neighborhood, regarding a concerning photograph Staff A screen shot on social media (Snapchat) which included a long term care resident, and Staff C, Certified Nursing Assistant (CNA) who is a caregiver. In the photograph, caregiver Staff C, and Resident #1 are in a split frame side by side, resident is in side lying position with a tie dyed t-shirt on and a purple and green tie dye blanket, likely lying in bed with exposed peri area. Review of the Employee Timesheet with a run dated 9/9/25 at 1:15 p.m., revealed Staff C, CNA, was allowed to work on 8/3/25 from 1:52 p.m. - 10:07 p.m. Observation on 9/8/25 at 2:00 p.m., Resident #1 was lying in bed on her back with a yellow and black blanket over her and wearing a pink sweatshirt. Interview on 9/8/25 at 2:00 p.m., Resident #1 was not able to recall or remember a photograph being taken and would giggle during the interview. Interview on 9/9/25 at 11:30 a.m., Staff B, Registered Nurse (RN) at the facility and also CNA instructor, stated she had CNA students at the facility 8/1/25-8/3/25 and on 8/3/25 at about 2:00 pm it had been brought to her attention a picture had been sent to one of the students in the CNA class of a resident and another CNA at the facility. Staff B stated she recognized both people in the photo. Staff B stated took my students into a room and explained to them that social media and taking pictures was not allowed while they were in the facility and that the perception of others in the facility could cause harm/danger, she explained that it is not appropriate that pictures be taken of any of the residents and sent. Staff B stated did not call any facility staff. Staff B said she was in teacher mode and not in nurse mode, and was more worried about what we were going to do as a college then a facility. Staff B stated I know that I should of called someone from the facility and sent Staff C home, but I messed up on that part. Staff B stated I did not realize until facility called me on 8/4/25 and explained that since I was still a prn employee of the facility that I needed to have called someone on the administrative side and sent Staff C home and separated from other residents at the facility. Interview on 9/9/25 at 4:45 p.m., the facility Administrator acknowledged that Staff C, worked on 8/3/25 from 1:52 p.m.- 10:07 pm. The Administrator confirmed that the expectation of the staff are to separate an alleged abuser from the resident and all residents in the neighborhoods. The Dependent Adult Abuse Policy dated 3/25, documented the policy is that all residents have the right to be free from abuse, neglect, misappropriation of residents property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the medical symptoms. This includes prohibiting staff from taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment including cameras, smart phones, and other electronic devices to take, keep, distribute photographs and/or recordings on social media or through multimedia messages. The facility terminated the employee and all team members were re-educated on facility Social Media Agreement on 8/4/25. Campus Leadership and department email sent, as well as utilized their mass communication software text them all to send messages to all employees. Delivery confirmation received. A text is going to all team member, please remind everyone you work with of the following and post at huddle boards, nurse desks, or anywhere else your team members congregate for shared information. Employees may not post any pictures of residents, their personal belongings, or any part of their living space to the employees personal social media outlets or maintain any such pictures on their personal devices. This will result in discipline, up to and including termination.

2. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump blood well), coronary artery disease, and chronic kidney disease. Review of Census and Progress Notes revealed Resident #8 was admitted to the hospital for congestive heart failure from 3/5/25 to 3/6/25 and 3/10/25 to 3/17/25. The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #3 was not listed on the forms for March or April 2025. Based on clinical record review, staff interview and review of facility policy, the facility failed to notify the Long Term Care (LTC) Ombudsman for 2 of 2 residents reviewed who transferred to the hospital (Resident #3 and #16). The facility reported a census of 117 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 documented diagnoses of heart failure, respiratory failure, diabetes mellitus, anxiety, and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. Review of Resident #16 ' s Progress Notes revealed the following information: 10/9/24 Resident transferred to the emergency department and admitted to the hospital. 10/12/24 Resident readmitted to facility from the hospital. 10/13/24 Resident transferred to the emergency department and admitted to the hospital. 10/18/24 Resident readmitted to the facility from the hospital. 11/10/24 Resident transferred to the emergency department and admitted to the hospital. 11/13/24 Resident readmitted to the facility from the hospital. 4/15/25 Resident transferred to the emergency department from a pulmonology appointment and admitted to the hospital. 4/17/25 Resident readmitted to the facility from the hospital. Review of Resident #16 ' s Census tab revealed the following: 10/9/24 admitted to the hospital 10/12/24 readmitted to facility 10/13/24 admitted to the hospital 10/18/24 readmitted to the facility 11/10/24 admitted to the hospital 11/13/24 readmitted to the facility 4/15/25 admitted to the hospital 4/17/25 readmitted to the facility Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated October 2024, November 2024 and April 2025 lacked Resident #16 ' s name. During interview with the Chief Financial Officer on 7/02/25 at 8:36 a.m. stated the person responsible for Ombudsman notification is the Social Worker. The CFO stated she spoke with the Social Worker and and she relayed she misunderstood who needed to go on the report. The CFO stated the Social Worker would put the resident on the Ombudsman report if the resident/family did not want a bed hold. If the resident/family had or wanted a bed hold the Social Worker would not put them on the report. The CFO stated she will call the Ombudsman office and see how far back they would like the facility to correct this issue. The Chief Executive Officer (CEO) stated the facility will do education with the Social Worker so she understands the process. Per facility policy named Discharge (Appropriate/Involuntary/AMA (Against Medical Advice)), Transfers and Appeals with an effective date July 1st, 2025 revealed the Director of Social Services is responsible for submitting the monthly report of discharges and types of discharges to the state Ombudsman ' s office. The report will contain the information requested by the Ombudsman ' s office and be delivered in the manner that the office requests.

Based on clinical record review, staff interviews and policy review the facility failed to change indwelling catheter per physician orders for 1 of 1 resident reviewed (Resident #85) for catheter care. The facility reported a census of 117 residents. Findings include: Resident #85's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #85 required substantial/maximal assistance with toileting hygiene and transfers. The MDS indicated Resident #85 had an indwelling catheter. The MDS included diagnoses of obstructive uropathy (urine flow obstructed), urinary tract infection in the past 30 days, and cerebral infarction (CVA/stroke). A Progress Note dated 2/10/25 at 3:33 PM documented Resident #85 was readmitted to the facility from a hospitalization with an indwelling catheter and a follow up appointment with urology. The Care Plan with a start date of 4/16/25 revealed Resident #85 had an indwelling catheter . A Urology office visit form dated 3/11/25 directed staff to change Resident #85's catheter monthly at the facility. The Progress Note dated 5/19/25 at 9:00 AM revealed staff attempted to irrigate Resident #85's indwelling catheter and was unable to due to resistance. The note documented the indwelling catheter was removed and the urology office notified. The Progress Note dated 5/19/25 at 3:00 PM documented the Advance Registered Nurse Practitioner (ARNP) from the urology office directed staff to reinsert the indwelling catheter, obtain a urine culture and start cipro (antibiotic) twice a day for 7 days. The note documented an indwelling catheter was inserted and the urinalysis obtained. The June 2025 Treatment Administration Record (TAR) directed staff to change the indwelling catheter and drainage bag on 6/6/25. The June TAR lacked documentation the indwelling catheter and drainage bag had been changed during the month of June. The clinical record revealed the last time Resident #85's catheter was changed on 5/19/25. On 7/1/25 at 2:55 PM, Staff A, Registered Nurse (RN)/Skilled Care Coordinator acknowledged Resident #85's indwelling catheter had not been changed since 5/19/25. She said the treatment record was not updated after the catheter was changed on 5/19/25 to reflect the next time the catheter was due to be changed. She said the charge nurse did not change the catheter on 6/6/25 as it had been changed on 5/19 and then it was missed. A Progress Note on 7/1/25 at 5:16 PM documented Resident #85's catheter was changed and the TAR updated to change the catheter on the first of the month. On 7/3/25 at 1:44 PM, the Director of Nursing (DON) reported she expected the staff to follow the physician's order to change the catheter monthly. A facility policy titled Foley Catheters: catheter care reviewed July 2024 documented it was the facility policy that indwelling catheters receive appropriate care to prevent infection, to maintain cleanliness, dignity, and privacy along with comfort.

Based on observations, record review, staff interviews, and resident interview, the facility failed to change oxygen tubing and water humidifier for 1 of 1 resident reviewed (Resident #3) for respiratory services. The facility reported a census of 117 residents. Findings Include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump blood well), coronary artery disease, and chronic kidney disease. The MDS documented Resident #3 received oxygen and a non-invasive mechanical ventilator (CPAP) while a resident within the last 14 days. A Physician Order dated 12/30/24 directed Resident #3 to wear a CPAP machine (continuous positive airway pressure) (machine that uses mild air pressure to keep breathing airways open while you sleep) with oxygen at 2 liters at night. The Care Plan dated 4/9/25 documented Resident #3 required a CPAP machine with oxygen at 2 liters at night. The care plan directed staff to change the oxygen tubing weekly and check/replace the water humidifier as needed. On 6/30/25 at 1:58 PM, observation revealed Resident #3's CPAP machine and oxygen concentrator connected with undated oxygen tubing. The water humidifier attached to the oxygen concentrator was not dated and had a very small amount of water in the container. Resident #3 said she was not sure the last time the oxygen tubing or water humidifier had been changed. On 7/1/25 at 2:35 PM, observation revealed oxygen tubing and the water humidifier not dated. In addition, the water humidifier connected to the oxygen concentrator was empty and without water. Review of the December 2024 to July 2025 Treatment Administration Records (TAR) lacked documentation Resident #3's oxygen tubing and water humidifier had been changed/replaced. On 7/1/25 at 2:45 PM, Staff B, Registered Nurse (RN) reported the staff document when the oxygen tubing was changed on the TAR. She said the oxygen tubing was to be changed weekly. On 7/1/25 at 2:50 PM, Staff A, RN/Skilled Care Coordinator verified Resident #3's oxygen tubing was not on the TAR to be changed weekly. She said she was not aware Resident #3 was on oxygen with the CPAP machine. Staff A reported she expected the oxygen tubing to be changed weekly, dated and documented on the TAR. In addition, she expected the water humidifier to be dated and changed as needed. On 7/3/25 at 1:30 PM, the Director of Nursing (DON) reported the facility did not have a policy regarding oxygen administration/services. She said she would expect the staff to change and date the oxygen tubing weekly.

Based on record review, staff interview and policy review, the facility failed to report an allegation of abuse timely after the allegation was made for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 116 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 99 indicating inability to complete the interview. The resident ' s diagnosis included Alzheimer ' s disease and left pelvic fracture. The Care Plan dated 12/12/24 documented Resident #1 needed assistance to complete activities of daily living including toileting related to history of pelvic fracture and weakness. The resident required staff assistance of one with a walker for transfers and ambulation and used the wheelchair for primary locomotion. The Progress Notes for Resident #1 dated 12/14/24 at 8:18 PM documented the Director of Nursing (DON) received a call from the charge nurse at approximately 4:52 PM informing her that the resident had been involved in an allegation of abuse. At 7:16 PM, Staff A, Registered Nurse (RN), documented a head to toe assessment had been completed on the resident and no marks or bruises were noted on his back or skin. After the assessment, the Department of Inspections Appeals and Licensing (DIAL), family, provider and police were notified. The facility investigation dated 12/14/24 of the allegation included staff interviews. The investigation revealed on 12/14/24 at approximately 4:52 PM, Staff B, Licensed Practical Nurse (LPN) called the DON to inform her of a situation that happened 3 weeks ago. The investigation included a re-enactment in which Staff F, CNA backhanded Resident #1 in the upper back. During an interview on 12/30/24 at 1:32 PM, Staff E, CNA revealed she and Staff F, CNA had sat Resident #1 on the toilet on 11/20/24 and when he was completed Staff E was trying to get the resident to let go of the bar next to the toilet when the resident bit her. Staff E reported Staff F then hit the resident across his back with the back of her hand and told the resident we don't bite people. Staff E stated she then notified Staff C, RN of the incident and that the incident happened around 9-9:15 PM. During an interview on 12/30/24 at 2:30 PM, Staff B, Licensed Practical Nurse (LPN) revealed she could not remember the exact date when Staff D, CNA had reached out to her to ask her about the abuse policy and told her about the alleged incident that she had heard happened about 3 weeks ago. Staff B reported she had been told by Staff D that Resident #1 had bitten one of the CNAs and Staff F had then backhanded him in the back. Staff B stated she then reached out to the DON and the DON and Staff A came in shortly after their conversation and statements were obtained. During an interview on 12/30/24 at 3:04 PM, Staff C, RN stated nobody had told her about the allegation of abuse towards Resident #1 on 11/20/24. Stated if she had been notified she would have separated the CNA from the residents and then called the supervisor and it is most likely the alleged abuser would have been sent home. During an interview on 12/31/24 at 9:40 AM, Staff F, CNA stated on the date of the alleged incident she had been in Resident #1 ' s bathroom with another CNA (stated she could not remember the name of the other CNA) when as the other CNA was pulling the resident ' s shirt down the resident hit the other CNA. Staff F reported she told the resident we can ' t hit other people, that is not nice. Staff F denied hitting the resident across his back or in any other way. An Employee Counseling Report dated 12/14/24 documented Staff E did not follow up to assure the facility abuse policy was followed through on after witnessing a team member hit a resident. Staff E signed the written warning on 12/14/24. An Employee Counseling Report dated 12/14/24 documented on 11/20/24 Staff C allegedly received report from a CNA regarding physical abuse of a resident and did not notify parties per facility policy and procedures. Staff C signed the written warning on 12/17/24. Review of facility policy titled Dependent Adult Abuse, Manual for Handling Abuse Related Issues, effective 3/15/24 documented residents must not be subjected to abuse by anyone including facility staff. Any staff member observing or aware of an abuse situation occurring will make sure the resident is safe and will report it immediately to their Charge Nurse/Supervisor. The Charge Nurse/Supervisor will notify the Administrator or his/her designee, Director of Nursing and/or responsible department head immediately upon receiving notice of a suspected Dependent Adult Abuse or Resident Abuse, and prior to investigating. The Administrator or his/her designee will immediately notify appropriate state entities (DIAL, DHS and/or law enforcement).

Based on record review, staff interview and policy review, the facility failed to separate an alleged abuser from a resident for 1 of 1 residents reviewed for alleged abuse (Resident #1). The facility reported a census of 116 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) score of 99 indicating inability to complete the interview. The resident ' s diagnosis included Alzheimer ' s disease and left pelvic fracture. The Care Plan dated 12/12/24 documented Resident #1 needed assistance to complete activities of daily living including toileting related to history of pelvic fracture and weakness. The resident required staff assistance of one with a walker for transfers and ambulation and used the wheelchair for primary locomotion. The Progress Notes for Resident #1 dated 12/14/24 at 8:18 PM documented the Director of Nursing (DON) received a call from the charge nurse at approximately 4:52 PM informing her that the resident had been involved in an allegation of abuse. During an interview on 12/30/24 at 1:32 PM, Staff E, CNA revealed she and Staff F, CNA had sat Resident #1 on the toilet on 11/20/24 and when he was completed Staff E was trying to get the resident to let go of the bar next to the toilet when the resident bit her. Staff E reported Staff F then hit the resident across his back with the back of her hand and told the resident we don ' t bite people. Staff E stated she then notified Staff C, RN of the incident and that the incident happened around 9-9:15 PM. Staff E stated she had knowledge of the need to notify the nurse of an allegation of abuse but was not aware of the need to immediately separate the alleged abuser from the resident. An Employee Counseling Report dated 12/14/24 documented Staff E did not follow up to assure the facility abuse policy was followed through on after witnessing a team member hit a resident. Staff E signed the written warning on 12/14/24. Review of facility policy titled Dependent Adult Abuse, Manual for Handling Abuse Related Issues, effective 3/15/24 documented residents must not be subjected to abuse by anyone including facility staff. Any staff member observing or aware of an abuse situation occurring will make sure the resident is safe and will report it immediately to their Charge Nurse/Supervisor. The Charge Nurse/Supervisor will notify the Administrator or his/her designee, Director of Nursing and/or responsible department head immediately upon receiving notice of a suspected Dependent Adult Abuse or Resident Abuse, and prior to investigating. The Administrator or his/her designee will immediately notify appropriate state entities (DIAL, DHS and/or law enforcement).

Based on record review and staff interview, the facility failed to report an allegation of abuse immediately, but not later than 2 hours after the allegation was made for 1 resident (Resident #1). The facility reported a census of 118 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident was dependant with activities of daily living (ADL's) including toileting hygiene. The resident's diagnoses included a fracture (humerus/arm). The Care Plan dated 10/20/24 included the resident needed help to complete her ADL's related to a fracture of her left humerus. The resident was unable to transfer and ambulate, and used a wheelchair for all mobility and able to propel the wheelchair and get around. The resident needed assistance with dressing and toileting. The Nursing Notes dated 11/14/24 at 10:41 a.m. documented the Director of Nursing (DON)| received a call from the unit lead informing her of a report of the resident voicing being sexually assaulted by a man. At 11 a.m. the resident returned from a hair appointment and the DON went into res room and did an assessment. After the assessment the family, provider, police and DIAL were notified of the allegation. The facility investigation dated 11/14/24 of the resident's allegation included staff interviews. Staff A Certified Nursing Assistant (CNA) said the resident told her 5 nights previously a man went in her room and touched her and sexually assaulted her. On 11/20/24 at 2:23 p.m. Staff A said the morning before (11/13/24) the resident said she had a secret, and she told Staff A that a man came to her room during the night and touched her and sexually assaulted her. Staff A said she reported it to the nurse, and she figured it was taken care of. On 11/20/24 at 11:20 a.m. Staff C CNA stated the resident had never told her anything about a sexual assault or being molested. She said on 11/13/24 Staff A told her the resident made the comment to her and Staff C told Staff A not to tell her, to go and tell the nurse. Staff C said she has never heard anything like that from the resident. A typed document dated 11/14/24 signed by Staff B Licensed Practical Nurse (LPN) documented on 11/13/24 the resident had a skin assessment that showed no new areas than the ones currently being monitored in the skin conditions tab. At around 1 p.m. Staff B received a report the resident said a man sexually assaulted her a few days prior. Staff B attempted to speak with the resident but she had aggressive language toward staff saying they were trying to kill her and poisoning her food. On 11/14/24 Staff B and 2 CNA's observed the resident had a large amount of blood drainage from her perineal area while performing incontinent care. The resident stated staff beat her up in the shower all the time. Staff A attempted a contact to obtain a treatment and further action. On 11/20/24 at 8:40 a.m. Staff B said Staff C CNA and Staff A had been caring for the resident and she had made the comment about a sexual assault and they notified her. Staff B was dealing with the resident and some other residents behavior wise. Resident #1 liked another resident and was calling out his name and going up and down the halls looking for him. She spent time with the resident. The resident experienced sundowning (symptoms people with dementia got in the late afternoon early evening) and she got behavioral and difficult to deal with in the afternoon and evenings. That was on 11/13/24. The next morning it had been reported to another nurse and the DON came up. They started making arrangements for the resident to go to the hospital. On 11/20/24 at 12:29 p.m. the DON stated Staff B was a newer nurse and there were things going on and she didn't do anything about the report on Wednesday. She received a written warning for not doing so. An Employee Counseling Report documented on 11/13/24 Staff B was notified by a team member that a resident mentioned being sexually assaulted. Staff B did not report to a supervisor. Staff B signed the written warning on 11/14/24. The facility Dependent Adult Abuse policy effective 3/15/24 documented residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or any other individual. The Charge Nurse/Supervisor would notify the Administrator or his/her designee, Director of Nursing and/or responsible department head immediately upon receiving notice of a suspected Dependent Adult Abuse or Resident Abuse, and prior to investigating. The Administrator or his/her designee would immediately notify appropriate state entities (DIAL, DHS and/or law enforcement, if appropriate).

Based on observations, interviews, and record review, the facility failed to use safety principles while transporting 2 residents in their wheelchairs (Residents #56 and #71). An observation revealed both pushed from the dining area to their rooms without the staff applying foot pedals on to their wheelchairs. Each resident had to hold their feet off the floor during transport. The facility reported a census of 116. Findings include: 1. Resident #56's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS documented Resident #56 used a wheelchair and walker in the prior 7 days. Resident #56 required total assistance from staff to wheel 50 feet or more in her wheelchair (w/c). The MDS included diagnoses of Alzheimer's disease, restless leg syndrome, weakness and the presence of a right artificial hip. On 8/5/24 at 12:21 PM, witnessed Staff A, Certified Nurse Aide (CNA), push Resident #56 in her w/c from the dining room back to her room without foot pedals on the w/c. Resident #56 lifted her feet approximately one inch off the floor during the transport. Staff A stated described Resident #56 as usually independent. Sometimes if she got tired, Staff A pushed her. Staff A stated it probably would be safer to put the w/c pedals on the wheelchair prior to pushing a resident. Staff A added Resident #56 seemed tired that day. 2. Resident #71's MDS assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. The MDS documented Resident #71 used a wheelchair and walker in the prior 7 days. Resident #71 required total assistance from staff to wheel 50 feet or more in her wheelchair. The MDS included diagnoses of non traumatic brain dysfunction and schizophrenia. On 8/5/24 at 12:19 PM witnessed Staff B, Registered Nurse (RN), push Resident #71 from the dining room to his room without any foot pedals on the w/c. When asked if she felt safe pushing Resident #71, Staff B replied he refused having w/c pedals on. Staff B reported she felt safe to push him in his w/c without the foot pedals on as he usually did a good job holding his feet up. Resident #71's had his feet lifted approximately 1 foot off of the ground. On 8/5/24 12:30 PM, Staff C, RN, reported it wouldn't be okay to push a resident without foot pedals. She described Staff A as a new employee and she would reeducate them. Staff C explained Staff B shouldn't push Resident #71 in a w/c without the foot pedals. When told Staff B said she felt safe to push Resident #71 without foot pedals, Staff D, Unit Coordinator responded yeah, until it isn't alright. Staff C and Staff D both concurred the staff shouldn't push residents in their w/c without the foot pedals on. They said both of the residents could propel themselves in their w/c's by using their feet. The observation the staff pushed each approximately a distance of 50 to 60 feet. On 8/6/24 at 11:00 AM, the Director of Nursing (DON) acknowledged that it wasn't safe to push residents in their wheelchairs without foot pedals in place. This DON stated she reeducated both staff. She reflected her disappointment of having 1 being a RN. The facility didn't have a policy on wheelchair pedal placement.

Based on observations, interviews, and record review, the facility failed to check proper gastrostomy tube (a tube inserted through a hole in the abdomen into the stomach to administer nutrition and medications) placement prior to administering medications to 1 of 1 resident observed (Resident #49). The facility reported a census of 116 residents. Findings include: Resident #49's August 2024 Treatment Administration Record (TAR) directed the staff to check tube placement prior to morning and evening medication administration. The ordered instructed to use litmus paper to check PH (acidic level) by aspirating 5 milliliters (ml)(cc) of stomach content and then check with the litmus paper. After verification, replace the aspirated contents back in the stomach. On 8/6/24 at 10:02 AM, observed Staff E, Registered Nurse (RN), administer crushed medications diluted in water through Resident #49's gastrostomy tube (g tube). Staff E flushed the g tube before, during, and after administering the medications. Staff E failed to check the g tube placement with the litmus paper as ordered. On 8/6/24 at 11:37 AM, when inquired about checking the g-tube placement, Staff E replied she forgot to check it. She said she flushed it prior to administering the medications but didn't check residual (left over amount) prior to administration of the medications. On 8/6/24 at 1:34 PM, the Director of Nursing (DON) confirmed Resident #49 had orders to both check residual and Litmus test prior to administering medications. The DON acknowledged Staff E forgot to check placement prior to administering Resident #49's medication through the g tube. A Naso Gastric Tubes / Gastrostomy Feeding Tube policy dated June 2023, directed the nurse to check placement per standards of practice or according to Physician orders. The nurse must check the residual per standard of practice or according to the physician orders. The nurse should report the residual amounts according to the perimeters established by the Physician.

Based on clinical record review, staff interview and policy review, the facility failed to complete post dialysis assessments for 1 of 1 resident reviewed for receiving dialysis (Resident #113). The facility reported a census of 116 residents. Findings include: Resident #113's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS included diagnoses of stage 4 chronic kidney disease and toxic nephropathy (kidney disease). Resident #113 received dialysis in the 14-day lookback period. Resident #113's Physician Orders included the following orders dated 5/7/24: a. Vital signs before dialysis 3 times a week b. Vital signs after dialysis 3 times a week c. Assessment in Interdisciplinary Notes 3 times a week The undated Care Plan Problem indicated since Resident #113 returned from the hospital her kidneys still didn't function as they did previously and she had to do dialysis three times a week. The Care Plan Intervention dated 7/1/24 indicated Resident #113 received dialysis starting 5/8/24 three times a week and the nurse needs to assess her before and after dialysis treatment as needed. The Dialysis policy reviewed July 2024 directed an ongoing assessment and monitoring of the resident's condition for complications before and after dialysis treatment. The policy listed the nursing team as responsible for completing the pre and post dialysis assessments. The assessments include documentation regarding vascular access, checking for a thrill (indicating dialysis access is working), a bruit (indicating dialysis access is working), potential bleeding, or other complications. Resident #113's Progress Notes dated 6/1/24 - 8/7/24 reflected post dialysis assessments didn't get completed on 6/3/24, 6/24/24, 7/1/24, 7/10/24, 7/12/24, 7/15/24, and 8/5/24. During an interview on 8/7/24 at 3:09 PM, the Director of Nursing (DON) acknowledged Resident #113 didn't have post dialysis assessments consistently completed. The DON expected the staff complete the post dialysis assessment per policy.

Based on record review and staff interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment no less than 3 months after the last assessment for 2 of 2 residents reviewed (Resident #40 and #105). The facility reported a census of 116 residents. Findings include: 1) The MDS Assessment Lookup for Resident #40 showed she had an admission MDS dated [DATE]. The record also showed the facility had not completed a quarterly assessment. It had been over 4-1/2 months since the admission assessment. 2) The MDS Assessment Lookup for Resident #105 showed she had an admission MDS dated [DATE]. On 1/25/24 the record also showed the facility had not completed a quarterly assessment. It had been over 4-1/2 months since the admission assessment. On 01/24/24 at 9:08 a.m. the MDS coordinator said the skilled MDS coordinator did MDS assessments when the resident's went off skilled. She didn't know if that would be considered a Quarterly assessment. On 1/25/24 at 8:14 a.m. the Director of Nursing (DON) stated she would have to look into the MDS issue. At 9:59 a.m. the DON confirmed the assessments for the 2 residents were not done timely.

Based on observation, record review, and staff interview the facility failed to accurately complete the Residents' Minimum Data Set (MDS) assessments by not coding for an unhealed pressure ulcer (soft tissue injuries from prolonged pressure to areas of the body) and use of physical restraints for 2 of 2 residents reviewed. (Residents #49 and #76). The facility reported a census of 116 residents. Findings include: 1. Review of Resident #49's MDS assessment dated [DATE], shows an admitted [DATE], with diagnoses of Alzheimer's disease, Dementia, stroke, and incontinent of bowel and bladder, on hospice care with full dependence on staff for transfers and cares. Observations of Resident #49's personal care on 1/25/24 at 8:40 AM revealed a pressure ulcer on the resident's coccyx. Resident #49's MDS assessment dated [DATE], lacked documentation of any pressure ulcer. Record review of the Hospice plan of care updates dated 12/7/22 and 9/9/23 noted a Stage 2 pressure ulcer to the coccyx. With treatment to the pressure ulcer ordered by the Hospice Provider. Interview on 1/25/24 at 9:54 AM, the MDS Coordinator and Director of Nursing (DON) confirmed the MDS was not completed accurately and expectations are to complete them accurately. 2. Review of Resident #76's MDS assessment dated [DATE], shows an admitted [DATE], with diagnoses of Alzheimer's disease and Dementia, a BIMS score of 3 (indicating severe cognitive impairment), and assist of 1 for transfers. Observation on 1/22/24 at 1:50 PM revealed a merry walker (restraint device with wheels that allows residents to stand and walk at will but limits where they can go) in Resident #76's room. Record review of the Care Plan dated 1/11/2024 for Resident #76, indicated use of a merry walker to provide least restrictive alternative for safe independent ambulation with assist of 1 to get in and out of merry walker (Resident is not able to get out of merry walker independently) and distant supervision while in use. Resident #76's MDS assessment dated [DATE] lacked documentation of physical restraint use. Review of Resident #76's Restraint Record for the month of December 2023, indicated use of the merry walker. Interview on 1/22/24 at 1:50 PM with a staff nurse stated Resident #76 does use the merry walker but not very often. She circles the lounge area when used and is supervised by nurses and CNAs. Interview on 1/25/24 at 11:36 AM, the DON confirmed the MDS was not completed accurately and expectations are to complete them accurately.

Based on clinical record review and staff interviews, the facility failed to follow a comprehensive Care Plan for 1 of 1 residents reviewed for transfers (Resident #104). The facility reported a census of 116 residents. Findings include: The Minimum Data Set, dated dated dated [DATE] documented Resident #104 had diagnoses including hip fracture and non-Alzheimer's dementia. The MDS further documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating severe cognitive impairment. Review of the Care Plan for Resident #104 documented 10/3/23 the resident required assistance of 2. Review of Progress Notes for Resident #104 dated 10/15/23 revealed the resident was admitted to the hospital with a spontaneous left hip fracture. During an interview 1/25/24 at 10:05 AM, Staff A, Certified Nursing Assistant (CNA) revealed she took Resident #104 to the bathroom on 10/15/23. Staff A stated she thought the resident required assistance of 1 at the time and found out later she required assistance of 2. Staff A reported she transferred the resident and heard a pop when she went to pivot the resident in the bathroom without additional assistance. Staff A reported the resident's transfer status was updated in the computer immediately and also in the huddle binder. Staff A stated she did not keep up with the huddle binder and did not review the huddle binder 10/15/23 when she arrived at work. During an interview 1/25/24 at 1:42 PM, the Director of Nursing revealed there is not a policy in regards to staff following a resident's Care Plan however the expectation to follow Care Plans is taught during the orientation process.

Based on clinical record review, interviews, and facility policy review the facility failed to ensure one (1) of four (4) residents received adequate supervision to protect against hazards in the environment (Resident #3). The facility's staff failed to implement safety measures to prevent a fall by not locking the resident's wheelchair brakes and not using a gait belt when transferring a resident. The record review and staff interviews revealed that Resident #3 required assistance with the use of a gait belt for transfers and ambulation. On 1/30/23, one staff member (Staff A, Certified Nurse Aide CNA) assisted Resident #3 to transfer without a gait belt. As Resident #3 went to sit in the wheelchair, it had one unlocked brake causing the wheelchair to move. As the wheelchair moved and Staff A did not have a gait belt on Resident #3, he fell to the floor. Resident #3 required a transfer to the local emergency room (ER). While at the ER, they determined Resident #3 sustained a right intertrochanteric femoral neck fracture (broken hip). Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 14 of 15 on Brief Interview for Mental Status (BIMS) test, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), cerebrovascular accident (stroke), and respiratory failure. The MDS indicated that Resident #3 required extensive assistance of two persons for dressing, bed mobility, and transfers. Resident #3 did not have a fall since his admission. The Fall Management Promise signed on 9/14/22 by Staff A listed that she promised to do her part to reduce the number of falls the residents experience. She understood that it is up to her to observe the residents and offer interventions that might help keep the resident safe. Staff A realized that resident safety started with her. The Skills Review and Competency Checklists signed by Staff A on 9/14/22 indicated that she completed the transfers/gait belt use. The note listed that she successfullly completed the neighborhood tour and checklist. She felt confident that she could find her way around the building and locate the items listed. Staff A would be responsible and account for the information listed. The [NAME] Belt Policy signed by Staff A on 9/14/22 instructed to use gait belts for the transfer and ambulation procedures implemented for the residents in the facility. When worn around the waist of a resident, the gait belt assists team members by allowing a secure hold on the resident. It minimizes the risk of resident injury from falls. It minimizes the risk of injury for the team members assisting. The Care Plan Category started 11/20/22 related to activities of daily living (ADL's) indicated that Resident #3 needed help to complete his ADLs related to his recent Cerebrovascular Accident (CVA) and weakness. The Care Plan instructed that Resident #3 needed assistance with transfers, ambulation, and dressing. The Interventions directed the following dated 11/30/22: *Walk to/from the bathroom with front wheeled walker and one assist *Staff to hold onto gait belt for increased safety. The Interdisciplinary Notes dated 1/30/23 at 10:19 P.M., at 6:30 p.m. indicated that after arriving to Resident #3's room, they observed him lying on floor in supine position with his head pointed towards entry door and his feet towards the window. The staff witnessed Resident #3's fall. Resident #3 appeared alert and oriented to person, place, and time. The staff reported that as Resident #3 walked from the bathroom to his bed, midway through Resident #3 wanted to remove his jeans to put on his pajama bottoms. When Resident #3 attempted to sit on his wheelchair, it had only one brake locked and resident fell landing on right hip. The staff reported Resident #3 did not hit his head. The assessment revealed that Resident #3 wore shoes for foot wear, his floor did not have clutter, but the staff did not use a gait belt. Range of motion (ROM) to Resident #3's right lower extremity revealed that not with in normal limits. Resident stated I think I broke my hip. Right hip noted to have some swelling/bulging to anterior aspect. Resident was not able to move right leg without pain. A Fall Risk assessment dated [DATE] documented a score of 7, indicating a low risk for falls. The FSI - Falls Scene Investigation report listed that Resident #3 had a witnessed fall on 1/30/23 at 6:30 p.m. The report identified that Staff A assisted Resident #3 to stand up so he could put his pajamas on. When Resident #3 went to sit down, he only had one side of his wheelchair locked. The wheelchair slid out from underneath him, causing him to land on his right hip. Resident #3 complained of severe pain to right lower extremity and he could not bear weight. Resident #3 had a gait belt but it was not in use at the time of his fall. An X-Ray report dated 1/30/23 at 7:25 p.m. documented an acute comminuted right intertrochanteric femoral neck fracture related to a fall with pain and deformity. The Physician Transfer Order Report Instructions dated 2/7/23 at 1:07 p.m. indicated that Resident #3 had a diagnosis of closed fracture of right hip. The instructions directed that he keeps the operative extremity elevated as much as possible and weight bearing as tolerated. On 5/15/23 at 4:30 p.m., Staff A stated that on 1/30/23 Resident #3 wanted to stand and change from jeans into his pajama bottoms. Staff A confirmed that she did not use a gait belt. She added that when Resident #3 went to sit down in the wheelchair, he did not have one of his wheelchair brakes locked and the wheelchair rolled away causing Resident #3 to fall to the floor. Staff A recalled that Resident #3 complained of pain right away. Staff A explained that she had not checked his Care Plan and was new to the floor at the facility. Staff A reported that she received counseling to always follow the Care Plan. On 5/15/23 at 1:30 p.m., Staff B, Licensed Practical Nurse (LPN), reported that the staff called him to Resident #3's room after he fell . Staff B recalled being surprised right away when he entered the room and he did not have on a gait belt. Staff B replied that he expected all staff when providing transfers use a gait belt. On 5/15/23 at 5:30 p.m. the facility Administrator confirmed they expected for the staff to follow the Care Plan for resident transfers. In addition, the Administrator expected the staff to use a gait belt for all staff assisted transfers and ambulation. Staff A's Employee Counseling Report, listed a written warning dated 2/20/23. The report indicated that Staff A assisted Resident #3 with his hour of sleep cares. Staff A did not apply a gait belt when resident stood up from wheelchair to pull pants up. Then as Resident #3 attempted to sit down, the wheelchair did not have one brake locked, resulting in him falling and getting hip fracture. To the form instructed to correct the violation as using a gait belt when assisting a resident from sitting to standing, with transfers, ambulation, and lock wheelchair brakes when resident standing from wheelchair.

Based on observation, record and facility policy review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 10 residents (Resident #1) identified by the facility at high risk for elopement. Resident #1, who was cognitively impaired, exited the facility unsupervised and without staff knowledge for 46 minutes in his wheelchair with weather temperature 88 degrees. The facility reported a census of 111 residents. 1. Resident #1 had an Admission Minimum Data Set (MDS) assessment dated [DATE], that documented diagnoses that included: hypertension, arthritis, anxiety, [CONDITION(S)] and [CONDITION(S)]. The MDS assessed the resident with a score of 3 of 15 on a BIMS (Brief interview for Mental Status) test which indicated severely impaired cognition. The MDS revealed fluctuating disorganized thinking, delusions and physical behavioral symptoms directed towards others. The resident required extensive supervision with locomotion on the unit. The MDS did not identify wandering behavior. The resident used a wheelchair for mobility. The resident admitted to the facility 4/8/21. A Montreal Cognitive assessment dated [DATE], documented a score of 12/30 that identified moderate cognitive deficits and performance below average compared to same age population. The resident exhibited significant deficits within the executive function domain, attention domain, delayed recall domain, and orientation domain. The resident's delayed recall, self-awareness, and reasoning/judgement were impaired. The resident's cognitively ability did not appear consistent and safe for living alone. An Elopement Assessment form dated 4/8/21, documented: *is the resident cognitively impaired with poor decision-making skills-yes *does the resident have a pertinent diagnosis-yes *does the resident have any visual or auditory deficits-yes Interventions: mark all that apply: *visual checks A care plan dated as initiated 4/8/21, identified a focus area problem area of resident at risk for falling related to change in environment, [CONDITION(S)] brain injury. Interventions included: *15 minute visual checks put into place (4/9/21) An entry in the Interdisciplinary Notes dated 4/10/21 at 4:56 a.m., revealed when staff made rounds at 4:20 a.m., the resident just woke up and stated he planned to get ready and 'go to get the team and go to Texas'. Staff attempted to reorient the resident to place and the resident didn't believe staff. The resident denied admitting to the facility or falling early Friday morning. The resident did not understand so staff placed the resident in wheelchair and pushed him in the hall as staff made rounds. Staff could not leave the resident alone in hall as he kept trying to get up and leave. When the resident attempted to get up, he appeared very unsteady. Staff monitored the resident at the nurses station for safety reasons. An entry in the Interdisciplinary Notes dated 5/15/21 at 10:51 p.m., revealed at 9:15 p.m., staff found the resident standing in his room at the dresser drawers. Staff helped the resident into his wheelchair. The resident didn't want to stay in the room or go to bed so the resident rolled around the unit in his wheelchair. The resident attempted to go out big doors (exit unit) several times, and went into other residents rooms. Staff tried to redirect and brought him to the nurses station. An entry in the Interdisciplinary Notes dated 6/6/21 at 7:06 a.m. identified a late entry documented by Staff B RN (registered nurse) for the evening of 6/5/21. 7:55 p.m., Staff on the resident's unit received a call from switchboard identifying a man at the switchboard area that identified his name as [NAME] [NAME] and the man stated he was stuck Switchboard asked there was a resident by that name with a white beard. Staff informed switchboard there was not a resident on Arbor Lane by that name. 8:15 p.m., Staff D RN (medication pass nurse), asked Staff B if Staff B had seen the resident. Staff B stated she had not. Staff D informed Staff B the resident was missing. Staff B recalled the telephone call from the switchboard earlier regarding a man at the switchboard area that had a beard but a different name. Staff D immediately left the neighborhood to go to switchboard/lobby area to see the man was Resident #1 from the unit. Staff B phoned and Staff D 5 minutes later and Staff D identified Resident #1 as the man at the switchboard. Resident #1 was with switchboard staff, a police officer, security guard, and Staff C RN another nurse form Arbor Lane. Staff C left the facility after her shift and saw Resident #1 in the lobby and asked what he was doing there. Staff C identified the resident to switchboard staff, and police officer, and identified the resident as a resident from Arbor Lane unit. Very shortly after that is when another staff arrived in lobby area. Staff G (switchboard) reportedly told staff the resident headed toward the fort because a friend or brother that had a booth there (for Frontier Days). The resident's wheelchair wheel ran off the sidewalk and the resident got stuck in the grass. Staff escorted the resident back to this neighborhood. Staff G gave the resident some cold water to drink while resident sat in the lobby area. The resident stated he felt hot due to being outside in the hot weather for an unknown period of time. 8:23 p.m., Staff B notified the supervisor on call of the elopement and the resident safely back in the neighborhood. Upon return to residents room, Staff B assessed the resident head-to-toe. Vital signs: Temperature 97.0 degrees Fahrenheit, pulse=66, respirations=16, blood pressure=132/80, oxygen saturation at 97% on room air. Staff did not observe injuries or areas of skin impairment, except for [MEDICATION(S)] wrinkles across mid back and sacral area with no redness. The residents face appeared slightly reddened, but identified as normal for resident. The resident had been incontinent of urine. When asked, the resident stated he still felt slightly warm from being outside. Staff provided cold pop to the resident. Staff B talked with the resident to found out more detail about why, when, and where the resident went. The resident appeared very forgetful and could not remember some parts. The resident stated he did not have a plan when he left-that he planned to just figure out something. The resident stated he wanted to get out of here, saying he needed to do that once in a while. The resident wanted to see his mom and his mom worked at a party but did not know where. When asked how he left, the resident stated I walked out. Staff reminded the resident that he used a wheelchair and the resident agreed he wheeled himself all that distance and headed downtown. When asked what happened next, the resident stated his mom found him and took him somewhere (resident could not remember where). When asked how resident returned, the resident stated he returned to the front door looking for someone to talk to. When asked if resident found someone, he stated yes. When asked how he returned to his room, the resident said he settled in here (room) and came up by elevator by himself. 9:20 p.m., Staff B phoned the resident's mother and notified her of the elopement with safe return back to neighborhood. The resident's mother stated was amazed the resident could physically wheel themselves that far, negotiate the elevator and make it out the front door. Staff explained the resident would get a wanderguard bracelet that would alert if the resident left the neighborhood in the future. 9:30 p.m., Staff B informed the physician (palliative care) of the incident and received a verbal order to place wanderguard. 9:45 p.m., After explaining the purpose, staff placed an activated wanderguard bracelet on the resident's right wrist. 9:45 p.m., Staff replaced the original wanderguard bracelet with another activated one with #28 on the back. Original wanderguard de-activated. Contacted IT (information technology) to get wanderguard connected with correct residents information. An Incident Report dated 6/5/21 at 8:10 p.m. and documented by Staff B revealed the following: Elopement. Switchboard operator notified staff that someone named [NAME] [NAME] in lobby and wondered if we had a missing person. Staff did not know at that time the resident actually left the floor. Arbor Lane nurse identified the resident at 8:10 p.m. Another resident of Friendship Haven found the resident outside in a wheelchair with one wheel of the chair off the sidewalk in the grass and resident unable to go any further. The other resident then brought Resident #1 back to Friendship Haven lobby through the front door. Switchboard called the police and when they could not identify the resident because resident offered false names. After Arbor Lane nurse identified the resident, nurse and another Arbor Lane nurse escorted the resident back to his room. The resident informed Staff B that he didn't have a plan when he left, but he just needed to get out of here. Resident wanted to see mom who worked at a party but didn't know where. The resident stated he walked out. The resident used a wheelchair, and when wheelchair use brought to the resident's attention he confirmed he wheeled out to the lobby and out the front door and down the side walk, heading for down town. The resident said his mom found him and took him somewhere else but could not remember where. The resident said he returned by himself to the front door looking for some one to talk to. The resident then stated he settled in here (his room). When asked it resident came up the elevator to room by themselves, resident said yes. A physician order signed and dated 6/5/21 at 9:30 a.m., instructed staff to apply wanderguard bracelet to resident due to risk of wandering/elopement, check placement and battery twice a day. The facilities investigation: Saturday June 5th 2021 8:39 p.m., the facility Director of Nursing (DON) notified the facility administrator of elopement 9:00 p.m., facility director of nursing called director of IT to get surveillance footage. Director of IT reports that will pull footage Sunday morning. 9:13 p.m., DON called Switchboard operator. Switchboard operator gave report to DON. DON asked switchboard operator to return to facility to write a statement regarding incident. 10:00 p.m., DON, received verbal report from nurse. 10:00 p.m., Switchboard operator posted picture of resident at Switchboard with name and room number. Main doors to Health Center shut/closed and signs placed on doors. 10:23 p.m., DON placed call to DIA (Department of Inspections & Appeals) hotline to report elopement. 11:10 p.m., DON sent email to Arbor Lane team members communicating resident now has a wanderguard and used diligence with rounding and visual checks. 11:31 p.m., DON sent an email to everyone email group communicating to keep main Health Center Doors closed until further notice. 11:38 p.m., DON sent email to everyone email group at Friendship Haven with photo of resident attached, asking team members if they observed resident outside of Arbor Lane without a team member to please stay with resident or bring resident back to Arbor Lane. Arbor Lanes number posted in email. Sunday June 6th, 2021 11:11 a.m., DON place call to tenant, Town Home resident who brought Resident #1 back into the building. Left message to return call. 11:36 a.m., DON spoke to director of IT, IT to give more information on timeline to help obtain surveillance. 12:15 p.m., DON sent email to Journeys (CCDI unit) team to look at possible option for resident to move to Journeys. 1:44 p.m., DON/Administrator received communication form IT that resident left the building at 6:49 p.m., via the Welcome Center entrance. Tenant, from Town home, brought back in the building via the [NAME] Place entrance at 7:35 p.m. Tenant wheels resident through the hallway, past [NAME] Place Library, past the Celebration Center and up to Switchboard. According to surveillance video the resident was outside for approximately 46 minutes. The temperature at the time was around 87 degrees outside. According to the video footage/pictures, the resident wore a black t-shirt, black shorts, white socks and black shoes. 3:37 p.m., DON received a return phone call from tenant resident who attempted to give details of where tenant found the resident the evening before. The details were difficult to follow on the phone. The tenant reported she brought the resident back in through the Welcome Center and did not walk through the building. According to video footage, the tenant's recall was not accurate. DON set up a in-person meeting with the tenant for Monday morning at Monday June 7th, 2021 8:15 a.m., DON, Administrator and Arbor Lane Neighborhood Coordinator and Arbor Lane Clinical Coordinator met to debrief and review investigation from the weekend. Clinical coordinator for Arbor Lane to complete questionnaires on all team members who work in Arbor Lane and to follow up with ARNP (advanced registered nurse practitioner) to request a urine analysis and occupational (OT)/speech (ST) evaluation and treatment orders for a cognitive assessment for the resident. 10:32 a.m., DON provided switchboard a list of residents who wear wanderguards. Pictures printed of each resident for switchboard team members to access easily. 11:32 a.m., IT provided Catalyst, Stone Heights and Arbor Lane an accutech pager. The pager will alert when the accutech/wander guard is set off. The neighborhood must assign one team member each shift to carry the pager and respond to 1st floor if the pager goes off. The pager has a different sound/tone than the Iphone alerts. 11:50 a.m., IT provided Switchboard with an accutech pager. The pager will alert Switchboard when the wanderguard system is activated on the 1st floor. 12:30 p.m., DON and Administrator met with Arbor Lane and Journeys team members to discuss option for a possible room move to Journeys CCDI locked neighborhood. At this time Journeys is full so it would require a resident in Journeys to move to accommodate this option. 2:00 p.m., Arbor Lane Team Meetings held. 4:30 p.m., Second Arbor Lane meeting held. 4:40 p.m., Arbor Lane Neighborhood Coordinator spoke with resident's mom on the phone regarding a potential move to Journeys. Tour of Journeys set up for 10:00 a.m. on Tuesday, June 8th, 2021. 7:29 p.m., Online report file to DIA. Tuesday June 8th, 2021 9:00 a.m., DON, Administrator and CEO and Director of Social Services met to discuss elopement and next interventions. At this time, move to Journeys postponed and looked at securing the main Health Center door with a key pad. Administrator has made contacts to move on this intervention as quickly as possible. Plan of Action *Wanderguard implemented. Doctor order received and added to care plan and ETAR, 6/5/21 *Resident picture placed at switchboard 6/5/21 *Main Health Center doors closed with signs place on both sides of doors. 6/5/21 *Residents picture sent out to everyone email group. 6/5/21 *Elopement Assessment re-evaluated. 6/5/21 and 6/7/21 *Order received for urine analysis with culture is indicated. 6/7/21 *OT/ST orders received to evaluate and treat for cognitive. 6/7/21 *Arbor Lane Team meetings held to review elopement process, review 15 minute visual check process, review wander guard expectations, discuss expectations with pager deployment and review residents plan of care. 6/7/21 *All tem meeting scheduled for June 9th. 6/7/21 *Pagers deployed to each neighborhood (Catalyst, Stone Heights, and Arbor Lane). One team member to carry the pager each shift and respond to 1st floor if alarm sounds. 6/7/21 *List of residents with wander guards and pictures to Switchboard. 6/7/21 *Switchboard given an accutech pager. 6/7/21 *Companion hours reviewed and adjusted. Resident to receive approximately 2 hours of 1-1 companion time per day. 6/7/21 *Vendor contacted to secure main door to health center with key pad. 6/8/21 Facility Conclusion: Friendship Haven felt the Frontier Days Celebration at the Fort next to Friendship Haven triggered the resident to leave. There was loud music next door and resident voiced wanting to hear the band when resident brought back inside. Resident in a band when younger and enjoys music. Earlier in the day, staff observed resident looking out the west window watching Frontier Days. Friendship Haven implemented additional safety measure (outlined under plan of action) to decrease risk of wandering and exit seeking and will review and update as needed. Self Report dated 6/7/21 at 7:19 p.m. Reporting Information: Approximate Date Time Occurred: 6/5/21 at 6:48 p.m. Location Occurred: Friendship Haven-elopement Date Aware: 6/5/21 Law Enforcement Notified: yes Incident Summary: On June 5th 2021 at 6:48 p.m., the resident, a resident at Arbor Lane left the [NAME] Health Center without staff knowledge. Resident went out the front doors in a wheelchair. Another resident who lives on campus brought resident back inside Friendship Haven at 7:35 p.m. Resident outside for approximately 46-47 minutes. Head-to-toe Assessment preformed when resident returned to neighborhood. No injuries noted. Corrective Action Description: 1. Head to toe Assessment completed. 2. Dr and family notified of the incident. 3. Wander guard placed on resident and activated. 4. Picture of resident placed at Switchboard. 5. Main doors to Health Center closed and signs placed on doors. The CFS (call for service)-Command Log dated 6/5/21 documented: 7:45:00 p.m., New CFS 7:46:38 p.m., male in wheelchair-out on sidewalk. doesn't know where he belongs because he stated he came form frontier days 7:46:57 p.m., welcome center 7:49:01 p.m., enroute 7:50:49 p.m., on scene 7:56:10 p.m., clear alarms 7:58:37 p.m., [NAME] [NAME] [NAME] 8:22:03 p.m., the male was a resident here at Friendship Haven. Has severe dementia and thought he was a [NAME] [NAME]. A nurse identified him and got him back to his room. 8:26:07 p.m., complete 9:41:02 p.m., Upon arrival, I spoke to switchboard who is a staff member at Friendship Haven. Staff advised an older male who was at the frontier days event was walking around and staff did not know who resident was. I spoke to the male who gave me a name of [NAME] [NAME]. I was not able to find anything in our system for the name given to me. The male also gave me a incorrect social security number and stated his son [NAME] [NAME], was working as a vendor at the frontier days event. After exercising several avenues of trying to identify the male and having security walk around to find the son, no success was made. Later, a female nurse (unknown name) came and identified the male and was in fact a resident of Friendship Have. Staff then took resident to room and I was no longer needed. Review of the Missing Residents/Resident Guard with last reviewed 3/2021. Policy Statement It is the policy of Friendship Haven to take precautions for those residents identified at risk of wandering and to have policies in place to conduct a thorough search of the campus when a resident is missing from any health center neighborhood. Procedure: At the time of admission and when permission is granted, facility will identify all new residents with a photograph maintained in the residents electronic record. A list of all potential wanderers assigned a resident guard will be maintained in each neighborhood and updated on a routine basis. The Health Center, with the exception of the Journeys neighborhood, is equipped with the Resident Guard alarm system. Sensors are placed on neighborhood external exit doors on first floor and various other building locations. The health center is also equipped with security cameras in various locations which are monitored by the switchboard. An assessment will be completed for every resident upon admission and with each MDS and select an appropriate approach to mitigate risk of elopement. Residents identified in Catalyst, Stone Heights, and Arbor Lane as having risk factor for wandering may wear the signaling device/arm band. The residents attending physician will be contacted for a physicians order for the device. The residents family/responsible agent will be contacted and informed of the Resident Guard system and rationale for its use. After the physicians order obtained, the use of the Resident Guard will be added to the resident treatment record and daily use monitored by nursing staff. Physicians will review the order every 75 days. If the Resident Guard sensor is activated, team members will be alerted via page/text/email. Alerts will be resident specific. The Housekeeping Department will be responsible for monthly testing of the alarms. The Director of Nursing and/or designee will be responsible for ordering and maintaining a supply of the wristbands, and the Resident Guard Testing Device. Catalyst, Stone Heights, and Arbor Lane Neighborhoods: 1. In the event an alarm should be triggered-a resident specific page will be sent to Neighborhood staff to respond and a search of the area around the alarm. If the resident is not located outside the door triggering the alarm, search procedure should be started. The alarm is not to be shut off until the resident re-enters or is located. 2. The neighborhood nurse will inform the switchboard who will alert all staff of a code yellow. The nurse will coordinate a room-to-room search, including the basement, stairwells and ground. If switchboard is unoccupied, Nurse will send email to Sara Code Yellow. 3. In the event an alarm doesn't sound and a resident is missing-the neighborhood nurse will inform the switchboard who will alert staff of a code yellow. The nurse will coordinate a room-to-room search including the basement, stairwells, and ground. If switchboard is unoccupied, Nurse will send email to Sara Code Yellow. 4. Administration and law enforcement will be notified if resident can not be found. On 6/14/21 at 2:00 p.m., Staff A CNA (certified nursing assistant) stated Staff A worked on 6/5/21 the 2-10 p.m. shift on Arbor Lane and they were short one staff member. Staff A worked the north east hall. Staff A said she remembered transferring the resident from the recliner to the wheelchair and taking resident to the dining room for supper around 5:30 p.m. Staff A said the resident ate a little, not much, and then the resident sat with other gentlemen at a table and they visited. Staff A then said they observed the resident by the window between 6:00 p.m.-6:15 p.m. and the resident looked out the window. Staff A went to the dining room and started to clean off the tables, Staff A went back up northeast hallway to answer a call light and came back down north hall to answer a call light on another hall. Staff A thought she saw the resident in his room in the wheelchair around 7:00 p.m., but cant actually say for sure that the resident was in their room at that time. Staff A then got done answering the call light on the other hallway and around 7:30 p.m., Staff A went back to the residents room to help the resident get ready for bed and the resident was not in his room. Staff A started to look for the resident in the bathroom, and then all the other rooms on the floor. As Staff A went in and out of other residents' rooms on the north east side of the facility, Staff A observed another staff come out of a room and the southeast side of the facility, around 8:00 p.m. Staff A told that staff of the resident not in their room or in any other of the rooms she checked and asked the other staff to help look for the resident. Staff A looked into more rooms on the northeast side and another staff went down stairs to see if the resident had by chance left the floor. When Staff A went by the resident about 8:20 p.m.-8:30 p.m., the nurse was in the residents room doing vitals, so Staff A went and started assisting other residents getting them ready for bed. Resident #1 was on 15 minute visual checks due to attempting to transfer without staff help. The resident did go downstairs with staff to go for car rides with his mom. On the day of the elopement, the resident wore shorts, t-shirt and ankle socks along with tan slip-on shoes. On 6/14/21 at 3:00 p.m., Staff B RN came into work on 6/5/21 6:00 p.m. - 6:00 a.m., shift. Staff B remembered around 7:55 p.m. they got a phone call from the switchboard on the facility phone that staff carried with them, about a man at the welcome center desk who gave the name of [NAME] [NAME]. They asked Staff B if Arbor Lane had a resident by that name. Staff B said no we don't have a resident on Arbor Lane by the name of [NAME] [NAME]. Staff B did not think anymore about it until 8:15 p.m. when another staff member said the east side aide reported a resident missing and staff could not locate the resident anywhere on the floor. Staff B informed the staff member of earlier the switchboard call earlier. The staff member then said she would run down to the switchboard to make sure the man was not the missing resident. The staff member called Staff B about 5 minutes later and said yes it was the missing resident from Arbor Lane down at the switchboard and the resident was coming back up to the floor. The last time Staff B saw the resident was around 6:10 p.m.-6:20 p.m., the resident sat in the east side common area watching television. Staff B completed a head to toe assessment, vital signs and skin check after staff brought the resident back to their room around 8:20 p.m. Staff B asked if the resident if had a plan to leave and he said no-he just wanted out of here for a while and wanted to see his mom at a party somewhere downtown. And then mom came by and picked up the resident and brought him back here. The resident's temperature was fine and showed no signs of sunburn or dehydration. Staff B placed a wanderguard on the residents right wrist after the incident. On 6/14/21 at 3:30 p.m., Staff C RN worked 6/5/21 stayed over from day shift to assist on the 2 p.m. to 10 p.m. shift due to them short handed and needing extra help. Staff C stayed over to help with the supper meal. Staff C last saw the resident at the end of west hallway window looking outside at Frontier Days. After supper, the resident sat at a table with other residents visiting probably 6:10 p.m.-6:15 p.m. That was the last time, Staff C saw the resident. At that time, Staff C answered a call light on the north east side of Arbor Lane and started to assist a resident with going to the bathroom and getting ready for bed. After 8:00 p.m Staff A came up to Staff C and asked if Staff C saw the resident and if she could help look. Staff C did not see the resident and said she would go downstairs just to make sure the resident didn't leave the floor. Staff C went to the welcome center desk and switchboard and as she came around the corner, she saw the resident with a police officer. The resident said his name was [NAME] [NAME]. Staff C told the resident and police officer his name and that he lived on Arbor Lane. The resident appeared sweaty but no redness or sunburn. On 6/14/21 at 4:30 p.m., Staff D RN stated she worked 6/5/21 from 6:00 p.m.-9:00 p.m., as the medication nurse and only passed medications for that time frame. At 6:15 p.m. the resident sat at the dining room table visiting with other residents and eating his supper. Staff D last remembered seeing the resident in the day room around 6:30 p.m. Around 7:00 p.m., Staff D started to pass medications on the south east side of Arbor Lane and at that time the resident was not in the day room, the resident left. Staff A got Staff D around 8:00 p.m., and asked if Staff D saw the resident and the resident was missing. Staff D said she would go look on the north west side of the hallway and started to search. Staff D ran into Staff B and explained a resident was missing. Staff B said she wondered if that is the man downstairs at the switchboard Staff D went downstairs, saw Resident #1 in a wheelchair and police officer and Staff C standing by him. Staff D identified him to the police officer that he was a resident from Arbor Lane. Staff D went to the computer and pulled up a picture of the resident and the police officer verified the man as Resident #1. As Staff D transported the resident back to Arbor Lane she asked the resident what he tried to do and he said he planned to listen to the music across the street. The resident went right out the front doors and got stuck. Staff D took the resident's vital signs which were in normal limits. The resident said he felt really thirsty so Staff D got him a Mountain Dew. When Staff D returned from getting the pop, Staff B completed a head to toe assessment and another set of vitals. The resident wore a black pair of shorts, t-shirt, ankle socks and brown slip-on shoes. Staff D did not observe any sunburn on legs, arms or forehead. On 6/15/21 at 1:30 p.m., the town home tenant resident said she took a walk outside on 6/5/21 and went around the building to take a look at Frontier Days when she noticed a man in a wheelchair on the side walk that seemed stuck. One wheel rested in the grass and the other wheel sat in dirt and the man could not move so the tenant asked if he wanted some help and he said yes that would be great. The resident didn't say where he was going. The tenant asked him if he felt hot and he said that he was. When the tenant touched his back it felt pretty sweaty so she then helped him get unstuck and then she pushed him into the welcome center entrance. The tenant knew she could get help there. The tenant pushed him through the doors of the welcome center entrance and didn't see anyone at the desk so she pushed him down to another entrance and didn't see anyone there either so she pushed him back through to the welcome center entrance and that time, there was a lady there. The tenant told the lady that this man was outside and didn't know where he was suppose to go so the tenant brought him here. The lady at the desk said that she would take it from here so tenant left and went home. On 6/15/21 at 2:35 p.m., Staff F (security guard) worked 6/5/21 from 8:00 p.m.-6:00 a.m., as the security guard for the facility. He arrived to work that night around 7:45 p.m., and punched in and proceeded to go to the front entrance like I normal and locked the front doors for the night. As Staff F came around the corner on first floor, he noticed a police officer standing by a man in a wheelchair by the desk. The police officer asked the man what his name was and what was his date of birth and security number, the guy in the wheelchair told the police officer that his name was [NAME] [NAME] and that his son was at the Frontier Days at a booth, so Staff F told the switchboard operator and the police officer that he knew the guy that put Frontier Days together and Staff F would go over there and maybe they could announce over the PA system for a guy by that name to come to a certain area. Staff F left the facility and went to Frontier Days and asked if they would mind announcing over the PA system that if anyone knew a [NAME] [NAME] to please come to a spot over by a certain vendor. Staff F waited over by the vendor for 10-15 minutes and no one came. Staff F went back to the facility around 8:15 p.m.-8:20 p.m., when he arrived back into the facility, Staff D and Staff C identified the guy as a resident from Arbor Lane and said he was missing and staff were out looking for him. Staff F stated it was pretty hot out that day but he didn't know the temperature. On 6/16/21 at 10:41 a.m., Staff G (welcome Center/Gift shop coordinator) stated she worked 6/5/21 at the front desk of the welcome center exit. Staff G worked on the computer and didn't see the resident leave the facility. Staff G did not remember the resident even opening the doors to go out of the facility. Staff G said the next thing she knew, a tenant from one of the town homes had a male resident in a wheelchair at the desk and asked if Staff G knew who the resident was and where he belonged because the town home tenant resident[TRUNCATED]

Based on observation, staff interviews, and record review, the facility failed to provide adequate supervision for a resident who required staff assistance for one of four residents reviewed (Resident #3). On 6/2/20, a nurse aide took the resident outside for approximately 25 minutes, coming back in to retrieve a pendant (5 minutes or less) and back outside at 1:37 PM. Staff then left Resident #3 outside unsupervised on an enclosed secure patio, wearing a long-sleeved thick pink ribbed shirt. The temperature at that time per State Climatologist in Fort Dodge was 96 degrees Fahrenheit (F) with a relative humidity of 35%, which resulted in a heat index of 98 F. At 2:16 PM, staff returned the resident inside. Following heat exposure, the resident experienced a condition change. The resident appeared lethargic, confused and weak. The resident's temperature was 102.2 F (average temperature is 98.6) with a pulse of 105 (an average pulse is 80-100). The resident's ability to stand and transfer declined and she required increased staff assistance. Due to the lack of adequate supervision, the facility's actions caused the resident's health and safety to be in Immediate Jeopardy. The facility reported a census of 97 residents. Findings include: A Minimum Data Set (MDS) completed with an Assessment Reference Date of 4/23/20 showed a Brief Interview for Mental Status score of 14, indicating intact cognition. The resident had [DIAGNOSES REDACTED]. The MDS showed the resident required limited assistance of one staff member with ambulation and locomotion in the seven day lookback period. The resident experienced two falls with no injury since the last assessment. The resident record did not contain Occupational Therapy (OT) screening or nurse screening for safety when outside on the secured patio. The Interdisciplinary Note for Resident #3, written by Staff G (RN) dated 6/2/20 at 4:19 PM revealed a caregiver assisted the resident outside onto the patio at approximately 1:40 PM. The resident sat outside for 30 minutes in the area shaded by the building. The nurse checked on the resident at 2:15 PM, and the resident stated she was ready to come inside. The resident appeared weak and confused. The nurse assisted the resident in the recliner with an extensive assist of one. The resident's vital signs were: temperature of 102.2, pulse of 105, respirations 24, blood pressure of 126/80, and oxygen saturation of 94%. The resident received cold fluids, staff assisted with removing layers of clothing, and applied cold cloths to the neck and forehead. At 3:00 PM, the resident's temperature was 100.2. The resident appeared more alert and responded to questions appropriately. The resident reported she did not know what happened to her. The resident denied chest pain, nausea, or vomiting. The resident spoke with her family. The nurse notified the family of heat exposure. At 3:30 PM, the resident's temperature was 98.7. The resident denied concerns. The nurse informed the physician and family of the incident via the phone. A care plan intervention dated 1/24/20 identified the resident as an assist of one staff with ambulation with the four-wheeled walker due to increased falls. One staff assisted the resident with showers and when walking outside of the neighborhood. The care plan identified the resident planned to use the call light as needed. The resident did not use a gait belt per the resident's request and staff educated the resident regarding gait belt use. The resident verbalized she understood the risks of not using the gait belt. A care plan problem dated 1/24/20 identified the resident at risk for falls related to increased weakness and recent falls. The care plan identified the resident with poor safety awareness, and impulsivity which increased the risk of falls. Staff educated the resident at length regarding the use of [MEDICATION NAME] and the risks involved in the case of a fall occurred. The resident used a walker to assist with mobility. On 6/4/20 at 1:21 PM, the resident stated she insists on sitting outside every day. The resident said she sat outside every day except today (6/4/20). The resident stated she was not ill but couldn't see well. The resident reported that someone sits outside with her and approximately two to three other residents that also sit outside. During a follow-up interview on 6/4/20 at 3:33 PM, the resident stated she only remembered feeling better after cooling down. The resident stated she knew better but said identified herself as a sun freak for years. The resident denied having a pendant call light because it felt too heavy for her. The resident stated if the pendant call light was half the size, she would wear it, but it didn't matter because someone is always outside with her. On 6/8/20 at 8:53 AM, the surveyor examined the sweater the resident wore on 6/2/20. Observation revealed the sweater as a thick pink ribbed long-sleeved turtle neck. Staff Interviews: On 6/4/20 at 1:34 PM, Staff B, Registered Nurse (RN), stated one resident got too warm on 6/2/20, and nurses monitored the resident. She noted staff should sit with residents when they are outside, as they can not be outside alone. Staff B denied any other issues with residents having problems with being outside. The nurse reported that six other residents sit outside with one staff, with no more than four residents at a time. On 6/4/20 at 1:51 PM, Staff E, Caregiver, stated a lot of the residents like to go out together when the weather is nice. The caregiver reported taking the resident for a walk on 6/2/20. The resident and the caregiver had a glass of water together while sitting outside. When Staff E needed to come inside, the resident didn't want to go inside. Staff E took the resident inside and put on her pendant call light then took the resident out to the enclosed patio to sit at around 1:37 PM. Staff E indicated she informed the oncoming shift that the resident was out on the patio during the 2:00 PM huddle. Staff E stated the protocol for residents to be outside alone included the resident having a pendant call light or a cellphone to contact someone. On 6/8/29 at 11:54 AM, Staff E stated the time the resident and Staff E was outside before the resident sitting out on the patio alone was between 15-25 minutes max. They came back in to get the pendant call light and then Staff E returned the resident outside to the secured patio at 1:37 p.m. In a follow up interview on 6/10/20 at 9:29 AM, Staff E stated while Resident #3 and herself sat outside and had a glass of water, they sat between the apartment buildings. Staff E reported that after this time sitting outside, the resident and herself went into the facility at approximately 1:35 PM to get the resident's pendant. Staff E said that they were only in the building for around 5 minutes. After getting the pendant, Staff E assisted the resident to the enclosed patio, not the same patio where she and the resident previously sat. On 6/4/20 at 2:35 PM, Staff G, RN, stated she became aware around 2:00 PM that the resident was outside. Staff G made rounds and wasn't sure how long the resident was out. Staff G stated she only knew of one resident that was allowed to be independent outside, and it wasn't Resident #3. Staff G said she has worked for the facility for approximately four years and did not recall the previous year's standards. Staff G denied knowing any other residents that had issues with being outside. Staff G did not know of any policies regarding residents being on the patio independently. Staff G stated staff received verbal education and communication regarding residents left outside unsupervised, especially if the resident was a fall risk. She stated Resident #3 should receive staff supervision while outside due to the resident's history of many falls and inferior vision. During a follow-up interview on 6/4/20 at 3:20 PM, Staff G stated the resident was very lethargic but was alert when returned into the facility. The resident's usual transfer status was a stand by assist to limited assistance. However, following the incident on 6/2/20, the resident required extensive assistance to get into the recliner. The resident did not know where she was or what was going on. Staff G said she didn't remember the resident using her pendant in the past but the resident occasionally utilized a touchpad call light when in the her room. Staff G identified the resident as forgetful and made self transfers in the past without activating a call light. Staff G reported the resident wore the pendant while outside on 6/2/20. The pendant rested on the outside of the resident's sweater and the resident would know it was there. Staff G believed the temperature was in the mid to upper 90s F on the day of the incident. On 6/4/20 at 2:27 PM, Staff F, Caregiver, said the protocol last year was that, if the resident was independent, they could go outside alone. Staff F stated that Staff E did report the resident as out on the patio during the huddle. She said she did not see the resident outside on the East patio as she needed to assist someone in the west part of the neighborhood. On 6/8/20 at 10:23 AM, Staff J, Caregiver, reported offgoing staff identified the resident as outside during shift report. After receiving the report, Staff J answered a call light. Staff J said the next thing she knew, the nurse brought Resident #3 inside. Staff J stated someone needed to sit with the resident while outside, and she did not know of any residents that could sit out alone. On 6/4/20 at 1:36 PM Staff C, Household Coordinator stated the resident did sit outside alone. Staff C worked at home when the incident occurred. Staff C met with the caregiver who assisted the resident outside 6/4/20. On 6/4/20 at 1:39 PM, Staff D, Caregiver, stated she just returned from maternity leave and only worked certain days. Staff D denied hearing about any issues with the resident sitting on the patio. Staff D reported that a few residents sit outside but never alone. On 6/4/20 at 4:16 PM, Staff N, Skilled Care Coordinator, said a nurse contacted her about Resident #3 sitting outside. Staff N identified the protocol as obtaining an OT screening to determine a resident's ability to sit out on the patio alone. When returned inside, Staff N stated the resident felt warm to the touch but refused to have the sweater removed. A nurse convinced the resident to remove it. After removal of the sweater, the nurse applied cold washcloths and assessed the patient. Staff N stated caregivers knew of the rule not to leave a resident outside alone. Staff N identified Staff E as a very good aide who mentors new staff. Staff N said Staff G started to call staff to determine who left the resident outside alone after assessing the resident. Staff N said Staff G did not know who left the resident, but Staff F knew. Staff N stated at the time, Staff F assisted another resident in their room. Staff N reported she did not know if the facility had a written policy regarding residents outside on the patio but would look into it. Staff N stated the expectation is for staff to supervise residents outside unless care planned otherwise. During a follow-up interview on 6/8/20 at 8:40 AM, Staff N reported no policy due to the decision of whether residents sit outside unsupervised as individualized based on OT screening for safety. Observations: Observation of 6/2/20 surveillance video (the day of the incident) at 1:37 p.m. showed Staff E CNA (certified nurse aide) assist the resident via wheelchair to Catalyst's east secured patio. Staff E returned to the building one minute later and opened blinds to the patio door. At time stamp 1:42 PM, Staff G walked up to the nurses station and then walked away from the desk one minute later. At timestamp 1:49 PM, note an unidentified person, seated at the computer with their back away from the patio doors. At time stamp 1:58 PM, an unidentified person arose from the computer station and walked away from the nurses station. At 29 minutes into the video, Staff N walked over to the cupboard of the nurses station, removed an item and walked away from the area. Thirty-three minutes into the video, Staff G arrived at the nurses station and used the phone with her back to the patio doors. Staff G finished the call and walked away from the area. At thirty-seven minutes and 52 seconds into the video, a staff member walked up to the patio window, looked out, and walked away. At thirty-eight minutes and forty seconds into the video, two staff members exited the door onto the patio. At thirty-nine minutes and fifteen seconds (2:16 p.m.), the two staff members return the resident inside via wheelchair. At thirty-nine minutes and forty-three seconds, the video ended with the two staff pushing the resident into the facility away from the camera's view. The resident returned the resident inside at 2:16 p.m. Observation on 6/4/20 at 1:14 PM showed the patio as bright and sunny. Observation on 6/8/20 at 8:53 AM seen the bright patio sunny with no shade and breezy. Physician Interview: On 6/8/20 at 9:28 AM, the resident's primary physician revealed the facility notified him of the incident. The physician identified the resident's ability to sit alone on the patio as hard to determine due to not seeing the resident in awhile. The physician revealed that ideally the all residents should not sit outside without staff. He stated the resident sitting outside unsupervised in 98 degree heat for approximately 35 minutes placed the resident in imminent danger and the resident should not sit outside that long. Following notification, the physician directed staff to supply the resident with cool washcloths and encourage fluids. He instructed the nurse to call if fever increased or continued or the resident's condition changed right away. On 6/8/20 at 9:44 AM, the Director of Nursing (DON) said Staff C conducted staff education. After the surveyor expressed concerns, staff placed the education on the screening table. All staff read the education before beginning their shift and signed it, stating they read it. The caregiver received a counseling session from her supervisor. During a follow-up interview on 6/8/20 at 9:53 AM, the DON stated that each situation is individualized regarding a resident's ability to sit independently on the patio. The DON reported nurses or OT decided if the resident could sit on the patio alone. The DON said therapy is usually involved for residents with cognition concerns. The DON felt each neighborhood could make the decisions. During an observation on 6/8/20 at 10:56 AM, noted the patio area with shade on the south side and breezy. The door to the east patio covered contained a sign with the following printed on the sign: a. Everyone must wear a mask while outside. b. Four residents per staff member. The sign included in black handwriting that residents must have a staff member outside with them. No sign observed to the west patio. During a follow-up interview on 6/8/20 at 11:43 AM, Staff G stated the resident was sitting to the north of the door. Due to where the resident was sitting, the resident was not able to be seen from the nurses' station. The nurse stated the area had slightly more shade than at present, but it was covering the resident. During a follow-up interview on 6/8/20 at 12:08 PM, Staff N stated that she texted the Catalyst neighborhood staff to ensure the team knew about the new policy. During an interview on 6/8/20 at 12:11 PM, the Administrator reported that education on new policies went out to everyone who had worked from 6/6/20 afternoon. The Administrator stated outside of the staff who received individual education in the Catalyst neighborhood, she did not know of any other education provided to the team. Follow Up Regarding Surveillance Camera footage: During a follow-up interview on 6/8/20 at 1:40 PM, the Administrator stated the facility did have a camera for the east patio. The Administrator noted the video did not show the resident on the patio. However, the footage showed when staff took the resident onto the patio and back in from the facility. On 6/9/20 at 12:50 PM, Staff O, Transitions Coordinator, assisted this surveyor by sitting in a chair in the approximate location Staff G described where the resident sat when the incident occurred. While Staff O sat in the chair, this surveyor went into the facility and looked out the window. Staff N and Staff P observed from the door to see if Staff O was visible. During this observation, the only part of Staff O visible from the nurses' station was Staff O's feet and the leg of the chair. Staff N opened the door and stated you could see almost the entire patio from the doorway. While doing this, Staff P looked out and said she was surprised to see Staff O outside as she did not know she was out there. During an interview on 6/9/20 at 1:49 PM, Staff H stated she did see the resident on the patio but reported not knowing the resident was outside until she received the report in the huddle. Staff H stated she and Staff G went straight out after the huddle to bring the resident in from the patio. An Employee Counseling Report dated 6/4/20 indicated Staff E received counseling related to the incident. The counseling report identified the reason for disciplinary action as: on 6/2/20, Staff E took a resident outside. Staff E left the resident alone and then went to the 2:00 PM huddle. At 2:15 PM, the nurse noticed the resident outside. By that time, the resident appeared weak and overheated. Employee comments revealed Staff E took the resident outside around 1:40 PM and informed the second shift the resident sat on the secured patio with a pendant. The area what must be done to correct the violation contained the following information: Staff must stay outside with resident or call for another staff member to come out. Bring resident inside if staff unable to go outside with resident. Weather: On 6/8/20 at 10:17 a.m. the State Climatologist identified the temperature as 96 degrees with relative humidity 35% making the heat index 98 degrees. Abatement: In addition to the employee counseling on 6/4/20, the facility abated the immediate jeopardy on 6/6/20 during the investigation by issuing a memo to all employees and residents dated 6/6/20 that contained reminders to be aware of temperature and heat index-stay inside if too hot. Avoid peak times. Plan activities in the early morning or when the sun starts to set. Dress appropriately-wear loose light colored clothing. Apply adequate sunscreen SPF above 15. Stay hydrated by drinking plenty of cool water. Avoid caffeine and alcohol. Spend as much time as possible in air conditioned spaces. If outside stay in shady area if possible. If escorting a resident to the patio and/or outside, please verify care plan of resident to see if they require supervision while outside. Warning signs of heat related illness may include but are not limited to: increased body temperature, weakness, headache, muscle cramps, dizziness, confusion, nausea/vomiting and weak pulse. If you have signs of heat related illness or observe someone else who is, come in from the outside immediately and notify a team member and/or supervisor. Immediate interventions may include: giving water, applying a cold wash cloth to wrists, ankles, armpits and neck to lower the temperature, check vital signs. The facility was informed of the immediate jeopardy situation on 6/9/20.

Based on observation, record review, resident, staff, and wound nurse interviews, the facility failed to properly assess and implement adequate interventions in order to prevent pressure sores for 2 of 5 residents reviewed (Resident #9 and #11). The facility reported a census of 92 residents. Findings include: 1. A MDS (Minimum Data Set) dated 11/20/15 identified Resident #11 ' s Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicated intact cognition. The MDS identified that, Resident #11 required extensive assistance from 2 staff members for bed mobility, transfers, dressing, and toilet use. Resident #11 ' s balance during transition and walking revealed he/she was unsteady moving on and off the toilet, surface to surface transfers, moving seated to standing and turning or walking activity did not occur. Resident #11 exhibited one sided lower extremity range of motion impairment and used a wheel chair for mobility. The MDS identified Resident #11 at risk for pressure ulcer development, lacked the presence of any pressure ulcers and had a surgical wound. The MDS documented Resident #11 required the following skin and ulcer treatments: pressure reducing device for the chair and bed, nutrition or hydration interventions to manage skin problems, surgical wound care, and the application of ointments and dressings to locations other than the feet. A History and Physical (H & P) dated 11/3/15 and Physician Transfer Order Report dated 11/6/15, identified Resident #11 had a left [MEDICAL CONDITION] after a fall resulted with insertion of a nail/rod in the left femur intertrochanteric on 12/28/13. Resident #11 developed an infection of the left hip joint, had the hardware removed and an antibiotic spacer inserted 4/29/15, received long term antibiotic treatment, and had a left total hip replacement 11/3/15. The report documented Resident #11 had an ulcer of the left heel that required debridement and a partial calcanectomy (removal of the heel bone) on 7/2/15. The H & P revealed the resident's other [DIAGNOSES REDACTED]. The report revealed the Resident #11 transferred to a skilled nursing facility 11/6/15. A Braden Scale For Predicting Pressure Sore Risk identified Resident scored a 14 on 5/6/15, 15 on 7/4/15, and 17 on 11/7/15. A score of 18 or less indicated the resident at risk for pressure sore development. An electronic record Care Plan Historical Copy with a date of 11/11/15 identified Resident #11 with short term memory loss, increased nutrition needs for would healing. The Care Plan identified Resident #11 with some difficulty repositioning self and had a stage 4 pressure wound to the left heel that had a healing date of 9/15/15. The Care Plan interventions directed staff to: a. Assist the resident with repositioning every 1 1/2 to 2 hours. b. Encourage the resident to lie down on his/her sides when in bed. c. A Geofoam mattress on Resident #11's bed and a pressure reduction device to the chair. An alternating air cushion on the chair and wheel chair. d. Received [MEDICATION NAME] powder and [MEDICATION NAME] twice daily. e. Float heels when in bed and a waffle boot to bilateral lower extremities. Make sure the waffle boots in place daily. An electronic record Point of Care Resident ADL (Activity of Daily Living)/Daily Care List for CNA's (Certified Nurse's Aides) dated 11/6/15 directed staff to float Resident #11's heels at all times when in bed, apply waffle boots to Resident #11's feet, encourage to lie down between meals, pressure reduction device to chair, and Geofoam mattress to the bed. The Medication Record For 11/2015 revealed Resident #11 received a Multivitamin with iron daily and Oyster Shell Calcium with Vitamin D twice daily. The Treatment Record For 11/2015 revealed the resident received [MEDICATION NAME] and [MEDICATION NAME] twice daily. The record directed staff Resident #11 required to wear waffle boots day and night and may remove briefly when needed. The record revealed staff documented Resident #11 refused to wear the boots in the a.m. on 11/7 and 11/13/15 and the boots had not been worn on 11/8, 11/11, and 11/12/15. The record revealed staff documented Resident #11 wore the boots every p.m. from 11/6 to 11/15/15. The record lacked documentation Resident #11 wore the waffle boots after 11/15/15. Interdisciplinary Notes revealed the following: a. An entry dated 11/6/15 at 6:00 p.m. revealed Resident #11 returned from the hospital and 2 staff members are to use an EZ stand (mechanical lift) for transfers until seen by PT (physical therapy), weight bearing as tolerated on the left leg, [MEDICAL CONDITION] wraps to the bilateral lower extremities, and use an abduction foam/pillow between legs when in bed. An entry dated 11/10/15 at 9:44 p.m. documented Resident #11 refused the abduction pillow and staff educated the resident. b. An entry dated 11/10/15 at 5:10 p.m. documented Resident #11 seen by a physician and the stand lift was discontinued due to resident safety. c. An entry dated 11/13/15 at 6:14 p.m. revealed a PT order to discontinue the bilateral leg [MEDICAL CONDITION] wraps and apply compression socks during the day and remove at night. d. An entry dated 11/14/15 at 1:46 p.m. revealed Resident #11 had 1+ non [MEDICAL CONDITION] to the bilateral lower legs prior to applying the compression stockings and Resident #11's pedal pulses as palpable. e. Entries dated 11/17, 11/18, 11/28, 11/29, and 12/3/15 revealed the resident had 1+ [MEDICAL CONDITION] to the bilateral lower extremities. Entries dated 11/15, 11/16, 11/19, 11/20, 11/22, 11/23, and 11/26/15 revealed the resident had 2+ [MEDICAL CONDITION] to the bilateral lower extremities. f. An entry dated 11/24/15 at 1:54 a.m. documented Resident #11 stated he/she had moderate pain in the bilateral lower extremities, especially the heels. Documentation revealed Resident #11 received [MEDICATION NAME] (narcotic like [MEDICATION NAME]) at 6:30 p.m. and [MEDICATION NAME] (narcotic [MEDICATION NAME]) later in the evening at 11:45 p.m. for pain. g. An entry dated 12/3/15 at 2:03 a.m. revealed staff members observed an oval shaped purple/blue area on Resident #11's left heel that measured 1.4 cm (centimeter) by 1.6 cm, wound edges intact and the surrounding skin was pink in color. The entry revealed Resident #11 had pain at the site and staff applied heel boots. The staff notified the physician and a directive for the Wound Nurse to evaluate on next rounds was obtained on 12/3/15 at 10:12 a.m. An Incident Report dated 12/2/15 at 9:45 p.m. identified the left heel wound, an intervention for heel boots was initiated and staff members confirmed no injury caused the wound. h. An entry dated 12/8/15 at 3:01 p.m. revealed Resident #11 was seen by a physician, orders to discontinue the scheduled [MEDICATION NAME] and begin [MEDICATION NAME] 50 mg twice daily and 1 to 2 additional tablets 2 times daily PRN (as needed), apply [MEDICATION NAME] to the heel twice daily, air lift boots. Wound Nurse (WN) entries revealed the following: a. An entry dated 12/10/15 at 12:31 p.m. identified Resident #11 with a DTI (Deep Tissue Injury) to the left heel that measured 3.0 cm by 3.0 cm, red and purple color, and with a small intact blister. The WN directed staff to continue to apply [MEDICATION NAME] to the heel twice daily, continue to wear the current heel lift boots, and float heels when in bed. b. An entry dated 12/15/15 at 12:29 p.m. documented the DTI improving, measured 2.5 cm by 2.5 cm, light brown color due to [MEDICATION NAME], without redness and signs of infection, and heel lift boots in place. The WN directed Resident #11 able to walk with therapy and to stop walking if any signs of irritation observed. c. An entry dated 12/22/15 at 12:00 p.m. documented the DTI measured 2.8 cm by 2.3 cm, darker in color and without open areas, redness, and signs of infection. The WN documented Resident #11 had a new closed small light brown area without redness and signs of infection on the tip of the left great toe. The WN directed staff to apply [MEDICATION NAME] twice daily to both areas, continue the heel lift boots except when showered, and try to keep the left foot dry when showered. d. An entry dated 12/29/15 at 12:11 p.m. revealed the left heel DTI now a Stage 3 pressure wound, light yellow with some red, without signs of infection, and a small amount of drainage. The WN observed the heel lift boots without much air, a staff nurse planned to address this, and Resident #11 needed to continue to wear the heel lift boot. The WN directed staff to discontinue the [MEDICATION NAME] to the heel, clean the heel with normal saline, apply Santyl, and cover with [MEDICATION NAME] border. The left great toe had eschar, measured 0.5 cm by 0.7 cm, and the WN directed to continue to apply [MEDICATION NAME] twice daily. e. An entry dated 1/5/16 at 11:31 a.m. documented the left heel wound unstageable, measured 0.5 cm by 1.5 cm, without redness, odor, and drainage, and directed staff to discontinue the Santyl dressing, apply [MEDICATION NAME] twice daily, and let air dry. The left great toe wound measured 0.7 cm by 0.9 cm, had dry eschar, without signs of infection, and continue the [MEDICATION NAME] treatment. f. An entry dated 1/12/16 at 11:46 a.m. documented both areas had eschar. The left heel measured 0.9 cm by 1.0 cm and the left great toe 0.5 cm by 0.8 cm and both areas without drainage and signs of infections. The WN recommended for staff members to continue the same treatment and Resident #11 to go to the Wound Center for an evaluation of the left heel on 1/13/16. The Wound Healing Center (WHC) reports revealed the following: a. On 1/15/16 at 2:00 p.m. the left lateral calcaneus wound measured 1.0 cm by 1.3 cm by 0.1 cm, classified a Stage 3 pressure ulcer, had a small amount of serosanguinous red brown drainage without odor, a small amount (identified as 1 to 33%) of granulation tissue, and large amount (identified as 67 to 100%) of necrotic tissue. After debridement, the heel wound measured 1.0 cm by 1.3 cm by 0.3 cm. The WHC directed staff to clean the area with saline, apply [MEDICATION NAME], and cover with foam and gauze dressing daily. b. On 1/22/16 the left lateral calcaneus Stage 3 pressure ulcer measured 1.0 cm by 1.3 cm by 0.1 cm, had a small amount of serosanguinous red brown drainage without odor, a small amount of granulation tissue, and large amount of necrotic tissue. After debridement, the heel wound measured 1.3 cm by 1.0 cm by 0.3 cm. The WHC directed staff to continue to clean the area with saline, apply [MEDICATION NAME], and cover with foam and gauze dressing daily. On 1/22/16 the WHC identified the left great toe a Stage 3 pressure ulcer, measured 0.6 cm by 0.6 cm by 0.1 cm, had a medium amount of purulent yellow, brown, and green drainage, without granulation, and had a large amount of eschar. After debridement, the toe wound measured 0.6 cm by 0.6 cm by 0.3 cm. The WHC directed staff to continue to clean the area with saline, apply [MEDICATION NAME], and cover with foam and gauze dressing daily. A physician WHC Progress Note dated 1/22/16 revealed Resident #11 ' s Physician documented no significant history of lower extremity arterial disease, had a history of [REDACTED]. The physician documented that arterial testing performed 6/11/15 revealed no significant arterial disease suspected in either leg. The physician's assessment documented the left foot warm, without pallor, mottling, and cyanosis, and pedal pulses good. The physician documented the heel ulcer undoubtedly was related to pressure and not related to the calcenectomy. The physician did not feel Resident #11 had significant lower extremity arterial disease, the heel ulcer improved, and a new left great toe ulcer developed. c. A WHC report dated 1/29/16 documented the left lateral calcaneus Stage 3 pressure ulcer measured 1.0 cm by 0.9 cm by 0.1 cm, had a small amount of serosanguinous red brown drainage without odor, granulation and necrotic amount medium (identified as 34 to 66%). After debridement, the heel wound measured 1.0 cm by 0.9 cm by 0.2 cm. The 1/29/16 WHC report documented the left great toe was a Stage 3 pressure ulcer and measured 0.3 cm by 0.3 cm by 0.1 cm, had a small amount of serosanguinous red brown drainage, a large amount of granulation, and had a small amount of adhered slough tissue. After debridement, the toe wound measured 0.3 cm by 0.3 cm by 0.2 cm. The WHC directed staff to continue to clean the heel and toe areas with saline, apply [MEDICATION NAME], and cover with foam and gauze dressing daily. d. A WHC report dated 2/5/16 documented the left lateral calcaneus Stage 3 pressure ulcer measured 0.9 cm by 0.8 cm by 0.1 cm, had a small amount of serosanguinous red brown drainage without odor, granulation amount small and necrotic/eschar amount large. After debridement, the heel wound measured 0.9 cm by 0.8 cm by 0.3 cm. The 2/5/16 WHC report documented the left great toe Stage 3 pressure ulcer measured 0.3 cm by 0.7 cm by 0.1 cm, without drainage, a small amount of granulation and large amount of eschar/adhered slough tissue. After debridement, the toe wound measured 0.3 cm by 0.7 cm by 0.2 cm. The WHC directed staff to continue to clean the heel and toe areas with saline, apply [MEDICATION NAME], and cover with foam and gauze dressing daily. Resident #11's 1/21/16 MDS assessment revealed the resident had a BIMS of 7 (a score of 0 to 7 indicates severe cognitive impairment) and had 2 Stage 3 pressure ulcers. The MDS identified a Stage 3 pressure ulcer had full thickness tissue loss, subcutaneous fat possibly visible, bone, tendon, and muscle not exposed, slough not obscuring the depth of tissue loss possible, and undermining and tunneling possible. The MDS identified an unstageable pressure ulcer had slough or eschar that covered the wound bed. During initial resident tour 2/9/16 at approximately 9:40 a.m. the Unit Manager, LPN (Licensed Practical Nurse) stated Resident #11 had pressure sores on a heel and toe obtained at the facility and used a stand lift for transfers. Observation revealed Resident #11 sat in a wheelchair in the room with an air type of waffle boot on the left foot. Observation at 11:45 a.m. revealed Resident #11 sitting in a wheel chair in the dining room with an air flow pressure relief mattress on wheelchair seat, bilateral foot pedals on the wheelchair, the air boot on the left foot, and a shoe on the right foot. During an observation 2/10/16 at 1:35 p.m. Staff A RN (Registered Nurse) provided wound care to the left great toe and heel as prescribed. Observation revealed the toe wound had dry yellowish tissue and the heel wound was slightly moist with yellowish tissue. Neither wound had redness or odor. Resident #11 nodded yes when asked if the wounds caused pain. Staff A RN reapplied Resident #11's air waffle boot. Resident #11 had a Geofoam mattress on top of the regular mattress on the bed. The Foot Waffle Heel Elevator Custom product guide provided by the facility directed the waffle cushion surrounds the lower leg in air and designed to float the heel while maintaining skin integrity. The guide directed the boot recommended for the prevention and treatment of [REDACTED]. The Geo-Matt Therapeutic Foam Overlay product guide provided by the facility revealed the bed mattress provided support for the head, torso, and lower extremities. The mattress absorbs pressure points to allow for the body's natural curvature to minimize the effects of pressure and shearing and the surface made to minimize perspiration build up. During an interview 2/10/16 at 10:30 a.m. the Unit Manager LPN verified Resident #11's record revealed the waffle boot discontinued on 11/16/15 and restarted on 12/8/15. The Unit Manager LPN lacked awareness of when and why staff members removed the boot from the treatment sheet and she believed the boot was applied to Resident #11 ' s foot during the interim but staff members failed to document it on the treatment record. During an interview 2/10/16 at 12:15 p.m. the Unit Manager LPN stated she called the staff nurse that discontinued the waffle boot. The staff nurse stated she stopped the waffle boot because Resident #11 refused to wear the boot and the previous pressure ulcer healed. During an interview 2/10/16 at 3:40 p.m. the DON (Director of Nursing) stated the nurses received education from the Wound Center related to pressure ulcers, wound care, staging and documentation on 8/13/15 and presented a copy of the education. The DON presented a copy of information titled Pressure Ulcers provided on 8/18 to 8/19/15 at the August Skills Fair for all certified and professional nursing staff. During an interview 2/10/16 at 3:55 p.m. the Unit Manager LPN stated CNA's provide care for resident ' s based on the Point Of Care for each resident. The Unit Manager LPN stated the intervention to float Resident #11's heels was added to the Point Of Care and CNA's signed off on the interventions during the shift. The Unit Manager LPN stated staff nurses needed to look at the Care Plan in the electronic record to find the intervention to float Resident #11's heels. During an interview 2/10/16 at 4:55 p.m. Staff B LPN, verified she discontinued the heel boot from Resident #11's treatment sheet on 11/16/15 and failed to document a note in the Interdisciplinary Notes explaining why. Staff B stated thought she discussed this with someone (a co-worker, wound clinic, or physician), however unable to remember who or why the boot discontinued. Staff B stated if she received a physician's orders [REDACTED]. The clinical record failed to contain any physician order [REDACTED]. During an interview 2/11/16 at 8:15 a.m. a Wound Health Clinic Nurse (WHC) stated she assessed Resident #11 at the WHC and not at the facility. The WHC Nurse stated she recommended Resident #11 wear a pressure relief boot the rest of his/her life once a pressure ulcer developed. During an interview 2/11/16 at 8:30 a.m. a Wound Nurse stated Resident #11 had a DTI due to pressure. During the morning of 2/11/16 the DON presented a copy of pressure sore education reviewed with Staff B that day. 2. A MDS dated [DATE] identified Resident #9 with short and long term memory impairment, severely impaired cognitive skills for daily decision making, non-fluctuating continuous inattention and disorganized thinking. The MDS revealed, Resident #9 required extensive assistance from 2 staff members for bed mobility, transfers, toilet use and personal hygiene. According to the MDS Resident #9 ' s balance during transition and walking revealed a lack of walking or turning while walking occurred and Resident #9 was only able to stabilize with staff assistance moving from seated to standing, on or off the toilet and surface to surface transfers. The MDS listed Resident #9 used a wheelchair for mobility. According to the MDS Resident #9's [DIAGNOSES REDACTED]. The MDS listed Resident #9 at risk for pressure ulcer development and without any pressure ulcers at the time of the assessment. The MDS documented Resident #9 utilized the following, pressure reducing devices in the chair and bed, nutrition or dehydration interventions to manage skin problems, and applications of ointments/medications other than the feet. A Braden Scale For Predicting Pressure Sore Risk identified the resident scored a 15 on 12/23/15 and a score of 18 or less indicated the resident at risk for pressure sore development. Resident #9's Care Plan identified a problem with repositioning and at risk for skin break down, start date 12/23/15. The interventions directed staff to reposition Resident #9 before and after meals, at HS (hour of sleep) and when needed during rounds, had a pressure reduction mattress and a pressure reducing device on the chair when needed. The Care Plan identified Resident #9 with pressure areas to the bilateral heels on 11/18/15, heels floated when in bed, and the areas healed 11/24/15. An entry dated 1/30/16 revealed Resident #9 had areas on the right and left heel, staff to float heels and apply heel lift boots at all times, apply [MEDICATION NAME] twice daily, and the Wound Nurse (WN) to see Resident #9. Resident #9's Care Plan revealed he/she required a stand lift and 1 staff for transfers (dated 12/23/15). An Incident Report dated 1/29/16 at 2:41 a.m. identified Resident #9 exhibited a 1.2 cm by 0.8 cm hard intact purple pressure area on the left heel. An Incident Report dated 1/29/16 at 2:47 a.m. documented Resident #9 exhibited a 1.8 cm by 2.0 cm hard dark red intact area on the right heel with a 0.8 cm by 0.8 cm dark park purple area. The staff notified the physician via facsimile. An Interdisciplinary Notes sheet dated 1/29/16 at 6:07 p.m. revealed the physician directed staff to apply [MEDICATION NAME] to the bilateral heel areas twice daily and the WN to evaluate. A Wound Nurse entry dated 2/4/16 at 10:37 a.m. revealed Resident #9 appeared to present with DTI's on the posterior heels. The right heel measured 1.0 cm by 1.3 cm and the left heel measured 1.0 cm by 2.0 cm brownish in color and without any open areas. The WN directed staff to continue to apply [MEDICATION NAME] twice daily and allow to air dry, wear heel lift boots at all times except when showered, and to float the heels when in bed. A Wound Nurse entry dated 2/9/16 at 9:57 a.m. identified Resident #9 with DTI's on the bilateral heels. The right heel measured 1.0 cm by 1.3 cm and the left heel 1.0 cm by 1.0 cm, neither had drainage or signs of infection, and continue the same treatment. According to the Medication Record For 1/2016 and 2/2016 directed staff to apply [MEDICATION NAME] wipes to Resident #9's bilateral heels (start date 1/29/16). The resident's Treatment Record For 1/2016 and 2/2016 directed staff to offer and encourage 1 scoop of protein supplement twice daily (start date 8/28/14) and Resident #9 received Resource 60 cc (cubic centimeters) 3 times daily (start date 12/9/15). An entry dated 2/4/16 directed staff Resident #9 required heel lift boots at all times except for bathing and staff documented as done except for the a.m. on 2/9/16. A laboratory report dated 12/3/15 revealed Resident #9 ' s [MEDICATION NAME] level registered low at 2.9 grams/deciliter (g/dl) according to the laboratory report normal values range between 3.4 to 5.0 g/dl. A facility Dietitian note dated 2/9/16 at 10:28 a.m. revealed the dietitian received notice Resident #9 had pressure sores, his/her weight was 138lbs, interventions included extra pudding twice daily, a protein supplement 3 times daily, and 2 calorie house supplement 3 times daily. The notes revealed Resident #9's intakes varied and staff encouraged additional calorie dense foods. During an observation 2/10/16 at 1:52 p.m. Staff A RN, applied a [MEDICATION NAME] swab to each heel and allowed the areas to air dry. Staff A RN asked Resident #9 if his/her heels hurt. Resident #9 replied both heels hurt, the right more. During an interview 2/10/16 at 10:45 a.m. the Unit Manager LPN stated the intervention to float Resident #9's heels failed to be added to the treatment sheet after addition to the Care Plan. The Unit Manager stated the staff floated heels with a pillow. During an interview 2/10/16 at 3:55 p.m. the Unit Manager LPN stated CNA's provide care for resident ' s based on the Point Of Care for each resident. The Unit Manager stated the intervention to float Resident #9's heels failed to be added to the Point Of Care. According to the Unit Manager LPN staff members placed information on a Huddle Board. The Huddle Board located on the wall by the East and West units contained information to update staff with new interventions for care. The Unit Manager LPN confirmed the facility failed to document the intervention to float Resident #9's heels on the treatment sheet for the nurses to sign off. The nursing staff members are required to access the Care Plan in the electronic record to see intervention to float Resident #9's heels. The Unit Manager stated Resident #9's heel lift boots are a new type of boot, just recently obtained by the facility. The Maxxcare Heel Pro Evolution product guide documented the heel lift boot had air cells that floated the heel to reduce pressure and prevent ulcers and resident's able to walk while wearing the boot. During an interview 2/10/16 at 3:15 p.m. Staff C CNA, stated she was unable to remember the interventions in place prior to Resident #9's current heel ulcers and knew he/she used pressure relief boots at one time. During an interview at 4:32 p.m. Staff C stated she tried to float Resident #9's heels when she worked. During an interview 2/10/16 at 3:40 p.m., the DON verified when the intervention to float Resident #9's heels was added to the Care Plan in 11/2015, the staff members failed to add the intervention to Point Of Care in the electronic record for the CNA's to document when completed. During an interview 2/11/16 at 8:30 a.m. the Wound Nurse stated Resident #9's DTI's are due to pressure. During an interview 2/11/16 at 9:05 a.m. Staff A RN, stated Resident #9 used various heel boots and a pillow to float the heels before the DTI's developed. Staff F CNA, present in the room at the same time. Staff A and Staff F stated Resident #9 had blue, pink, and white plaid thick boots with a Velcro strap at one time. Staff F and A stated Resident #9 kicked the boots off and staff members needed to reapply the boots. Staff A and Staff F stated Resident #9 also had waffle air boots with a slick surface that he/she was able to kick off. Staff F stated Resident #9 sat in the recliner frequently and staff needed to reapply pressure relief boots after he/she kicked them off. During an interview 2/11/16 at 10:45 a.m. the Unit Manager LPN verified addition of the heel lift boot to the treatment sheet on 2/4/16.