Every finding on record at Harmony Marshalltown

Based on observations, clinical record review, staff interviews and policy review, the facility failed to use Enhanced Barrier Precautions (EBP) during wound care for 2 of 2 residents observed (Resident #2 and Resident #3). The facility reported a census of 51 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS), dated [DATE], included diagnoses of fractures (broken bones) and other multiple trauma (severe injuries), heart failure (weak heart), and hip fracture. The MDS indicated Resident #2 had a risk of developing pressure ulcers (bedsores)/injuries.The Care Plan Focus initiated 12/5/25, indicated Resident #2 had a risk for alteration in skin integrity (skin health) related to history of falls, impaired mobility (limited movement), and hyperlipidemia (high cholesterol). On 4/7/26, Resident #2 developed a right sacrum (lower spine bone) unstageable pressure ulcer (bedsore). The Care Plan Focus initiated 1/6/26 included an area for Enhanced Barrier Precautions (EBP) related to pressure wound. The interventions included EBP precautions: staff to wear a gown and gloves while performing high-contact care activities (high contact care activities to include: bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, performing wound care).On 5/20/26 at 10:10 AM, Staff A, Registered Nurse (RN), performed wound care for Resident #2. An observation noted EBP signage by the door and a 3-drawer cart of Personal Protective Equipment (PPE) supplies right outside the door to Resident #2's room. Staff B, Certified Nursing Aide (CNA), and Staff C, CNA, assisted with the wound care. They used a gait belt to assist Resident #2 to a standing position by Resident #2's walker, removed his pants, and lowered his brief. Staff B and Staff C remained by Resident #2's side during the wound care and then assisted Resident #2 after wound care by pulling up his pants and brief, then lowered Resident #2 back to his wheelchair. Staff A performed the wound care, cleaned the wound, applied medicated cream, and a new border foam dressing. Throughout the wound care process, Staff A, Staff B, and Staff C didn't wear a gown.2. Resident #3's Minimum Data Set (MDS), dated [DATE], included diagnoses of stroke (brain clot), renal failure (kidney failure), diabetes mellitus (high blood sugar), and pressure ulcer (bedsore) of the right heel, stage 2. The MDS indicated Resident #3 had a risk of developing pressure ulcers (bedsores)/injuries and had one or more unhealed pressure ulcers (bedsores)/injuries.The Care Plan Focus initiated 2/4/26, indicated Resident #3 had a risk for alteration in skin integrity (skin health) related to type 2 diabetes (high blood sugar), weakness, acute kidney failure (sudden kidney failure), and falls. On 1/22/26, Resident #3 developed a stage 3 left ankle pressure ulcer (bedsore), which reopened 3/12/26. The Care Plan Focus initiated 5/11/26 included an area for EBP related to pressure wound. The interventions included EBP precautions: staff to wear a gown and gloves while performing high-contact care activities.On 5/20/26 at 9:50 AM, Staff A performed Resident #3's wound care. Observed an EBP sign by the door and a 3-drawer cart of PPE supplies right outside the door to Resident #3's room. Staff A entered the room, performed hand hygiene, donned (applied) gloves, and removed the current foam border from Resident #3's left ankle. Staff A proceeded with the wound care, cleaned the wound, applied medicated cream, a new pad, and new border foam dressing. Staff A didn't wear a gown throughout the entire wound care process.On 5/20/26 at 10:20 AM, Staff A acknowledged she didn't perform appropriate EBP and stated she should've worn a gown during wound care for both Resident #2 and Resident #3. Staff A added the CNAs who assisted with Resident #2's wound care should've worn a gown as well.On 5/20/26 at 10:30 AM, the Director of Nursing (DON) stated they expected staff to wear gowns during wound care in accordance with EBP guidelines. The DON stated Staff A, Staff B, and Staff C should've worn gowns during wound care for Resident #2 and Resident #3.The Enhanced Barrier Precautions policy dated March 2024 instructed to focus on minimizing risk of transmission of novel or targeted Multi-Drug-Resistant Organisms (MDROs) during high contact resident care activities for residents requiring EBP. For residents whom EBP are indicated, staff should use gowns and gloves during high contact resident care activities that provide opportunity for MDROs to transfer to staff hands and clothing. High contact resident care activities included wounds care: any skin opening requiring a dressing.

Based on observation, staff interview and manufacturer's recommendations, the facility failed to ensure the dishwasher temperature reached 120 degrees during the final rinse cycle. The facility reported a census of 40 residents. Findings include: On 1/13/26 at 12:30 PM observed the kitchen dishwasher reach a temperature of 88 degrees during the rinse cycle with the Dietary Manager (DM) present. The DM confirmed they measured the temperature using the temperature gauge on the right side of the dishwasher. When the DM placed a Hydrion test strip (color-changing paper test strip to measure sanitizer concentration) on dishware it got lost during the dishwashing cycle. The DM reported the dishwasher got up to 110 degrees after staff washed dishes for approximately 30 minutes as they check the temperature at that time. On 1/13/26 12:45 PM the DM reported she expected the dishwasher temperatures meet the manufacturer's recommendations of a minimum of 120 degrees during the rinse cycle. On 1/13/26 at 1:10 PM observed Staff F, Cook, wash dishes following lunch service. Staff F placed a Hydrion test strip on dishware and activated the dishwasher. The test strip turned light purple; a color option not listed when compared to the colors on the test strip container. The observation of the highest dishwasher temperature at the time of the cycle reached 92 degrees. Review of facility form titled, Dishwashing Record Low Temperature/Chemical, dated October 2025, November 2025, December 2025 and January 2025 revealed staff consistently documented the dishwasher temperature twice a day to be 110 degrees. Review of the manufacturer's recommendation plaque located on the dishwasher listed the dishwasher rinse temperature to be a minimum of 120 degrees. Review of a recommendation from the American Dish Service provided by the facility revealed water supply is to reach a minimum of 120 degrees. The Dishwashing: Machine Operation, policy dated 2020 instructed all dishwashing machines should operate according to manufacturer recommendations. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes.

Based on observation, facility records, facility policies, resident and staff interviews, the facility failed to provide bath/shower at least two times for week. The facility reported a census of 49 residents.Findings include: Resident #18's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #18 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) to shower/bathe self (washing, rinsing, and drying self). Resident #18 required substantial/maximal assistance (helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for tub/shower transfers (ability to get in and out of a tub/shower). The MDS included diagnoses of paraplegia (partial paralysis), post-traumatic stress disorder (PTSD or long-term effects of an incident that affects the person mental health), and cerebrovascular accident (CVA - stroke).The Documentation Survey Report for November 2025 documented bathing occurred 4 times on 11/1/25, 11/11/25, 11/21/25 and 11/25/25. The documentation reflected Resident #18 refused once on 11/14/25.The Documentation Survey Report for December 2025 documented bathing occurred 3 times on 12/2/25, 12/12/25, and 12/30/25. The documentation reflected Resident #18 refused once on 12/19/25.On 1/11/26 at 1:53 PM, Resident #18 verbalized he should've received a shower on Friday and still had received one. On 1/13/26 at 10:26, Staff J, Certified Nursing Assistant (CNA), reported residents receive baths twice per week unless they refuse. Staff J acknowledged baths are recorded in the electronic health record (EHR).During an interview on 1/13/26 at 10:28 AM, Staff B, Registered Nurse (RN), verbalized residents receive 2 baths per week unless requested otherwise or refused. Staff B stated refusals are documented in the (EHR) by the CNA. Staff B acknowledged Resident #18's EHR lacked documentation for baths. Staff B verbalized the documentation lacked baths marked indicating the staff received a bath/shower.During an interview on 1/13/26 at 11:33 AM, the Director of Nursing (DON) verbalized the facility provided baths 2 times per week unless a resident wanted them more often or refused to take them. The DON reported Resident #18's baths changed from Tuesday and Friday morning to Monday and Thursday evening effective 1/13/26. The DON reported staff document if baths were provided or refused in the EHR. The DON acknowledge the EHR lacked proof Resident #18 received a bath or refused them. The Hygiene-Bathing/Shower facility policy revised March 2024 directed staff to document in the EHR. The facility policy lacked the frequency of bath/shower or accommodating resident preferences/refusals.

Based on observation, facility records and staff interviews the facility failed to post the daily nurse staffing data which included the facility name, total number and actual hours worked at the beginning of each shift. The facility reported a census of 49 residents. Findings include:On 1/12/26 at 9:46 AM, the facility's CMS Staffing Report listed staffing for 1/5/26, 1/6/26, 1/7/26 and 1/8/26. The facility had the posting taped at eye level on the door of the Staffing Coordinator's office. The CMS Staffing Report posting lacked the facility's name and the posting for the current date of 1/12/26.During an interview on 1/12/26 at 9:46 AM, Staff I, Staff Coordinator, reported she had the responsibility to post the daily nurse staff posting. Staff I reported she printed it after the day/weekend passed.During an interview on 1/13/26 at 9:55 AM, the Director of Nursing (DON) described Staff I as responsible for the daily nurse staff posting. The DON acknowledged the daily nurse staff posting didn't have the current date posted and it lacked the facility's name. The DON explained they expected the facility to follow the regulation.The facility lacked a policy for daily nurse staff posting.

Based on clinical record review, observation, staff interview, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to follow Enhanced Barrier Precautions (EBP) practices during peri cares for 1 of 3 residents reviewed for bowel and bladder (Resident #6). In addition, the facility failed to perform hand hygiene for 1 of 1 resident reviewed for wound care (Resident #19) and failed to post Transmission Based Precautions (TBP) isolation signage for 1 of 6 residents reviewed for infection control (Resident #55).Findings include:1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Resident #6 used a walker and a wheelchair in the previous 7 days. Resident #6 required Partial/moderate assistance (helper does less than half the effort. Helper lifts,holds, or supports trunk or limbs, but provides less than half the effort.) with putting on and/or taking off footwear. The MDS included diagnoses of diabetes mellitus and unspecified osteoarthritis (weakening of the cartilage between bones that causes stiffness, pain, and decreased mobility). Resident #6 had a risk for developing pressure ulcers/injuries. The MDS listed Resident #6 had 1 stage 2 pressure ulcer. Resident #6 received pressure ulcer/injury care.The Skin Evaluation - Pressure Wound - V3 evaluation dated 1/8/26 reflected Resident #6 had a Stage III pressure ulcer to her right heel with an onset date of 8/25/25.The Care Plan Focus initiated 6/19/25 indicated Resident #6 needed EBP precautions related to wounds. The Interventions directed the staff to wear a gown and gloves while performing high-contact care activities such as providing hygiene or changing briefs.On 1/13/26 at 9:40 AM observed an EBP sign hanging on the wall to the left of Resident #6's room. In addition, noted a plastic container next to the door containing personal protective equipment (PPE).On 1/13/26 at 9:45 AM watched Staff D, Certified Nurse Aide (CNA), and Staff C, CNA, perform perineal (peri) care for Resident #6. During the care, Staff B, Registered Nurse (RN), entered the room to apply an ointment. The observation revealed no of the staff wore gowns during the care.In an interview on 1/13/26 at 9:53 AM Staff C stated Resident #6 needed EBP for her foot wound, but they didn't need to wear EBP as they didn't mess with her wound.2. Resident #19's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severe cognitive impairment. The MDS listed Resident #19 as dependent (helper does all of the effort) with toileting hygiene. The MDS reflected Resident #19 as always incontinent of bowel and bladder. The MDS included diagnoses of a stage 3 pressure ulcer of the right buttock and age-related physical debility (weakness due to age). Resident #19 had a risk for developing pressure ulcers/injuries. Resident #19 had 1 unhealed stage 3 pressure ulcer. Resident #19 received pressure ulcer/injury care.The LGHC (IA) Skin Evaluation - Pressure Wound - V3 dated 1/8/26 indicated Resident #19 had a Stage III pressure ulcer to her coccyx with an onset date of 9/17/25.On 1/13/26 at 9:00 AM watched Staff G, Licensed Practical Nurse (LPN), and Staff H, CNA, performed wound care to Resident #19's coccyx, her right cheek, and nose. Staff G completed wound care to Resident #19's coccyx and removed gloves. Without completing hand hygiene, she put on a new pair of gloves and completed wound care to Resident #19's right cheek. Staff G removed her gloves and without performing hand hygiene, applied new gloves to complete the last dressing change.3. Resident #55's admission Record reviewed 1/13/26 listed an admission diagnosis of COVID-19 on 1/8/26. The Order Summary Report reviewed 1/13/26 included an order dated 1/8/26 for transmission-based precautions of contact and droplet precautions for COVID-19 for 10 days (day 0 being 1/4/26).The Care Plan Focus initiated 1/13/26 indicated Resident #55 required isolation precautions related to COVID-19. The Interventions directed to maintain proper isolation precautions per facility policy.On 1/11/26 at 1:54 PM, observed Resident #55's door didn't have a TBP sign indicating his need for isolation and what PPE to use when entering the room. His room had a plastic container outside the door with PPE inside, including N95 face masks. On top of the container contained surgical masks and gloves.On 1/12/26 at 8:08 AM, witnessed Resident #55 door didn't have a TBP sign indicating his need for isolation and what PPE to use when entering the room.On 1/12/26 at 12:14 PM, noted Resident #55 door didn't have a TBP sign indicating his need for isolation and what PPE to use when entering the room.On 1/13/26 at 8:15 AM witnessed Staff A, Housekeeper, clean Resident #55's room wearing only a surgical mask and gloves. The door had a sign that directed to stop and not enter the room due to isolation precautions and to see the nurse for more information. The sign indicated isolation started 1/8/26 with an end date of 1/15/26.On 1/13/26 at 8:45 AM Staff B brought the surveyor the proper isolation sign for COVID. The sign indicated standard precautions plus airborne, contact, and droplet isolation. It also indicated that prior to entering the room, the person needed PPE needed of an N95 mask, eye protection, gown, and gloves.On 1/13/26 at 8:16 AM Staff A reported she didn't what PPE they should wear as the sign on the door didn't say. Staff A added the door didn't have a sign on 1/12/26, so she didn't wear any PPE that day.On 1/13/26 at 8:18 AM Staff B explained Resident #55 didn't have the correct sign on his door for COVID. She added she would make sure to put the correct sign on his door. Staff B explained to enter his room, the person should wear PPE of an N95 mask, face shield, gown and gloves. The correct sign indicated the proper PPE.On 1/13/26 at 8:20 AM Staff C, Certified Medication Aide (CMA), reported the facility put up the current sign on Resident #55's room some time the day before after lunch but before supper. Staff C confirmed the current sign isn't the correct sign. Staff C described the proper PPE as am N95 mask, face shield, gown, and gloves.On 1/13/26 at 11:55 AM the Administrator stated Resident #55's door should have had an isolation sign as he tested positive for COVID. She agreed hand washing should be performed between glove changes. When questioned about EBP, the Administrator replied the staff should use EBP with cares for Resident #6.On 1/13/26 at 12:14 PM Staff E, Infection Preventionist, stated the staff should've used EBP for Resident #6 due to her wound. Staff E added Resident #55 should have had a COVID isolation sign on his door. Also, acknowledged staff should preform hand hygiene between glove changes.On 1/13/26 at 1:35 PM the Director of Nursing (DON) stated hand hygiene should be performed between glove changes. She initially stated that Resident #6 wouldn't need EBP for peri care but then acknowledged the staff should use EBP for peri care. The DON added Resident #55 should have a COVID isolation sign on his door.The Hand Hygiene policy revised October 2023 instructed hand hygiene using alcohol-based hand rub is recommended after removing gloves including during wound dressing change.In a policy titled Infection Control Disease Specific Guidelines revised October 2023, it indicated that isolation for severe acute respiratory syndrome (SARS), also known as COVID, should be airborne, droplet, and contact with standard precautions.In a policy titled Enhanced Barrier Precautions revised March 2024, it directed to use EBP in conjunction with standard precautions for residents with wounds and/or indwelling medical devices. In addition, with residents for whom EBP is indicated, gowns and gloves should be worn during high contact care activities such as providing hygiene or changing briefs or assisting with toileting.The Centers for Disease Control and Prevention (CDC) document dated June 2021 titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities instructed skilled nursing facilities should consider EBP for residents with wounds or indwelling medical devices, regardless of Multi Drug Resistant Organisms (MDRO) colonization status or infection or colonization with an MDRO.

Based on clinical record review, resident interview, and staff interviews, the facility failed to provide a safe discharge for 1 out of 1 resident reviewed (Resident #2). On 7/3/25 at approximately 6:15 PM, Resident #2 exited the building to go see his support animal without staff knowledge. On 7/4/25 around 3:00 AM, Resident #2 requested to return to the facility. Due to the frustration of not being able to get a ride back to the facility, Resident #2 used his electric wheelchair and transported himself to a convenience store at 3:00 AM. At 5:30 AM the police notified the Administrator they found Resident #2. On 7/4/25 at 5:50 AM, the Administrator went to the convenience store and had Resident #2 sign a form indicating he left the facility against medical advice (AMA). The facility lacked documentation of education provided to Resident #2 for leaving AMA.On 7/23/25 at 3:30 PM, the Iowa Department of Inspections and Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 7/25/25 at 1:30 PM, after the staff competed the following:The facility updated their Point of Contact form on 7/17/25 to include additional resident emergency contacts to reach if an emergency situation occurs, such as elopement, or a potentially unsafe resident-initiated discharge.The facility provided staff education on 7/23/25 regarding the Point Of Contact form and the process regarding the chain of command if a resident refused to return from an elopement or their therapeutic leave including calling law enforcement if the resident left the premises and refused to return.The facility added administrative oversight regarding every facility or resident initiated discharge (including AMA) must be reviewed and cosigned by an administrative leader (i.e. Administrator, DON, SW, MDS or designee) before the resident leaves or AMA paperwork is initiated to verify full compliance with the Federal Regulations regarding notice and discharge planning requirements. The administrative team leader would verify the following checklist: Administrative Reviewer -Unplanned Discharge Checklist prior to resident discharge from facility:Right to remain: Verify resident (and representative, if any) was clearly told they may stay at the facility and receive continued care; discussion is documented. Offer root cause analysis and appropriate alternatives concerning their desire to leave the facility in order for the facility to encourage the resident to stay at the facility.Refusal captured: If the resident still chooses to leave, ensure refusal / AMA form is completed and scanned into the record.Medication safety: Confirm medication reconciliation is done and an adequate supply-or prescription-plus written instructions were offered/provided.Post-discharge supports: Confirm offers to arrange / initiate:Home-health or other appropriate community care services.b. A safe place to stay (e.g., confirmed address, shelter, family).Transportation: Ensure safe transportation to the chosen destination is arranged or offered and documented (method, driver, address). The facility educated the nursing staff and social services on 7/25/25 regarding a safe return escort:Any resident off premises who calls or appears without transport is met by facility staff and escorted back in a facility vehicle if available, family member, authorized representative, law enforcement, or emergency services.Staff must immediately notify the facility administrative staff to ensure no resident reentered the facility alone or is stranded and they complete an unplanned discharge checklist to ensure the resident's safety.The scope was lowered from an IJ to a G (harm that is not immediate) on 7/25/25 after ensuring the facility implemented the removal plan. The facility identified a census of 51 residents.Finding include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). The MDS indicated Resident #2 didn't smoke.Resident #3's Clinical Census listed an admission date of 7/3/25.The BIMS evaluation conducted 7/3/25 listed a score of 15.Resident #2's admission assessment dated [DATE] at 3:04 PM identified a BIMS score of 15. The assessment listed Resident #2 as dependent with activities of daily living and used a motorized wheelchair mobility. The assessment included diagnoses of diabetes mellitus, muscle weakness, need for assistance with personal cares, anxiety, chronic atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), bilateral (both sides) below knee amputation, and substance abuse.The Care Plan included the following Focuses initiated7/3/25 indicated Resident #2 used tobacco. The Goal listed he would adhere to the smoking policy. The Interventions directed:7/14/25: Complete a smoking evaluation as needed.7/14/25: Inform Resident and/or Responsible party of the smoking policy.7/14/25: Must keep smoking accessories secured when not in use by the facility staff.7/18/25: Dependent SmokerStaff to assist him to smoke in the designated areas at the designated smoking times.Staff to supervise while smoking.If needed must wear a protective smoking vest or apron.Resident #2 had a risk for ineffective breathing related to wheezing (caused by tightness in the lungs that make breathing difficult). The Intervention directed to provide medications as ordered.Resident #2 required assistance with ADLs. The Interventions directed the following:Assist with showers/bathing per scheduleDependent on staff for dressing, grooming, transferring, and bed mobility.Resident #2 received an anticoagulant (blood thinner) medication. The Intervention instructed to monitor for signs and symptoms of bleeding, bruising, headaches, bloody stool, bloody emesis or sputum.Resident #2 received psychotropic medications related to an anxiety disorder related to the targeted behaviors of restlessness, irritability, muscle tension, and sleep problems. The Intervention directed to provide medications as ordered.Resident #2's July 2025 Medication Administration Record (MAR) lacked documentation to reflect Resident #2 received the following medications on the evening of 7/3/25:Ramelteon (a medication used to help with sleep),Simvastatin (a medication used to help reduce the risk of a heart attack and stroke),Eliquis (medication to reduce risk of stroke or blood clots)Gabapentin (medication used to prevent and control partial seizures and reduce nerve pain).On 7/21/25 at 11:30 AM, observed Resident #2 lying in bed with a fan on him and covered with a sheet. He had his motorized wheelchair next to his bed and his blinds closed to the outside for privacy. Resident #2 stated he left the faciity on 7/3/25 around 6:15 PM, to go see his dog at a friend's house. He didn't know how long it took him to get to his friend's house or the direction he went but he got there. He told his friend he didn't want anyone to know where he was at until he had time with his dog. On 7/4/25 at 3:00 AM Resident #2 told his friend to call the facility to tell them he'd like to return to the facility because he got to see his dog. His friend called and told someone at the facility about him being ready to return to the facility. Resident #2 reported he waited, attempted to use the bathroom and became incontinent with stool. He added this made him mad as he had to clean his friend's bathroom and sit in his own stool. He started to make his back to the facility on his electric wheelchair. He got to a convenience store around 5:30 AM, as he already had the cops looking for him, they found him there. The next thing he knew, the Administrator came and got upset with him because he left the facility without telling anyone where he went. Resident #2 reported he got upset because he felt like the Administrator tried to make him feel bad for wanting to see his dog. The Administrator then told him if he didn't want to come back, he could sign the AMA paperwork. At this point, they told him he wouldn't come back to the facility. By that time, he reported being so angry sitting in his own stool and being unable to get clean, he just signed the paper work. Resident #2 explained after he calmed down for a little while, he realized he needed to go back to the facility for their help. Resident #2 added if someone would have gone to his friend's house and picked him up when his friend called, he would have returned to the facility. Resident #2 explained he left because he got so upset because he couldn't see his dog and no one came outside to help him while he smoked, so he left on his electric wheelchair to go to his friend's house. Resident #2 verified he didn't receive medications on 7/3/25 during the evening shift and he had orders to get medications at that time.On 7/16/25 at 12:30 PM, Resident #7 reported she knew about Resident #2 being out of the facility for 2 hours and the staff didn't even realize he left. She added it happened twice and the facility just wanted to cover it up and not do anything about it.On 7/16/25 at 2:20 PM, Staff L, Certified Medication Aide (CMA), stated she didn't know Resident #2 left the premises until staff came around and asked if anyone saw the new resident (Resident #2) on 7/3/25 at 8:30 PM. Staff L said she didn't see him at all since he ate in the dining room at a table by himself around 5:30 PM. Staff L explained she knew Resident #2 from high school and they knew some of the same people. Staff L attempted to contact a few of the mutual people. Staff L explained she attempted to call Resident #2's friend around 3 times without an answer. At 10:46 PM, Staff L sent him a text message to see if he saw Resident #2. At 2:43 AM, Staff L received a message back from Resident #2's friend about him being at his house and that he called the facility to report Resident #2 wanted to come back to the facility. Staff L explained they went home at 10:00 PM that night but knew Staff O, Licensed Practical Nurse (LPN), received the call about Resident #2 wanting to return to the facility.On 7/16/25 at 2:45 PM, Staff D, Certified Nurse Aide (CNA), said she last saw Resident #2 at the dining room table on 7/3/25 at 5:30 PM when he ate supper. When Staff D, took Resident #5 outside to smoke around 5:45 PM, she saw Resident #2 already out there smoking.On 7/16/25 at 3:00 PM, Staff E, CNA, said she last saw Resident #2 at 5:30 PM, in the dining room eating supper before she went back to her hallway to start passing room trays.On 7/16/25 at 3:15 PM, Resident #5 said when he went outside to smoke in the front of the facility on 7/3/25 at 5:45 PM, he saw Resident #2 already outside smoking. Resident #5 said around 6:00 PM, he came back in the facility and Resident #2 stayed outside still smoking.On 7/17/25 at 1:30 PM inquired with the Administrator and DON in regard to how the AMA came up with Resident #2 at the convenience store, the Administrator replied she got a phone call from the police stating they located Resident #2 at the convenience store. The Administrator went to the convenience store and Resident #2 told her he didn't want to go back to the facility, that it was a prison. The Administrator called the DON and told her to get a AMA form to fill out so that the facility didn't have any responsibility for Resident #2 leaving. Then around 9:23 AM on 7/4/25, Resident #2 showed up at the facility and wanted to come back so they readmitted him. When questioned about what happened related to the notes documenting Resident #2 called the facility 2:00 AM on 7/4/25 and wanted to come back, the Administrator replied that she and the DON were exhausted. She verbalized excuse her if she went to bed, let the police handle the situation, and didn't hear her phone go off when Staff O called that Resident #2 wanted to come back. She added when the police called her she went to the convenience store, she got very upset about the questioning of her chain of command with the nurse that attempted to call her at 3:00 AM to have Resident #2 come back. The Administrator then said well the facility didn't have transportation to bring him back at that time of the morning and asked what were they supposed to do. When questioned again and asked if he could transfer into a car and have the electric wheelchair stay there until someone could get it back to the facility, she got very upset and asked if she could leave to get someone else. The DON said they should have stayed up and kept looking for Resident #2. She added the nurses needed to have a chain of command so that another staff member could of went and got Resident #2 from his location. Staff R, Corporate Staff, came in and discussed the situation, she responded she understood and would look into it and get back.On 7/22/25 at 10:30 AM attempted to call Staff O, no answer voicemail left to return call. On 7/22/25 at 515 PM, Staff P, Corporate Staff, and Staff Q, Corporate Staff, reported they couldn't contact Staff O and thought she couldn't return the call in regards to a personal situation. Staff P said she had questions also in regards to how come no one went to Resident #2's friend's house to pick him up and why did the facility sign him out AMA if he wanted to return to the facility at 3 in the morning. Staff P added someone could of went and picked him up in a car, left the electric wheelchair at his friend's house and he would have been back safe. Staff P felt the Administration and Resident #2 must have had a confrontation, and Resident #2 felt they blamed him for leaving the facility. Staff P added the Administrator probably accused Resident #2 of leaving. This probably upset Resident #2, resulting in him saying he didn't want to come back to the facility and agreeing to sign the AMA form to live his life the way he wanted. Staff P said she got a telephone call from the Administrator stating Resident #2 returned to the facility at 9:30 AM and wanted to come back. Staff P told the Administrator to do everything she could to get him back and readmit him. They agreed the facility could have handled the incident better, adding someone from the facility could of went and got Resident #2 to bring him back when he called. They agreed the facility lacked documentation of the physician being involved in the AMA, the staff could have handled the education differently and Resident #2 would of came back.On 7/23/25 at 8:15 AM, the facility's physician verified that he was not involved with the education portion of Resident #2 discharged AMA. The Administrator told him Resident #2 signed out AMA. The physician said he expected the facility to follow the policy/procedure for discharging residents.On 7/23/25 at 9:10 AM Resident #2 stated he heard his friend talk to someone at the facility, he didn't know who he talked to but, his friend told them that he wanted to come back. He explained he waited and waited and got pissed off because no one came and got him so he left his friend's house. He went to the convenience store where the cops found him. He reported the Administrator came and had him sign AMA paperwork.On 7/23/25 at 12:45 AM, Resident #2 reported he became angry, upset, pissed off, that no one would listen to him about pooping his pants, being incontinent of urine and bowel. He added he felt embarrassed at his friend's home and that no one came to get him when he called at 3 AM. Resident #2 verbalized being scared, fearful, and upset that he had nowhere to go when Administrator had him sign the AMA papers. He calmed down while riding his electric wheelchair around town and realized he had nowhere to go, so he went back to the facility hoping that they would take him back, and he had somewhere to stay. On 7/23/25 at 5:00 PM, Staff M, Licensed Practical Nurse (LPN) explained Resident #2 came back to the facility on 7/4/25 about 9:30 AM. He had an odor of body sweat, bowel, and bladder incontinence. Staff M reported Staff H gave Resident #2 a shower.A review of an online map service for directions, reflected walking from the facility to Resident #2's payee's house via the east south street and south 7th avenue would take 1 hour and 14 minutes for 3 miles.The undated and untitled facility timeline of attempts to contact Resident #2, documented:7/3/25 at 8:50 PM, Administrator aware of inability to locate Resident #27/3/25 at 8:52 PM, the Administrator notified the DON Resident #2 left the building. The staff last saw Resident #2 when he went out to smoke. Resident #2 never came back in the facility.7/3/25 at 8:56 PM - 9:51 PM, the DON and Administrator left in vehicles to look for Resident #2 at various addresses familiar to him (mother's previous address, payee home).7/3/25 at 9:26 PM, the Administrator notified the [NAME] President of Operations.7/3/25 at 9:52 PM - 10:22 PM, the Administrator notified the police. The DON and Administrator regrouped at the facility and spoke to the police. The police posted an updated photo of Resident #2 on their Facebook page. The police reported they would perform their own search. The Administrator provided the police department with her business card for any contact needed. The police assigned a case number and completed a welfare check at the of Resident #2's payee. Resident #2's payee only allowed the police in the front living room of their home and denied Resident #2 being there.7/3/25 at 10:22 PM until 7/4/25 at 1:30 AM, the DON and Administrator returned to their vehicles to continue looking for Resident #2 in his familiar locations.The DON and Administrator couldn't locate Resident #2 and made a decision to stop the search. The DON and Administrator believed Resident #2 stayed at his payee's house, a handicap accessible house where Resident #2's therapy dog resided. 7/4/25 at 2:00 AM, Resident #2 called the facility to request a ride from his brother's home where staff looked for him several times.7/4/25 at 5:30 AM, the police notified the Administrator they located Resident #2 at a gas station7/4/25 at 5:50 AM, when the Administrator and DON arrived at gas station, Resident #2 stated he wanted to live his life and he wouldn't go back to the center. Resident #2 signed AMA paperwork.7/4/25 at 9:23 AM, Resident #2 returned to facility, apologized for his behavior on 7/3/25 and went to his room.7/5/25 at 9:33 AM, after arriving at the facility, the Administrator to speak with Resident #2 about expectations of living in the nursing facility. Resident #2 agreed he would follow the facility's expectations. The facility readmitted Resident #2 to the facility.The Police Department Report dated 7/3/25 at 9:53 PM, documented the facility reported a missing person, Resident #2. The note reflected they found Resident #2 and closed the case on 7/7/25 at 6:51 PM.The untitled typed statement from the Administrator dated 7/18/25 at 1:40 PM, indicated Staff L, Registered Nurse (RN), notified the Administrator that the staff couldn't find Resident #2 at the facility on 7/3/25 at 8:50 PM. The Administrator immediately notified the DON. They met at the facility and initiated a search for Resident #2 at 8:56 PM, in familiar places to him in town. The Administrator notified the police department to assist with searching for a resident. When the Administrator and DON regrouped at the facility at 1:30 AM, they spoke with the police department who stated they would continue to search for Resident #2 and notify them if they located Resident #2. On 7/4/25, the police notified the Administrator per phone at 5:30 AM, they found Resident #2 located at a gas station. The Administrator and DON went to the gas station to speak with Resident #2. The Administrator spoke with Resident #2. They discussed options for Resident #2 and offered him to return to the facility, which he declined. The Administrator discussed Resident #2's safety and best placement options for him. The Administrator attempted to convince Resident #2 several times to return to the facility and Resident #2 declined. Resident #2 told the Administrator and DON, he wanted to live his life, and he wouldn't go back to the center. The Administrator and DON offered a detailed explanation of discharging AMA and the possible consequences of the decision. Resident #2 chose to sign the AMA paperwork, and before leaving the gas station, Administrator told Resident #2, Be careful, if you need anything, please reach out to the facility. On 7/4/25 at approximately 9:30 AM, the Administrator returned to facility after the staff notified her Resident #2 returned to facility, apologized for his behaviors, and wanted to readmit to the facility. The Administrator went to Resident #2's room and spoke with him about the rules of living in a facility, and the rule of leaving the facility grounds, and the requirements if he wanted to do that. The conversation included, signing out at nurses' station in the sign out book, notifying nursing staff he wished to leave, letting the nursing staff know where he'll visit. Resident agreed to the said rules and wished to continue to stay in the facility. The staff readmitted Resident #2 to the facility. The facility policy title Discharge Against Medical Advice revised February 2024, instructed staff to ensure they followed the standard procedures for residents who choose to discharge against medical advice. The staff should provide the appropriate attention and make a reasonable effort to prevent a resident from leaving AMA. The staff must call the physician to notify of the pending AMA discharge. If the resident requested to leave facility against the advice of the attending physician, the facility should document a resident's discharge AMA order in the clinical record. In addition, the facility should assist in arranging post-discharge planning and care to the extent possible.

Based on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure residents safely returned to the building from smoking for 3 of 5 residents reviewed (Residents #1, #2, and #5). On 7/7/25 around 8:00 PM Resident #1 went outside to smoke. After smoking, she couldn't get back into the to the building and remained outside on 7/7/25 at 8:00 PM until 7/8/25 at 6:00 AM. The staff failed to do visual checks on Resident #1 for 10 hours. During the time Resident #1 couldn't get back into the building, the weather had a forecast of heavy rain shower with thunder and lightning. The rain began at 5:00 AM to 6:00 AM, this resulted in a temperature drop from 90 degrees Fahrenheit (F) to 72 degrees F. At that Resident #1 began to panic, became fearful, scared, and crying. Resident #1 reported she wouldn't go out alone to smoke in the evening in fear of it happening again. Resident #1 experienced serious actual psychosocial harm due to being left outside overnight and refused to go outside without another person. While touring the facility and courtyard with the Administrator, the door from the courtyard back in the building failed to open without excess force to move the handle on the door. This resulted in a serious likelihood of serious injury, impairment, or death to occur due the weather conditions and hazards in the courtyard. In addition, on 7/17/25 at 12:40 PM, observed Resident #5 yelling at staff because he couldn't open the courtyard door to come back in from smoking. He reported he rang the doorbell and no staff responded. The incident resulted in an immediate jeopardy situation to the safety of residents who went out to the courtyard.On 7/17/25 at 1:45 PM, the Iowa Department of Inspection, Appeals, and Licensing (DIAL) staff notified the facility staff the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility placed a doorbell in the courtyard area that can be heard at both nurses' stations. The designated smoking area has been moved from this courtyard.The facility changed the designated smoking area to the front of the building.The facility completed checks on all entrance/exit doors to ensure functionality. The front door functioned and any resident who couldn't independently open the door would have staff escort or supervision.The facility identified like residents who resided in the facility that smoke. The facility completed a smoking program on 7/17/25 and updated the residents' Care Plans. The facility completed assessment on safety with their ability to exit and enter the designated smoke area independently. The facility deemed any resident who couldn't enter or exit the door independently to the designated smoke area as a dependent smoker and would be supervised by staff during the designated smoking hours.The facility started to educate staff on 7/17/25 specific to visual rounds of residents, the smoking policy, and the change to designated smoking area.The courtyard door continued to have a functioning door alarm system to alert staff if any resident attempted to exit.In addition, the facility failed to ensure the safety of a cognitive resident (Resident #2) who left the facility unsupervised. When the Resident #2 attempted to call the facility to return, the facility failed to ensure he returned safely to the facility. The facility didn't go to Resident #2 until the police called around 5:30 AM. Due to Resident #2 not returning to the facility independently until around 9:30 AM, he missed his evening medications. The investigation determined Resident #2 used his electric wheelchair to go approximately 3 miles to return to the facility. The incident resulted in an immediate jeopardy situation.On 7/23/25 at 3:30 PM, the Iowa Department of Inspections and Appeals and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 7/25/25 at 1:30 PM, after the staff completed the following:The facility updated their Point of Contact form on 7/17/25 to include additional resident emergency contacts to reach if an emergency situation occurs, such as elopement, or a potentially unsafe resident-initiated discharge.The facility provided staff education on 7/23/25 regarding the Point of Contact form and the process regarding the chain of command if a resident refused to return from an elopement or their therapeutic leave including calling law enforcement if the resident left the premises and refused to return.The facility added administrative oversight regarding every facility or resident-initiated discharge (including AMA) must be reviewed and cosigned by an administrative leader (i.e. Administrator, DON, SW, MDS or designee) before the resident leaves or AMA paperwork is initiated to verify full compliance with the Federal Regulations regarding notice and discharge planning requirements. The administrative team leader would verify the following checklist: Transportation: Ensure safe transportation to the chosen destination is arranged or offered and documented (method, driver, address). The facility educated the nursing staff and social services on 7/25/25 regarding a safe return escort:Any resident off premises who calls or appears without transport is met by facility staff and escorted back in a facility vehicle if available, family member, authorized representative, law enforcement, or emergency services.Staff must immediately notify the facility administrative staff to ensure no resident reentered the facility alone or is stranded and they complete an unplanned discharge checklist to ensure the resident's safety.The scope was lowered from a J to a G on 7/25/25 after ensuring the facility implemented the removal plan. The facility identified a census of 51 residents.Finding include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).The Concern Form dated 7/8/25 reflected Staff A, Dietary Aide, heard pounding on the courtyard door. When she opened the door, Resident #1 told her she got locked outside all night. The Administrator and Director of Nursing (DON) visited with Resident #1, who educated her the facility didn't have the door locked. Resident #1 described the door as heavy and she couldn't open it fully to get back in facility. The form labeled Resident #1 as cognitively intact. The form reflected they educated Resident #1 to take her cellphone when she went out to smoke moving forward. Additionally, they installed a doorbell with receivers at each nurses' station. They educated the staff and smoking residents. They ordered the doorbell on 7/11/25 and installed it 7/16/25.The General Progress Notes dated 7/8/25 at 2:00 PM, documented Resident #1 reported she had difficulty opening the door. She described herself as too weak to pull it open as she normally had before. The nurse notified the doctor of her reported weakness. The nurse waited for a call back from the doctor to see if he would like to complete any labs for Resident #1.The handwritten document completed by Staff F, Licensed Practical Nurse (LPN), on 7/8/25 at 6:30 AM, reflected Resident #1 didn't have injuries to her head, her pupils reacted equally on both sides to light, she had speech clear, she didn't have any redness, bruising, or other injuries. The note described her skin as pink, warm, and intact. Resident #1 could bend and straighten extremities without difficulty. She denied pain. The assessment showed clear lung sounds, a strong unremarkable apical (a location on the chest over the heart) pulse. The note described Resident #1 as alert and walked with a wheelchair. When Resident #1 entered the facility, she voiced concerns that the door wouldn't open. She denied discomfort. The staff escorted her to her room where Staff F completed a thorough exam. Resident #1 changed her clothes and requested to go to dining room for breakfast. The nurse documented Resident #1's mood improved as she socialized with her peers. The Local Conditions Report from the localconditions.com website for Marshalltown printed 7/15/25 at 4:25 PM, documented the weather on 7/7/25 as an overcast with a high of 82 degrees and a low of 69 degrees Fahrenheit (F). The report listed the wind as moderate, blowing around 11 miles per hour (mph) and a gust of 14.1 mph at 12:00 AM. The report detailed the average humidity as higher around 79%, the maximum being 93% at 7:00 AM. The review of the hourly conditions reflected the following:8:00 PM, temperature 78 degrees, felt like 81 degrees with wind speeds at 3.1 mph out of the southeast and gusts up to 5.8 mph.9:00 PM, temperature 76 degrees, felt like 79 degrees with wind speeds at 4.9 mph out of the southeast and gusts up to 10.3 mph.10:00 PM, temperature 73 degrees, felt like 76 degrees with wind speeds at 6 mph out of the southeast and gusts up to 12.7 mph.11:00 PM, temperature 73 degrees, felt like 76 degrees with wind speeds at 6.7 mph out of the southeast with gusts up to 14.1 mph.The Local Condition Report for Marshalltown dated 7/15/25 at 4:25 PM, for 7/8/25 documented the weather had moderate or heavy rain shower with a high of 76 degrees F and a low of 68 degrees. The overall forecast listed rain as having 100% chance of a rainfall total of 1.8 inches. The report identified the wind as light at 8 mph at times with gusts up to 13.8 mph at 3:00 AM. The review of the hourly conditions reflected the following:12:00 AM, temperature 72 degrees, felt like 76 degrees with wind speeds at 5.6 mph out of the southeast and gusts up to 11.7 mph.1:00 AM, temperature 72 degrees, felt like 76 degrees with wind speeds at 5.4 mph out of the south and gusts up to 11.3 mph2:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 4.5 mph out of the south with gusts up to 9.4 mph.3:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 6.9 mph out of the west south west with gusts up to 13.8 mph.4:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds at 4.9 mph out of the southwest with gusts up to 9.6 mph.5:00 AM, temperature 72 degrees, felt like 76 degrees, with wind speeds of 6.5 mph out of the east south east with gust up to 13.1 mph and a precipitation of 0.02 inches of rainfall.6:00 AM, temperature 72 degrees, felt like 77 degrees with wind speeds of 4 mph out of the east northeast with gusts up to 7.2 mph and precipitation of 0.03 inches of rainfall.On 7/14/25 at 3:30 PM, observed Resident #1 sit on her bed with the head of bed elevated, doing a word puzzle and watching jeopardy on the television, dressed in capris, shoes, short sleeve t-shirt, wheelchair outside of the door to her room, and walker next to her bed.On 7/16/25 at 1:30 PM, the Administrator, Director of Nursing and the Surveyor went out to the courtyard on the east side of the dining room. Noted the door going to the courtyard didn't completely shut all the way, so staff asked over the walkie if anyone went outside and to make sure and check the dining room door, the Administrator pushed the door shut so that the alarm would stop sounding. During the walk through the courtyard, observed various hazards in the courtyard. The facility had a disconnected and nonfunctioning white button doorbell with a new black doorbell placed on the outside of the door frame of the door to the courtyard. In the yard, noted a white gate that didn't allow any resident to leave the facility from the outside courtyard. When attempting push down on the top of the door handle to open the door to go back in the facility, the door failed to open. The Administrator explained the door shouldn't have locked and verified the difficulty of opening the door. On 7/14/25 at 3:30 PM, Resident #1 said that on 7/7/25 at 7:00 PM, she went outside to have her last cigarette. She went out by herself through the dining room doors to the patio area designated for smoking. She said after she completed smoking, she proceeded to pull on the door to come in the facility but couldn't pull the door open. She saw a door bell and she rang it, but no one came. She rang it and pulled on the door again, and still no one came. She reported she stayed outside all night long in her wheelchair until someone from the kitchen came at 6:00 AM on 7/8/25. They saw her pounding on the door and asked her what she was doing outside. Resident #1 told her that she went out for a smoke and couldn't get back into the facility. She added she stayed out in the thunderstorm/lightning soaking wet. Staff A, Dietary Aide, let her in and took her to the nurse. She changed her clothes and got warm. At the time she wore shorts, shoes, and a t-shirt, as sat in her wheelchair outside. In order to keep warm, she pulled her arms inside of her shirt and tried to bring her knees up to her chest and still couldn't keep warm. Resident #1 explained being so scared and cold. She sat by the gas grill but didn't want to touch it due to the lightening. She just tried to huddle against the door to keep warm. Resident #1 reported they told her the door opened easy, it didn't lock, and she could get back in. Resident #1 declared well that didn't happen. She couldn't pull on the door to get it to open. She kept pushing on the door bell, she later learned that door bell was broken and it didn't work. Across from her bed had a calendar on the wall with blue dots on the date 7/7/25. The space had writing, that said outside all night long.On 7/16/25 at 1:10 PM, Staff A said that on 7/8/25 at 5:50 AM, she came into work in the kitchen. When she opened the double doors into the dining room, went over and turned on the lights to the dining room, she heard pounding on the window/door, and looked around the dining room and saw Resident #1 standing up at the door pounding on the window on the back-patio area where the smokers went. Staff A, went to the door and let Resident #1 inside. The door usually had a Velcro stop sign across, but it wasn't attached to the frame of the door. Staff A explained the alarm box with the code inside was turned off so the alarm didn't sound. Staff A explained Resident #1 was crying and shaking from being wet, scared, visibly upset, and shaking from being cold. Staff A explained when she came to work it was thundering and lightening outside.On 7/16/25 at 5:20 PM, Staff F, Licensed Practical Nurse (LPN) verified worked 6:00 PM - 6:00 AM on 7/7/25 to 7/8/25. She said around 8:00 PM, on 7/7/25, she looked outside and noticed Resident #1 sitting outside underneath the gazebo having a cigarette. She noted the Velcro side of the stop sign was down. She went to the lock box and opened it, finding the alarm off. She thought she should turn the alarm on, but with Resident #1 being outside she left the alarm off. On 7/8/25, at 6:00 AM, Staff A, brought Resident #1 to the east nurses' station. She reported Resident #1 was outside all night long and was cold, shivering, scared, frightened, and was hysterical. Staff F, LPN, and Staff G, LPN, proceeded to take Resident #1 to her room to put warm clothes on. They completed vitals and did a head-to-toe assessment.On 7/17/25 at 7:45 AM, Staff G verified on 7/8/25 at 6:00 AM, Resident #1 was left outside from 8:00 PM, on 7/7/25 until 6:00 AM, 7/8/25, when Staff A brought her to the east nurses' station. Staff G, added Resident #1 was soaking wet, cold, shivering, frightened, scared, and upset about being left outside in the thunderstorm, lightning, and rain. Staff G described Resident #1 as emotionally and psychosocially devasted about being outside all night long in the cold rain, with thunder and lightning. On 7/16/25 at 4:25 PM, Staff L, Certified Nursing Assistant (CNA), reported on 7/15/25, when they took Resident #18 out to smoke in the courtyard, they attempted to come back into the facility, but couldn't open the door and started to panic. Staff L, didn't know what to do and just about started pounding on the window in hopes someone would come and let them in. Staff L started to pound on the latch on top of the door handle and it finally let loose, letting her back in. Staff L reported being scared.2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). The MDS indicated Resident #2 didn't smoke.Resident #3's Clinical Census listed an admission date of 7/3/25.The BIMS evaluation conducted 7/3/25 listed a score of 15.Resident #2's admission assessment dated [DATE] at 3:04 PM identified a BIMS score of 15. The assessment listed Resident #2 as dependent with activities of daily living and used a motorized wheelchair mobility. The assessment included diagnoses of diabetes mellitus, muscle weakness, need for assistance with personal cares, anxiety, chronic atrial fibrillation (an irregular often rapid heart rate that commonly causes poor blood flow), bilateral (both sides) below knee amputation, and substance abuse.The Care Plan included the following Focuses:Resident #2 required assistance with ADLs. The Interventions directed the following:Assist with showers/bathing per scheduleDependent on staff for dressing, grooming, transferring, and bed mobility.Resident #2 received an anticoagulant (blood thinner) medication. The Intervention instructed to monitor for signs and symptoms of bleeding, bruising, headaches, bloody stool, bloody emesis or sputum.Resident #2 received psychotropic medications related to an anxiety disorder related to the targeted behaviors of restlessness, irritability, muscle tension, and sleep problems. The Intervention directed to provide medications as ordered.Resident #2's July 2025 Medication Administration Record (MAR) lacked documentation to reflect Resident #2 received the following medications on the evening of 7/3/25:Ramelteon (a medication used to help with sleep),Simvastatin (a medication used to help reduce the risk of a heart attack and stroke),Eliquis (medication to reduce risk of stroke or blood clots)Gabapentin (medication used to prevent and control partial seizures and reduce nerve pain).On 7/21/25 at 11:30 AM, observed Resident #2 lying in bed with a fan on him and covered with a sheet. He had his motorized wheelchair next to his bed and his blinds closed to the outside for privacy. Resident #2 stated he left the faciity on 7/3/25 around 6:15 PM, to go see his dog at a friend's house. He didn't know how long it took him to get to his friend's house or the direction he went but he got there. He told his friend he didn't want anyone to know where he was at until he had time with his dog. On 7/4/25 at 3:00 AM Resident #2 told his friend to call the facility to tell them he'd like to return to the facility because he got to see his dog. His friend called and told someone at the facility about him being ready to return to the facility. Resident #2 reported he waited, attempted to use the bathroom and became incontinent with stool. He added this made him mad as he had to clean his friend's bathroom and sit in his own stool. He started to make his back to the facility on his electric wheelchair. He got to a convenience store around 5:30 AM, as he already had the cops looking for him, they found him there. The next thing he knew, the Administrator came and got upset with him because he left the facility without telling anyone where he went. Resident #2 reported he got upset because he felt like the Administrator tried to make him feel bad for wanting to see his dog. The Administrator then told him if he didn't want to come back, he could sign the AMA paperwork. At this point, they told him he wouldn't come back to the facility. By that time, he reported being so angry sitting in his own stool and being unable to get clean, he just signed the paper work. Resident #2 explained after he calmed down for a little while, he realized he needed to go back to the facility for their help. Resident #2 added if someone would have gone to his friend's house and picked him up when his friend called, he would have returned to the facility. Resident #2 explained he left because he got so upset because he couldn't see his dog and no one came outside to help him while he smoked, so he left on his electric wheelchair to go to his friend's house. Resident #2 verified he didn't receive medications on 7/3/25 during the evening shift and he had orders to get medications at that time.On 7/16/25 at 12:30 PM, Resident #7 reported she knew about Resident #2 being out of the facility for 2 hours and the staff didn't even realize he left. She added it happened twice and the facility just wanted to cover it up and not do anything about it.On 7/16/25 at 2:20 PM, Staff L, Certified Medication Aide (CMA), stated she didn't know Resident #2 left the premises until staff came around and asked if anyone saw the new resident (Resident #2) on 7/3/25 at 8:30 PM. Staff L said she didn't see him at all since he ate in the dining room at a table by himself around 5:30 PM. Staff L explained she knew Resident #2 from high school and they knew some of the same people. Staff L attempted to contact a few of the mutual people. Staff L explained she attempted to call Resident #2's friend around 3 times without an answer. At 10:46 PM, Staff L sent him a text message to see if he saw Resident #2. At 2:43 AM, Staff L received a message back from Resident #2's friend about him being at his house and that he called the facility to report Resident #2 wanted to come back to the facility. Staff L explained they went home at 10:00 PM that night but knew Staff O, Licensed Practical Nurse (LPN), received the call about Resident #2 wanting to return to the facility.On 7/16/25 at 2:45 PM, Staff D, Certified Nurse Aide (CNA), said she last saw Resident #2 at the dining room table on 7/3/25 at 5:30 PM when he ate supper. When Staff D, took Resident #5 outside to smoke around 5:45 PM, she saw Resident #2 already out there smoking.On 7/16/25 at 3:00 PM, Staff E, CNA, said she last saw Resident #2 at 5:30 PM, in the dining room eating supper before she went back to her hallway to start passing room trays.On 7/16/25 at 3:15 PM, Resident #5 said when he went outside to smoke in the front of the facility on 7/3/25 at 5:45 PM, he saw Resident #2 already outside smoking. Resident #5 said around 6:00 PM, he came back in the facility and Resident #2 stayed outside still smoking.On 7/17/25 at 1:30 PM inquired with the Administrator and DON in regards to how the AMA came up with Resident #2 at the convenience store, the Administrator replied she got a phone call from the police stating they located Resident #2 at the convenience store. The Administrator went to the convenience store and Resident #2 told her he didn't want to go back to the facility, that it was a prison. The Administrator called the DON and told her to get a AMA form to fill out so that the facility didn't have any responsibility for Resident #2 leaving. Then around 9:23 AM on 7/4/25, Resident #2 showed up at the facility and wanted to come back so they readmitted him. When questioned about what happened related to the notes documenting Resident #2 called the facility 2:00 AM on 7/4/25 and wanted to come back, the Administrator replied that she and the DON were exhausted. She verbalized excuse her if she went to bed, let the police handle the situation, and didn't hear her phone go off when Staff O called that Resident #2 wanted to come back. She added when the police called her she went to the convenience store, she got very upset about the questioning of her chain of command with the nurse that attempted to call her at 3:00 AM to have Resident #2 come back. The Administrator then said well the facility didn't have transportation to bring him back at that time of the morning and asked what were they supposed to do. When questioned again and asked if he could transfer into a car and have the electric wheelchair stay there until someone could get it back to the facility, she got very upset and asked if she could leave to get someone else. The DON said they should have stayed up and kept looking for Resident #2. She added the nurses needed to have a chain of command so that another staff member could of went and got Resident #2 from his location. Staff R, Corporate Staff, came in and discussed the situation, she responded she understood and would look into it and get back.On 7/22/25 at 515 PM, Staff P, Corporate Staff, and Staff Q, Corporate Staff, reported they couldn't contact Staff O and thought she couldn't return the call in regards to a personal situation. Staff P said she had questions also in regards to how come no one went to Resident #2's friend's house to pick him up and why did the facility sign him out AMA if he wanted to return to the facility at 3 in the morning. Staff P added someone could of went and picked him up in a car, left the electric wheelchair at his friend's house and he would have been back safe. Staff P felt the Administration and Resident #2 must have had a confrontation, and Resident #2 felt they blamed him for leaving the facility. Staff P added the Administrator probably accused Resident #2 of leaving. This probably upset Resident #2, resulting in him saying he didn't want to come back to the facility and agreeing to sign the AMA form to live his life the way he wanted. Staff P said she got a telephone call from the Administrator stating Resident #2 returned to the facility at 9:30 AM and wanted to come back. Staff P told the Administrator to do everything she could to get him back and readmit him. They agreed the facility could have handled the incident better, adding someone from the facility could of went and got Resident #2 to bring him back when he called. They agreed the facility lacked documentation of the physician being involved in the AMA, the staff could have handled the education differently and Resident #2 would of came back.On 7/22/25 at 10:30 AM attempted to call Staff O, no answer voicemail left to return call.On 7/23/25 at 8:55 AM, Staff H, CNA, verified Resident #2 received a shower on 7/4/25, due to have an odor of sweat, bladder, and bowel incontinence. Staff H reported Resident #2 appreciated the shower.On 7/23/25 at 9:10 AM Resident #2 stated he heard his friend talk to someone at the facility, he didn't know who he talked to but, his friend told them that he wanted to come back. He explained he waited and waited and got pissed off because no one came and got him, so he left his friend's house. He went to the convenience store where the cops found him. He reported the Administrator came and had him sign AMA paperwork.On 7/23/24 at 12:45 AM, Resident #2 reported he became angry, upset, and pissed off, that no one would listen to him about pooping his pants, being incontinent of urine and bowel. He added he felt embarrassed at his friend's home and that no one came to get him when he called at 3 AM. Resident #2 verbalized being scared, fearful, and upset that he had nowhere to go when Administrator had him sign the AMA papers. He calmed down while riding his electric wheelchair around town and realized he had nowhere to go, so he went back to the facility hoping that they would take him back, and he had somewhere to stay. On 7/23/25 at 5:00 PM, Staff M, Licensed Practical Nurse (LPN) explained Resident #2 came back to the facility on 7/4/25 about 9:30 AM. He had an odor of body sweat, bowel, and bladder incontinence. Staff M reported Staff H gave Resident #2 a shower.The undated and untitled facility timeline of attempts to contact Resident #2, documented:7/3/25 at 8:50 PM, Administrator aware of inability to locate Resident #27/3/25 at 8:52 PM, the Administrator notified the DON Resident #2 left the building. The staff last saw Resident #2 when he went out to smoke. Resident #2 never came back in the facility.7/3/25 at 8:56 PM - 9:51 PM, the DON and Administrator left in vehicles to look for Resident #2 at various addresses familiar to him (mother's previous address, payee home).7/3/25 at 9:26 PM, the Administrator notified the [NAME] President of Operations.7/3/25 at 9:52 PM - 10:22 PM, the Administrator notified the police. The DON and Administrator regrouped at the facility and spoke to the police. The police posted an updated photo of Resident #2 on their Facebook page. The police reported they would perform their own search. The Administrator provided the police department with her business card for any contact needed. The police assigned a case number and completed a welfare check at the of Resident #2's payee. Resident #2's payee only allowed the police in the front living room of their home and denied Resident #2 being there.7/3/25 at 10:22 PM until 7/4/25 at 1:30 AM, the DON and Administrator returned to their vehicles to continue looking for Resident #2 in his familiar locations.The DON and Administrator couldn't locate Resident #2 and made a decision to stop the search. The DON and Administrator believed Resident #2 stayed at his payee's house, a handicap accessible house where Resident #2's therapy dog resided. 7/4/25 at 2:00 AM, Resident #2 called the facility to request a ride from his brother's home where staff looked for him several times.7/4/25 at 5:30 AM, the police notified the Administrator they located Resident #2 at a gas station7/4/25 at 5:50 AM, when the Administrator and DON arrived at gas station, Resident #2 stated he wanted to live his life and he wouldn't go back to the center. Resident #2 signed AMA paperwork.7/4/25 at 9:23 AM, Resident #2 returned to facility, apologized for his behavior on 7/3/25 and went to his room.7/5/25 at 9:33 AM, after arriving at the facility, the Administrator to speak with Resident #2 about expectations of living in the nursing facility. Resident #2 agreed he would follow the facility's expectations. The facility readmitted Resident #2 to the facility.The Police Department Report dated 7/3/25 at 9:53 PM, documented the facility reported Resident #2 missing. The report reflected they found Resident #2 and closed the case on 7/7/25 at 6:51 PM.A review of an online map service for directions, reflected walking from the facility to Resident #2's payee's house via the east south street and south 7th avenue would take 1 hour and 14 minutes for 3 miles.The website titled timeanddate.com reflected weather information from CustomWeather. The website indicated on 7/3/25 at 6:35 PM, the city of Marshalltown had a temperature of 90 degrees Fahrenheit (F) with sunny skies and wind at 10 miles per hour. In addition, on 7/4/25 at 8:55 AM the website showed a temperature of 81 degrees F with sunny skies and wind at 8 miles per hour.The untitled typed statement from the Administrator dated 7/18/25 at 1:40 PM, indicated Staff L, Registered Nurse (RN), notified the Administrator that the staff couldn't find Resident #2 at the facility on 7/3/25 at 8:50 PM. The Administrator immediately notified the DON. They met at the facility and initiated a search for Resident #2 at 8:56 PM, in familiar places to him in town. The Administrator notified the police department to assist with searching for a resident. When the Administrator and DON regrouped at the facility at 1:30 AM, they spoke with the police department who stated they would continue to search for Resident #2 and notify them if they located Resident #2. On 7/4/25, the police notified the Administrator per phone at 5:30

Based on staff interviews, clinical record review and policy review the facility failed to provide interventions to prevent a deep tissue injury (a type of pressure injury that occurs when underlying soft tissue is damaged due to prolonged pressure, often over bony prominence.) from performing for 1 of 2 residents reviewed (Resident #3). The facility identified a census of 51 residents. Findings include: Determining the Stage of Pressure Injury:Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified they had memory problems with severely impaired daily decision-making abilities. Resident #3 required substantial to maximal assistance for all activities of daily living (ADLs), except listed them as totally dependent on putting on/off of footwear and moving from one position to another. The MDS reflected Resident #3 admitted with a Stage 2 and a Stage 3 pressure area.Resident #3's Medical Diagnoses reviewed 7/21/25 included diagnoses of anxiety, mild cognitive impairment, osteoarthritis,(type of arthritis that occurs when flexible tissue at the ends of bones wears down), osteoporosis (a disease that weakens bones that gets worse over time and increases the risk for a bone fracture) and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings), and chronic pain.The Care Plan Focus initiated 5/12/25, identified Resident #3 had a risk for alteration in skin integrity related to cognitive impairment, osteoporosis with limited mobility, pressure areas to coccyx (a small triangular bone located at the bottom of the spine, just below the sacrum, also known as the tail bone), and right buttock on admit. The Focus included the go for Resident #3 to not develop skin alterations outside of the disease process. The Interventions directed staff the following:Encourage good nutrition and hydration in order to promote healthier skinEncourage Resident #3 to reposition.Resident #3's admission Orders dated 5/12/25, lacked treatment orders for the pressure areas on her coccyx and right buttock.The admission Summary Note dated 5/12/25 at 3:24 PM, documented, Resident #3 arrived via private vehicle. The note described Resident #3 as alert and oriented with intermittent (comes and goes) confusion at times. The note included the following assessment:Abdomen is soft, non-tender.Pressure areas Coccyx 1.0 cm X 1.0 cmRight buttock 5.0 cm x 5.0 cmScattered bruising noted throughout body.Resident #3 denied pain or discomfort at that time. Resident #3 required the assistance of 2 staff for transfers.Resident #3's Nursing - Admission/readmission assessment dated [DATE] at 8:12 PM, identified the following skin alterations:Stage 2 pressure area to coccyx that measured a length of 1.0 centimeter (cm) by a width of 1.0 cm by a depth of 0.1 cm. Stage 3 pressure ulcer to her right buttock that measured a length of 5.0 cm by a width of 5.0 cm by a depth of 0.2 cm. The Assessment included the following Interventions not marked: Administer treatment per physician's orderObserve skin condition with ADLs caresProvide preventive skin care Use pillow/positioning devices as needed.Resident #3's May 2025 Medication Administration Record (MAR), lacked treatment orders for her coccyx and/or her right buttock pressure areas.The Skin Evaluation-Pressure Wound form dated 5/16/25 at 11:36 AM, documented a new alteration to left heel-pressure ulcer that measured a length of 6.0 cm by a width of 7.0 cm, suspected deep tissue injury, fluid filled blister/ boggy (abnormal texture of tissues characterized by sponginess, usually because of high fluid content) heel. The skin assessment described the skin temperature as cool and dry. The note indicated Resident #3 had a pressure ulcer/blister area noted to her left heel area with the skin intact. They staged the wound as a suspected deep tissue injury that measured 6 cm x 7 cm. The note described the appearance of the wound bed as dark red/purple in color with the skin intact and dry at the time. The surrounding skin appeared intact but slightly reddened. The nurse applied skin prep and a dressing for protection.The Skin Evaluation-Pressure Wound form dated 5/16/25 at 11:36 AM, documented a new alteration to Resident #3's right heel of a pressure ulcer that measured a length of 2.5 cm by a width of 3.5 cm. The noted described the area as a suspected deep tissue injury with a blister no longer intact, with an irregular shape and scant amount of serous (clear) drainage from wound. The note indicated they applied Skin prep to the peri (outer) wound and a dressing. The Skin/Wound Note dated 5/16/25 at 1:35 PM, labeled as a late entry reflected the day shift nurse notified the wound nurse of a new area to Resident #3's left heel. The wound nurse observed a fluid filled blister to her left heel area, Resident #3 didn't reported pain at the time. The note reflected they would treat the area as a pressure area. The facility notified the Primary Care Provider (PCP) and planned to complete a new alteration weekly assessment. The area measured 6.0 cm x 7.0 cm.The Alert Note dated 5/16/25 at 7:33 PM, documented the nurse received notification Resident #3 had a noted change in condition. The nurse assessed Resident #3 revealing the following assessment, she responded to her name, had cold hands, placed on continuous oxygen at 2 liters per nasal cannula (L/NC) and notified the on-call physician. The on-call physician gave new orders to send Resident #3 to the hospital for further evaluation.The Emergency Department admission notes dated 5/17/25 at 4:42 AM, revealed multiple wounds present on admission: Pressure injury to right back at the shoulder with a Mepilex with border dressing. The assessment reflected dry; eschar (dead tissue that eventually sloughs off healthy skin after an injury) tissue.Pressure injury to the right heel with a Mepilex with border dressing. The assessment reflected the site appeared red, pink, purple, and fragile.Pressure injury left heel with a Mepilex with border dressing. The assessment reflected the site appeared to have a Fragile fluid filled blister area with a scant amount of serous (clear) drainageThe General Progress Note dated 5/19/25 at 10:52 AM, identified the local hospital visited with the facility and Resident #3 would transfer to the Hospice house that day.On 7/22/25 at 1:45 PM, Staff B, Certified Nursing Assistant (CNA), verified Resident #3 had loose stools. She didn't have a dressing or ointments applied to her coccyx or right buttock pressure area when Resident #3 went to the bathroom. Staff B added Resident #3 said ouch that hurts when they provide care to clean her up. In addition, Staff B reported she didn't have a pressure reduction cushion in the seat of her wheelchair or in the recliner. Resident #3 like to sit and sleep in her recliner. Staff B explained Resident #3 didn't have protective heel boots or pillows used to float or elevate her heels and they rested on the footrest of the recliner. On 7/22/25 at 1:55 PM, Staff C, CNA, stated Resident #3 didn't receive a dressing or ointments to her coccyx or right buttock pressure areas when they completed incontinent care. In addition, Staff C, verified Resident #3 liked to sit up in her recliner to sleep. Staff C added she didn't have protective heel boots or pillows used to off load or elevate her heels, they rested on the foot rest of the recliner.On 7/22/25 at 2:10 PM, Staff G, Licensed Practical Nurse (LPN), verified Resident #3 didn't have treatments or a dressing ordered for her coccyx or right buttock pressure areas when she admitted to the facility.On 7/22/25 at 2:30 PM, Staff D, CNA, reported Resident #3 didn't have protective heel boots to elevate or keep her heels off loaded from the foot rest of the recliner. Staff D added her heels would rest on the foot rest. In addition, Staff D explained Resident #3 liked to sleep in her recliner and didn't like to lay down in bed.On 7/22/25 at 2:45 PM, Staff E, CNA, expressed Resident #3 liked to sleep in her recliner and she didn't use protective heel boots or pillows to off load her heels. Resident #3 rested her heels on the recliner's foot rest.On 7/22/25 at 3:15 PM, The Director of Nursing (DON), confirmed Resident #3's clinical record lacked any orders, treatments, or dressings to Resident #3 coccyx or right buttock pressure areas. The DON expected the nurses to obtain treatment orders from the physician. On 7/23/25 at 8:10 AM, the facility physician verified he didn't know Resident #3 had any open areas to her coccyx or right buttock. He would expect the nurses at the facility to inform him of those areas so he could order treatments or dressings to start right away. An email from the Administrator dated 8/5/25 at 2:23 PM, identified they decided Interventions for resident's skin on an individual basis, due to the possibility of scenarios.

Based on resident interview, staff interview, and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time (defined as 15 minutes or less) for 4 of 4 residents reviewed (Residents #2, #5, #18 and #19). The residents and staff reported low staffing caused missed or delayed resident care. The facility reported a census of 51 residents. Finding include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). On 7/21/25 at 11:30 AM, Resident #2 verified it took staff over 15 minutes to answer his call light to get him up for meals. He added he arrived late for some meals.2. Resident #5's MDS assessment dated [DATE] identified a BIMS score of 14, indicating no cognitive impairment. Resident #5 required substantial to maximal assistance with all ADLs. The MDS included diagnoses of muscle weakness and multiple sclerosis. On 7/17/25 at 1:15 PM, Resident #5 verified it took staff over 15 minutes to answer his call light. He added getting upset and arrived late to some meals.3. Resident #18's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. Resident #18 required partial to moderate assistance with transfers, dressing and personal hygiene. The MDS included diagnoses of diabetes mellitus and anxiety.On 7/21/25 at 1:10 PM, Resident #18 verified it took over 15 minutes for staff to answer her call light. She described it as upsetting.4. Resident #19's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. Resident #19 required partial to maximal assistance with ADLs. The MDS included diagnoses of congested heart failure (impaired heart function that results in a build up of fluid in the body) and muscle weakness. On 8/5/25 at 1:00 PM, Resident #19 reported being upset a couple of days ago she had her call light on from 6:23 AM -7:36 AM. She added being angry because the staff have to take the smokers outside, which resulted in her having to wait for someone to answer her call light. On 7/21/25 at 10:10 AM, Staff I, Certified Medication Aide (CMA), verified call lights can go unanswered for longer than 15 minutes. Staff I described it as frustrating the other residents didn't get the care they deserve because the facility worried about the rights of the residents who go out and smoke. On 7/21/25 at 10:30 AM, Staff K, Certified Nursing Assistant (CNA), reported having difficulty being able to answer the call lights within 15 minutes when you have to take one staff off the floor to take a resident outside to smoke. The facility policy titled Call Light Policy revised September 2023 instructed staff to ensure a prompt response to the resident's call for assistance. The facility also ensured proper working order of the call system. The facility shall answer call lights in a timely manner.

Based on resident and staff interviews, facility policy, the facility failed to provide adequate smoking policies for residents in regards to smoking times, smoking areas, and smoking safety for 4 of 4 resident reviewed (Residents #1, #2, #17, and #18). The facility identified a census of 51 residents.Finding include1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).On 7/16/25 at 11:35 AM, Resident #1 reported the smokers used to smoked out front of the facility and didn't have any time frames. She added staff and visitors complained about the smoke when they came into the facility, so they moved the smoking area to the back court yard by the dining room. Resident #1 added, since she got left outside over night, they went back to the front of the building. She explained they had smoking times and needed an assessment to see if they could smoke by themselves without staff supervision. She expressed confusion and she didn't know where to go anymore.2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #2 required partial to moderate assistance with transfers. In addition, listed Resident #2 as dependent with dressing and personal hygiene. The MDS included a diagnosis of need assistance with activities of daily living (ADLs). The Care Plan initiated date 7/14/25, the resident will adhere to smoking policy and interventions include to, smoking evaluation will be completed as needed, Inform resident and/or responsible party of smoking policy, Dependent Smoker: Staff to assist resident to designated smoking areas atdesignated smoking times, Dependent Smoker: Staff to supervise while smoking, Wear protective smoking vest or apron if needed, dependent Smoker: Must keep smoking accessories secured when not in use in control of facility staff.On 7/21/25 at 11:45 a.m., Resident #2, said that a couple of days ago around the 7:00 p.m. smoke times, a staff member took him out for a smoke, there were no smoking aprons available so she took me out anyway. Resident #2 stated that the smoking area once was out front, then it was changed to the court yard by the dining room, now it is back out front of the facility and that times vary depending on who is working and if they have time to take me out, due to being supervised by staff, I depend on their schedule when smoke breaks are. 3. Resident #17's MDS assessment dated [DATE] identified a BIMS score of 14, indicating no cognitive impairment. The MDS reflected they didn't have behaviors during the lookback period. Resident #17 required substantial to maximal assistance with transfers. The MDS listed Resident #17 as independent in the facility with an electric wheelchair for mobility.The Care Plan Focus related to tobacco use initiated 4/17/25 included the following Interventions:Smoking evaluation will be completed as neededResident #17 received education to sign himself in and out of facility when he left the premise.Resident #17 received education the facility is a smoke free facility, and he would leave the property to use tobacco product.Inform resident and/or responsible party of smoking policy.Dependent Smoker:Staff to assist resident to designated smoking areas at designated smoking times.Dependent Smoker: Staff to supervise while smoking.Wear protective smoking vest or apron if needed. Must keep smoking accessories secured in lock box when not in use.On 7/17/25 at 1:15 PM, Resident #17, sat in his room in his electric wheelchair. He reported being very upset the facility moved the smoking area to the front of the facility, as the visitors got upset because they had to walk through secondhand smoke. The facility moved the smoking area to the courtyard by the dining room, but then a lady got left outside all night. Now they moved the smoking area again, he never had smoke times, and now the facility would be enforcing smoke times. Resident #17 reported he had no idea what is going on. He used to be able to go out and smoke by himself, now they changed the rules again, so he needed supervision with a smoking apron. 4. Resident #18's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. Resident #18 required partial to moderate assistance with transfers, dressing and personal hygiene. The MDS included diagnoses of diabetes mellitus and anxiety.The Care Plan Focus initiated 11/11/24 reflected Resident #18 had a risk for health complications related to smoking and a history of smoking. The Care Plan included the following Interventions:11/11/24: Smoking evaluation will be completed as needed11/11/24: Inform resident and/or responsible party of smoking policy.11/11/24: Must keep smoking accessories secured by facility staff when not in use.Dependent Smoker:7/17/25: Staff to assist resident to designated smoking areas at designated smoking times.7/17/25: Staff to supervise while smoking.7/17/25: Wear protective smoking vest or apron if needed.On 7/21/25 at 1:10 PM, observed Resident #18 out front of the facility wearing a smoking apron with staff supervising. Resident #18 held a cigarette, as the staff member sat next to her on an iron bench.On 7/21/25 at 1:10 PM, witnessed Resident #18 visibly upset. She said the rules changed so many times at the facility that no one knew what is going on or happening. She expressed it got so frustrating, as seemed the facility had smoking out front of the facility, then changed it to the court yard by the dining room, and now moved it back out front of the facility. Resident #18 described it as hard to keep track of all the changes. She added they never had a time schedule and now the facility put one in place. The can't find staff anywhere around to take them out at the designated times. On 7/21/25 at 10:00 AM, Staff H, Certified Medication Aide (CMA), said they received some education but still didn't know what to do with smokers. She explained if they are independent then they can go out and smoke by themselves, if they need assistance than staff are to go out with them, and if they are dependent then they need to have a smokers apron on with them. Staff H added they changed the smokers' area to the front of the building on the right side with a smoking container in between two bench chairs. Staff H explained they don't allow anyone to go out by the dining room courtyard to smoke. Staff H reported it being hard to get stuff completed when they don't really have smoke times in place. The residents get upset and the call lights don't get answered when they have to take residents out to smoke. Then the residents who want to get up or go to an activity are late. Staff H expressed it shouldn't be that difficult for the facility to fix and put smoke times in place, then designate someone to go out with them.On 7/21/25 at 10:10 AM, Staff I, CMA, stated they received some education and training on smoking times the previous week, but still didn't know what they expect. The independent smokers can go outside as long as they sign themselves in and out any time of the day. The residents deemed dependent need staff assistance and a smoking apron, but the facility only had 2 smoking aprons. The facility had the smoking times posted on the corner of the west nurses' station. The times are 7:00 AM, 12:30 PM, 3:00 PM, and 7:00 PM, however, when residents hollered and yelled then they have to take them out even though they are deemed dependent.On 7/21/25 at 10:30 AM, Staff K, CNA, stated they received education in regards to smoke times and independent and dependent residents. However, the facility didn't make it very clear on where and when the resident go out to smoke. They had the smoke times posted at the corner of the west nurses' station and read 7:00 AM, 12:30 PM, 3:00 PM, and 7:00 PM, but they received direction, the resident got a 1/2 hour before and 1/2 hour after the posted time. They had to take out the dependent residents who smoke and have them put on a smoker's apron, but they only had 2 aprons to use at the facility.On 7/21/25 at 10:50 AM, Staff J, CNA, reported she didn't know for sure the current smoking policy. All the facility told them the week before about completion of a smoking assessment on all the smokers and they deemed everyone except for Resident #1 as dependent smokers. They needed to wear a smoker's apron, have staff assistance in and out of the facility, however, they only had 2 aprons. Supposedly the facility would order more aprons. They had the smoking times posted at the west corner of the nurses' station and say 7:00 AM, 12:30 PM, 3:00 PM and 7:00 PM. They didn't know for sure of who, what, or where the residents go to smoke. The administration said the smoking area moved from the dining room courtyard to the front of the building to the right.The facility policy titled Smoking Policy revised January 2024, instructed the facility may impose smoking restrictions at any time if determined that the resident can't smoke safely with the available levels of support and supervision. Resident could only smoke in the designated center locations outside of the center and at designated times set by the center. The designated smoking areas would consider protection of non-smoking residents from secondhand smoke.

Based on facility policy review, resident, and staff interviews, the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 4 resident reviewed (Resident #1). The facility identified a census of 51 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).Interview on 7/14/25 at 3:30 PM, Resident #1, reported when she got left her outside all night long on 7/7/25-7/8/25, the Director of Nursing (DON) and Administrator told her, she needed to make sure to take her cell phone with her at all times so she could get back into the facility. Resident #1 stated she felt degraded and disrespected for not taking her cell phone with her. She felt the facility thought it was her fault. Now she didn't go outside alone. Interview on 7/16/25 at 1:30 PM, the Administrator and DON, stated they expected Resident #1 to make sure she had her cellphone with her at all times. It is Resident #1's responsibility to make sure she had a way back into the facility.Interview on 7/17/25 at 12:30 PM, the DON reported they expected the staff to treat all residents with dignity and respect.The facility policy titled Resident Rights - Dignity and Respect revised date April 2024, instructed staff to treat all residents with dignity and respect while maintaining and enhancing his or her self-esteem and self-worth. Each Resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs except where the health, safety, or rights of the resident or other individuals in the facility would be endangered.

Based on clinical record review, facility policy review, and staff interview, the facility failed to notify the facility's physician of a incident related to a resident left outside all night long for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 51 residents.Finding include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).The Concern Form dated 7/8/25 reflected Staff A, Dietary Aide, heard pounding on the courtyard door. When she opened the door, Resident #1 told her she got locked outside all night. The Administrator and Director of Nursing (DON) visited with Resident #1, who educated her the facility didn't have the door locked. Resident #1 described the door as heavy and she couldn't open it fully to get back in facility. The form labeled Resident #1 as cognitively intact. The form reflected they educated Resident #1 to take her cellphone when she went out to smoke moving forward. Additionally, they installed a doorbell with receivers at each nurses' station. They educated the staff and smoking residents. They ordered the doorbell on 7/11/25 and installed it 7/16/25.The General Progress Notes dated 7/8/25 at 2:00 PM, documented Resident #1 reported she had difficulty opening the door. She described herself as to weak to pull it open as she normally had before. The nurse notified the doctor of her reported weakness. The nurse waited for a call back from the doctor to see if he would like to complete any labs for Resident #1.Interview on 7/23/25 at 8:15 AM, the facility physician reported they didn't know Resident #1 got left outside all night long. They expected the facility to notify him of the incident and added what a horrible thing to happen to Resident #1.Interview on 8/4/25 at 10:20 AM, the DON verified the clinical record lacked documentation that the facility notified the physician of Resident #1 being left outside. They expected the staff to notify the physician of any changes in a resident, an incident, a fall, or if they need a treatment.The facility policy titled Notification for Change of Condition revised June 2023, listed the purpose as the facility would provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when an accident occurred involving the resident which resulted in injury and had the potential for requiring physician intervention, health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on staff interview, clinical record review, facility document review, and policy review, the facility failed to maintain complete and accurate medical records for each resident. The facility failed to document an incident when a resident got left outside all night long in the electronic health record (EHR) for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51 residents.Finding include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented Resident #1 didn't have behaviors during the lookback period. The MDS listed Resident #1 as independent with activities of daily living (ADLs). The MDS included diagnoses of non-Alzheimer's dementia, anxiety, depression and dizziness.The Care Plan Focus related to tobacco use initiated 5/16/25 included the following Interventions:5/16/25: Smoking evaluation will be completed as needed.7/14/25: As of 7/8/2025 Independent Smoker: Must keep smoking accessories secured when not in use control of facility staff.7/14/25: Resident would check in and out and carry a cell phone while smoking.5/16/25: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas).The Concern Form dated 7/8/25, with no time, described the concern, Staff A (dietary Aide) heard pounding on courtyard door. Opened door for Resident #1 who stated she was locked out and has been outside all night. Administrator and Director of Nursing (DON) visited with resident, educated resident door was not locked. Resident states it was heavy and unable to open fully to get back in facility. Resident cognitively intact, Educated resident to take cell phone out smoking moving forward. Additionally, door bell installed, receivers at each nurses station. Educated staff and smoking residents ordered 7/11/25 and installed 7/16/25.The General Progress Notes dated 7/8/25 at 2:00 PM, documented Resident #1 reported she had difficulty opening the door. She described herself as to weak to pull it open as she normally had before. The nurse notified the doctor of her reported weakness. The nurse waited for a call back from the doctor to see if he would like to complete any labs for Resident #1.Review of a handwritten document dated 7/8/25 at 6:30 AM, reflected Resident #1 had no injuries to her head, had equal pupils to both eyes that reacted to light, had clear speech, had pink, warm, intact skin, without redness, bruising or other injuries to arms, legs, or torso. Resident #1 could bend and straighten extremities without difficulty. She denied pain, had clear lung sounds auscultation (listened to), they heard a strong and unremarkable apical pulse (specific location of the chest to listen to the heart). The note described Resident #1 as alert and walked with a wheelchair. When Resident #1 entered the facility , she voiced concerns that the door wouldn't open. She denied discomfort, the staff escorted her to her room to perform a thorough examination. Resident #1 changed her clothes and requested to go to dining room for breakfast. The note reflected Resident #1 had an improved mood and socialized with her peers.On 7/16/25 at 5:20 PM, Staff F, Licensed Practical Nurse (LPN), stated they received a directive to chart the incident on a concern form and administration would take care of it. They added to not to chart in Resident #1's clinical record. Staff F explained they didn't feel comfortable with not charting the incident but they did as a directed and charted on a plain piece of paper.On 7/17/25 at 7:45 AM, Staff G, LPN, reported the Administrator directed to not chart the incident with Resident #1 in the clinical record, do a concern form, and administration would handle the incident. Staff G, felt this went against professional standards of practice but followed the directive.On 7/22/25 at 4:30 PM, the DON acknowledged the staff should have charted the incident with Resident #3 in the clinical record and not just on a concern form. The DON reported they would provide education to all nursing staff to chart incidents, an unusual occurrence, or anything to do with a resident in the clinical record. The facility policy titled Alert Charting Guidelines revised October 2023 instructed staff to provide a guide to monitor documentation that may be needed following a change in a resident's condition or status. Residents are entered on the Alert Charting Log when they are identified as requiring continued follow-up and documentation. Residents should remain on the log for a minimum period of 72-hours unless their condition improved. Documentation in the electronic clinical record may include, but is not limited to patient evaluation findings, interventions planned to manage the patient's condition, physician notification and response.

Based on electronic health record review, staff interview, and state regulation review, the facility failed to initiate and complete resident assessments in a timely manner for 1 of 3 residents reviewed nursing for supervision (Resident #1). On 2/17/25, the facility staff observed a bruise to Resident #1's face. The facility failed to conduct neurological assessments following the injury to Resident #1's face, even after Resident #1 reported someone knocked her into the wall. Then on 4/7/25, after Resident #1 returned to the facility from exiting independently without staff knowledge, the facility failed to conduct a thorough assessment of her. The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii. Resident #1 walked with partial to moderate assistance of 2 staff with her FWW in her room, only to complete the walking ADL. b. 10/7/24: Resident #1 had a risk for falls related to dementia, weakness, and impaired safety awareness. i. Encourage the use of assistive devices as needed (PRN). ii. Assist Resident #1 with ambulation and transfers PRN. The General Progress Noted dated 2/17/25 at 7:30 AM, labeled Late Entry reflection a completion date of 2/18/25 at 1:38 PM, identified Staff A, Registered Nurse (RN), observed Resident #1 with facial bruising to her right eye and temple area. Resident #1 indicated another resident knocked her into a wall. Staff A documented Resident#1 denied pain and vision issues. The clinical record lacked an in depth nursing head to toe assessment or initiation of neurological checks with a start date of 2/17/25, when staff first identified Resident #1's facial bruising. A Neurological Evaluation Flow Sheet initiated 2/18/25 listed one entry completed by a staff member on 2/18/25 at 3:00 PM. Another staff member completed an entry on 2/18/25 without time identified. The flowsheet lacked further entries completed as staff, documented Resident #1 went to the hospital. Resident #1's electronic medical record lacked consistent documentation of vitals. The Incident Note dated 2/22/25 at 5:57 AM reflected Resident #1's roommate called for help due to Resident #1 lying on her back on the floor in front of the bedroom door. The assessment reflected Resident #1 hit her head and had a large bump on the right backside of her head. After notifying the provider, the facility received an order to transfer Resident #1 to the hospital. The General Progress Note dated 2/22/25 at 11:10 AM identified the hospital admitted Resident #1 to the hospital due to a fractured right hip. The Physician's Order Note dated 4/7/25 at 3:07 PM documented the nurse notified the physician Resident #1 eloped on the third shift. The clinical record lacked an in depth head-to-toe nursing assessment related to the elopement. During an interview on 4/8/25 at 10:40 AM, Staff B, Licensed Practical Nurse (LPN), reported they complete neurological (neuro) checks with falls (witnessed or unwitnessed) or with any head strike. They complete the checks every 30 minutes for 4 times, every 1 hour for 4 times, every 2 hours for 2 times, and every shift for 3 days. Staff B indicated they didn't need a physician order to initiate neurological checks. During an interview on 4/8/25 at 4:25 PM Staff C, RN, confirmed no one conducted an in depth head to toe assessment after they located Resident #1 after she eloped on 4/7/25. Staff C described Resident #1 as their normal self and didn't appear to have any acute medical concerns. Staff C voiced they didn't know they needed to do further resident assessment. During an interview on 4/9/25 at 9:00 AM, Staff D, RN, reported they worked as the nurse on call during the overnight hours on 4/6/25. At approximately 5:30 AM on 4/7/25, the facility staff called to inform them of Resident #1's elopement. Staff D acknowledged they should have informed the nurse on duty (Staff C) to complete a physical assessment on Resident #1. During an interview on 4/9/25 at 3:15 PM, Staff A confirmed they first saw the facial bruising on Resident #1 on 2/17/25. They described the bruising as newer with a puffy eye lid. Staff A assumed someone previously identified the area and didn't assess it further besides a brief physical overview. Staff A described Resident #1 as a little tearful but otherwise their usual self. Staff A explained they would have done an assessment if they knew Resident #1 didn't have facial bruising before. During an interview on 4/10/25 at 11:30 AM, the Director of Nursing (DON) explained the staff need to complete a nursing head-to-toe assessment with any falls (witness or unwitnessed), significant changes, resident-to-resident altercations, or elopements. The DON confirmed they didn't need a physician's order to initiate neurological checks. They record the checks on paper and not in the electronic health record. Per an email dated 4/8/25, the Administrator confirmed the facility didn't have policy related to the completion of nursing head-to-toe assessments or neurological checks.

Based on electronic health record review, facility document review, staff interviews, and policy review, the facility failed to provide adequate supervision resulting in a resident elopement for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii. Resident #1 walked with partial to moderate assistance of 2 staff with her FWW in her room, only to complete the walking ADL. b. 10/7/24: Resident #1 had a risk for falls related to dementia, weakness, and impaired safety awareness. i. Encourage the use of assistive devices as needed (PRN). ii. Assist Resident #1 with ambulation and transfers PRN. c. 8/26/24: Resident #1 had a risk for elopement/wandering related to dementia. i. Resident #1 had a left ankle wander guard ii. Check wander guard placement every shift and function every day. iii. Provide care in a calm and reassuring manner. iv. Providing reorientation to the surroundings and environment. v. Resident #1 is non compliant with the wander guard and at times attempted to remove the bracelet. The Elopement Risk Evaluation, completed 11/25/24, indicated Resident #1 had a known history of elopement, roamed/wandered throughout the facility and has attempted to leave the facility unsupervised. In addition, Resident #1 didn't respond favorably to staff redirection. The evaluation directed if a response of yes to the questions 2, 3, 4, or 5, assess the use of an alert bracelet and complete the Elopement Care Plan. The Physician's Order Note dated 4/7/25 at 3:07 PM documented the nurse notified the physician Resident #1 eloped on the third shift. Staff E's, Certified Nursing Assistant (CNA), written staff statement and investigation questionnaire dated 4/7/25 reflected at approximately 5:00 AM on 4/7/25 as Staff E assisted other residents she heard a door alarm sound. At the time, Staff E walked down the hallway and didn't notice Resident #1 in their room. Staff E checked outside and in Resident #1's room again without finding her. Staff E notified the nurse on duty (Staff C) as well one of the other CNAs. Staff E looked around the inside of the building as well as outside again. As Staff E looked in every resident's room, she heard the wander guard alarm sound at approximately 5:30 AM. When Staff E went to the front door, she discovered Resident #1 standing there. Staff E placed Resident #1 in a wheelchair. Resident #1 wore a 2 piece jumpsuit, socks, and shoes. Staff E described Resident #1 as extremely cold and cold to the touch with her wander guard on her ankle. Resident #1 tried to elope the previous morning/afternoon. Another resident reported he saw Resident #1 going down the hall around 4:00 AM very fast. Staff F's, CNA, written staff statement and investigation questionnaire dated 4/7/25 identified at 5:15 AM on 4/7/25, Staff E asked if they saw Resident #1 as they did their rounds. At that time, the 2 CNAs began looking for Resident #1. At 5:30 AM, Resident #1 casually walked in the front door without her walker with a runny nose, cold hands, and appeared very confused. Staff F reported Resident #1 attempted to leave the facility (exit seek) all day the previous day. Staff C's, Registered Nurse (RN), written staff statement and investigation questionnaire dated 4/7/25 indicated at approximately 5:00 AM on 4/7/25, he left the building to place belongings in his car. Staff C reported he entered the code to exit the building, waiting until the light turned green before proceeding. Staff C quickly placed his belongings in the car and re entered the building through the front door without triggering the alarm. As Staff C verify the narcotic count, Staff F alerted him about Resident #1 missing. Staff C searched the building and couldn't locate Resident #1. At approximately 5:45 AM, Staff C heard an alarm. The CNAs (Staff E and Staff F) ran to the front door where Resident #1 stood. Staff C described Resident #1 as cold and unable to say where or how they could exit the building. Resident #1 wore her wander guard on her left ankle and he verified it worked. Resident #1 wore a long-sleeved shirt and pants. During an interview on 4/8/25 at 10:20 AM, Staff G, CNA, voiced she understood Resident #1 may have went outside by herself but came back on their own over the weekend. During an interview on 4/8/25 at 10:40 AM, Staff B, Licensed Practical Nurse (LPN), stated during the end of shift report on 4/7/25, Staff C reported Resident #1 got out at approximately 5:00 AM and they found her at the front door. During an interview on 4/8/25 at 11:45 AM, Staff E stated Resident #1 eloped the morning of 4/7/25. Staff E reported they saw Resident #1 sitting in their recliner in their room at 3:45 AM. At 5:00 AM the front door alarm went off and she assumed Staff C set it off going out to their car. Staff E went to the front door, looked outside and didn't notice anything. While she walked down the hallway, Staff E didn't see Resident #1 in their room. Staff E alerted Staff C and the staff on the other side of the facility. Staff E reported they looked in Resident #1's room again before they looked outside the facility. At 5:30 AM, Staff E heard the wander guard alarm go off and they found Resident#1 at the front door. During an interview on 4/8/25 at 1:20 PM, Staff H, LPN, reported Resident #1 told the staff they were going home and she stood close enough to the front door the wander guard alarmed. This was towards the end of their 6:00 AM to 2:00 PM shift on 4/6/25. During an interview on 4/8/25 at 3:15 PM, Staff J, RN Consultant, explained all the doors are alarmed to a panel. The front door had the only wander guard alarm and they didn't have operational cameras. During an interview on 4/8/25 at 3:15 PM, Staff K, Administrative Assistant, explained they lock the outside sun room door nightly under the previous facility management, per policy. With the new management company in place, Staff K didn't know if they still had the procedure in place. During an interview on 4/8/25 at 4:25 PM, Staff C reported he went out to his car at approximately 5:00 AM on 4/7/25. Staff C denied hearing or seeing anyone behind them. Staff C returned to the building immediately after he placed his personal belongings in the car. They didn't see anything upon entering the building. Shortly after, Staff E alerted him about Resident #1 missing. Staff C and Staff E began looking for Resident #1 outside the building and in the parking lot. While he searched the inside of the building, Staff C heard an alarm go off as Staff E attended to it. Staff C saw Resident #1 in a wheelchair with other staff members. He described Resident #1 as cold and she couldn't remember what happened. Resident #1 wore sweatpants, hoodie, and shoes. During an interview on 4/9/25 at 8:00 AM, Staff I, CNA, reported they worked the day shift on 4/7/25. Towards the end of their shift, Resident #1 set off the wander guard alarm twice. The first time, Resident #1 didn't make it out the door as staff could redirect her. The second time, Resident #1 made it out the front door to the sun room but not out the door that lead to the outside. The staff managed to redirect Resident #1 back inside which set off the alarm. The Missing Patient Response Plan, revised January 2024, outlined the following staff procedures: a. Upon determining that a patient cannot be located, the nursing supervisor will notify the Administrator and the Director of Nursing b. All nursing staff will return to their area and search all areas accessible to patients c. Maintenance and available staff will search exterior areas once released from their own department

Based on electronic health record review, staff interview and policy review, the facility failed to ensure the nursing staff had the knowledge to initiate appropriate responses during resident care for 1 of 3 residents reviewed for nursing supervision (Resident #1). The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii. Resident #1 walked with partial to moderate assistance of 2 staff with her FWW in her room, only to complete the walking ADL. b. 10/7/24: Resident #1 had a risk for falls related to dementia, weakness, and impaired safety awareness. i. Encourage the use of assistive devices as needed (PRN). ii. Assist Resident #1 with ambulation and transfers PRN. c. 8/26/24: Resident #1 had a risk for elopement/wandering related to dementia. i. Resident #1 had a left ankle wander guard ii. Check wander guard placement every shift and function every day. iii. Provide care in a calm and reassuring manner. iv. Providing reorientation to the surroundings and environment. v. Resident #1 is non compliant with the wander guard and at times attempted to remove the bracelet. The General Progress Noted dated 2/17/25 at 7:30 AM, labeled Late Entry reflection a completion date of 2/18/25 at 1:38 PM, identified Staff A, Registered Nurse (RN), observed Resident #1 with facial bruising to her right eye and temple area. Resident #1 indicated another resident knocked her into a wall. Staff A documented Resident#1 denied pain and vision issues. The clinical record lacked an in depth nursing head to toe assessment or initiation of neurological checks with a start date of 2/17/25, when staff first identified Resident #1's facial bruising. The Physician's Order Note dated 4/7/25 at 3:07 PM documented the nurse notified the physician Resident #1 eloped on the third shift. The clinical record lacked an in depth nursing head-to-toe assessment within 1 hour of when the staff located Resident #1 during the third shift elopement. In addition, the clinical record lacked neurological checks. During an interview on 4/9/25 at 3:15 PM, Staff A, Registered Nurse (RN), confirmed they first saw the facial bruising on Resident #1 on 2/17/25. They described the bruising as newer with a puffy eye lid. Staff A assumed someone previously identified the area and didn't assess it further besides a brief physical overview. Staff A described Resident #1 as a little tearful but otherwise their usual self. Staff A explained they would have done an assessment if they knew Resident #1 didn't have facial bruising before. During an interview on 4/8/25 at 4:25 PM, Staff C, RN, reported they didn't know they needed to do a head to toe nursing assessment after they found Resident #1 after they left the faciity on their own on 4/7/25. Staff C described Resident #1 as cold and appeared to be her normal self. During an interview on 4/9/25, Staff D, RN, explained they directed Staff C to complete alarm checks and provide a written statement when he notified them of Resident #1's elopement. Staff D later realized they should have directed Staff C to also complete a head to toe nursing assessment. Per an email dated 4/8/25, the Administrator confirmed the facility didn't have policy related to the completion of nursing head-to-toe assessments or neurological checks. The Missing Patient Response Plan, revised January 2024, instructed the staff to examine the patient and record findings in the chart. Based on electronic health record review, staff interview and policy review, the facility failed to ensure the nursing staff had the knowledge to initiate appropriate responses during resident care for 1 of 3 residents reviewed for nursing supervision (Resident #1). The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii. Resident #1 walked with partial to moderate assistance of 2 staff with her FWW in her room, only to complete the walking ADL. b. 10/7/24: Resident #1 had a risk for falls related to dementia, weakness, and impaired safety awareness. i. Encourage the use of assistive devices as needed (PRN). ii. Assist Resident #1 with ambulation and transfers PRN. c. 8/26/24: Resident #1 had a risk for elopement/wandering related to dementia. i. Resident #1 had a left ankle wander guard ii. Check wander guard placement every shift and function every day. iii. Provide care in a calm and reassuring manner. iv. Providing reorientation to the surroundings and environment. v. Resident #1 is non compliant with the wander guard and at times attempted to remove the bracelet. The General Progress Noted dated 2/17/25 at 7:30 AM, labeled Late Entry reflection a completion date of 2/18/25 at 1:38 PM, identified Staff A, Registered Nurse (RN), observed Resident #1 with facial bruising to her right eye and temple area. Resident #1 indicated another resident knocked her into a wall. Staff A documented Resident#1 denied pain and vision issues. The clinical record lacked an in depth nursing head to toe assessment or initiation of neurological checks with a start date of 2/17/25, when staff first identified Resident #1's facial bruising. The Physician's Order Note dated 4/7/25 at 3:07 PM documented the nurse notified the physician Resident #1 eloped on the third shift. The clinical record lacked an in depth nursing head-to-toe assessment within 1 hour of when the staff located Resident #1 during the third shift elopement. In addition, the clinical record lacked neurological checks. During an interview on 4/9/25 at 3:15 PM, Staff A, Registered Nurse (RN), confirmed they first saw the facial bruising on Resident #1 on 2/17/25. They described the bruising as newer with a puffy eye lid. Staff A assumed someone previously identified the area and didn't assess it further besides a brief physical overview. Staff A described Resident #1 as a little tearful but otherwise their usual self. Staff A explained they would have done an assessment if they knew Resident #1 didn't have facial bruising before. During an interview on 4/8/25 at 4:25 PM, Staff C, RN, reported they didn't know they needed to do a head to toe nursing assessment after they found Resident #1 after they left the faciity on their own on 4/7/25. Staff C described Resident #1 as cold and appeared to be her normal self. During an interview on 4/9/25, Staff D, RN, explained they directed Staff C to complete alarm checks and provide a written statement when he notified them of Resident #1's elopement. Staff D later realized they should have directed Staff C to also complete a head to toe nursing assessment. Per an email dated 4/8/25, the Administrator confirmed the facility didn't have policy related to the completion of nursing head-to-toe assessments or neurological checks. The Missing Patient Response Plan, revised January 2024, instructed the staff to examine the patient and record findings in the chart.

Based on electronic health record review, staff interviews, and policy review, the facility failed to ensure the resident's medical record contained sufficient and adequate medical information for 2 of 3 residents reviewed for nursing supervision (Residents #1 and #3). The facility reported a census of 52. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii. Resident #1 walked with partial to moderate assistance of 2 staff with her FWW in her room, only to complete the walking ADL. b. 10/7/24: Resident #1 had a risk for falls related to dementia, weakness, and impaired safety awareness. i. Encourage the use of assistive devices as needed (PRN). ii. Assist Resident #1 with ambulation and transfers PRN. c. 8/26/24: Resident #1 had a risk for elopement/wandering related to dementia. i. Resident #1 had a left ankle wander guard ii. Check wander guard placement every shift and function every day. iii. Provide care in a calm and reassuring manner. iv. Providing reorientation to the surroundings and environment. v. Resident #1 is non compliant with the wander guard and at times attempted to remove the bracelet The Progress Noted dated 4/7/25 at 3:07 PM documented the physician communication of Resident #1's elopement on the third shift. No further Progress Note identified in the medical record detailing the elopement event (time, summary of event, resident condition, etc.,). The Incident Report #2819 dated 4/7/25 at 5:00 AM, reflected a Certified Nurse Aide (CNA) reported to the nurse they didn't know the location of Resident #1. At the bottom of the report had a disclaimer stating Privileged and Confidential Not part of the Clinical Record Quality Assurance Only Not Discoverable. During an interview on 4/10/25 at 11:30 AM, the Administrator declared the Progress Note dated 4/7/25 at 3:07 PM as sufficient documentation of Resident #1's elopement event. The Administrator added the late entry Progress Note dated 4/7/25 at 12:19 PM should have linked to the Incident Report within the facility's electronic health record. The Progress Note didn't get properly formatted, leaving the link non operational, and caused it to not link to the Incident Report. 2. Resident #3's MDS assessment, dated 1/22/25, identified a BIMS score of 6, indicating severe cognitive impairment. Resident #3 used a wheelchair for mobility. The MDS listed her as dependent on staff for transfers and bed mobility. The MDS included diagnoses of non Alzheimer's dementia and age related physical debility. The Care Plan Focus initiated 9/16/24 indicated Resident #3 required assistance with activities of daily living (ADLs). The Interventions reflected the following: a. Bathing: Dependent on assistance from 1 staff member b. Bed Mobility: Dependent with assistance from 2 staff members c. Transferring: Dependent with assistance from 2 staff members and a full-body mechanical lift. The Progress Noted dated 12/10/24 at 2:15 PM, identified Resident #3 had a skin tear to her left lower shin. The note reflected Resident #3 hit her leg on the full-body mechanical lift and tore open her skin. The nurse cleaned the area and applied steri strips. A Non Pressure Skin Condition Report, dated 12/10/24, reflected Resident #3 had a skin tear to her left shin. Resident #3's clinical record lacked further skin assessments or documentation of the skin tear on her left shin. The Skin/Wound Note dated 2/21/25 at 4:59 PM, identified Resident #3 had 2 3 bruises to the left shin. She reported they happened during a transfer. The note indicated they initiated a skin sheet to monitor the area. Resident #3's clinical record lacked a skin condition report for bruises to her left shin. In addition, the clinical record didn't have assessments or documentation of bruising identified. The Progress Noted dated 3/11/25 at 10:53 AM, identified a skin tear to the left outer calf measuring 2.5 x 1.5 cm. The area was cleansed with a triple antibiotic applied and covered. A Non Pressure Skin Condition Report for the injury wasn't initiated. No further assessment or documentation for the injury identified in the medical record. During an interview on 4/10/25 at 11:30 AM, the Director of Nursing (DON) explained the nursing staff complete the weekly skin audits. They document in the Treatment Administration Record, if they don't identify skin injuries, or by the Non Pressure Skin Condition Report, if they identify a skin injury. If a Non Pressure Skin Condition Report is initiated, the nursing staff documents further assessments of the injury, if present, on that report. If the injury resolves by the time nursing completes the weekly assessment, the staff document on the skin condition report or writes a Progress Note listing the injury as healed or resolved, thus, closing out the injury assessments/documentation. The DON reported she expected the nursing staff moving forward to close out all skin injuries. Per an email dated 4/10/25, the Administrator confirmed the facility didn't have a policy related to staff documentation. The Skin Management Guide, revised November 2023, instructed skin alterations are evaluated and documented by the licensed nurse. The Skin Evaluation Non-Pressure form is initiated upon identification of a skin injury, used to document healing status, and wound details weekly.

Based on observation, staff interview, and facility policy, the facility failed to protect food from contamination during meal service. The facility reported a census of 55 residents. Findings include: On 12/11/24 at 11:20 AM, observed Staff F, Dietary Aide, prepare multiple peanut butter and jelly sandwiches. Under constant observation Staff F repeatedly touched the bread with gloved hands while making the sandwiches. In addition, Staff F touched a variety of surfaces with their gloved hands including, but not limited to: the outside of the bread bag, the surface of the counter, pen pulled and replaced in Staff F's pocket, the peanut butter container, jelly squeeze bottle, and storage bags. On 12/11/24 at 12:20 PM, watched Staff G, Cook, prepare toast. Under constant observation Staff G touched the bread when placing slices in the toaster after touching a variety of surfaces with gloved hands including, the counter top, drawer handle, and toaster. On 12/11/24 at 12:25 PM, Staff E, Dietary Aide, prepared a grilled turkey and cheese sandwich. Under constant observation Staff E repeatedly touched the bread, cheese, and turkey while making the sandwich. In addition, Staff E touched a variety of surfaces with gloved hands including, but not limited to: the surface of the counter, refrigerator doors, items inside the refrigerator, containers of butter and cheese slices, and turkey packaging. Staff E, also used the same knife to spread butter on the bread after using it to open the plastic turkey package. During an interview on 12/12/24 at 10:18 AM, the Dietary Supervisor stated they expected the staff to wear gloves when handling ready to eat food and to handle food to prevent food borne illness by not touching food with bare hands or contaminated gloves. The facility policy labeled Disposable Glove Use dated January 2023 instructed disposable gloves shall be worn while handling ready to eat foods that don't require further cooking and for single task only. Gloves shall be discarded after each use and if they are soiled, torn, or contaminated.

Based on resident, family and staff interviews and policy review, the facility failed to maintain the confidentiality of a resident's private personal and medical records for 1 of 1 resident reviewed (Resident #27). The facility reported a census of 55 residents. Findings included: In an interview on 12/10/24 at 10:39 AM, Resident #27 reported their family member found another resident of the facility's death certificate who passed away on 11/23/34 on a bedside table in his room. He stated the family member turned it into the head nurse. He reported he didn't know it was there and didn't look at it prior to their family member finding the document. In an interview on 12/10/24 at 1:00 PM, Resident #27's family member reported a couple of weeks before they saw a paper on Resident #27's night stand below his television (TV). They thought it was a list of his upcoming appointments. When they opened it, they found it was actually another resident from the facility's death certificate. They explained they took the paper to the Director of Nursing (DON) and reported finding it in Resident #27's room. They added the DON told them that shouldn't be left in Resident #27's room. In an interview on 12/12/24 at 8:35 AM, the DON stated she remembered Resident #27's family member bringing her another resident from the facility's death certificate from 11/23/24. Resident #27's family member reported they worked in the health care field and knew finding the Death Certification was a confidentiality issue. The DON reported she didn't know how the certificate ended up in Resident #27's room and stated no staff admitted to leaving it in his room. She stated she expected everything resident related remain confidential. In a facility document labeled Compliance Plan last revised 1/1/24, instructed the facility and facility staff would protect the confidentiality of Protected Health Information (PHI) in accordance with state and federal privacy laws. This included all information about the facility's residents, including the fact if they are or were a resident of the facility.

Based on staff interview, clinical record review and Preadmission Screening and Resident Review (PASRR) evaluation, the facility failed to complete a PASRR screening for 1 out of 2 residents reviewed in the current sample who had mental health changes (Resident #40). The facility reported a census of 55 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] identified an incomplete Brief Interview for Mental Status (BIMS), due to being unable to complete the interview. The MDS included diagnoses of psychiatric/mood disorders including anxiety, depression, psychotic disorders. Resident #40 used antipsychotic and antidepressant medications within the lookback period. The Care Plan Focus dated 10/7/24 identified Resident #40 used psychotropic medications related to depression. The Care Plan lacked the updated mental health diagnosis. The Notice of PASRR Level I Screen Outcome dated 11/1/22 reflected the facility completed the assessment due to Resident #40's admission to the nursing facility. The PASRR indicated Resident #40 didn't have a mental health diagnosis known or suspected, and didn't receive mental health services. The PASRR directed, if changes occur or new information refutes these findings a new screen must be submitted. Resident #40's Medical Diagnosis reviewed on 12/11/24 included several updated diagnoses of the following: a. 10/31/22 - Delusional disorders classified as admission. b. 11/16/23 - Major depressive disorder no classification. c. 11/16/23 - Generalized anxiety disorder no classification. d. 10/31/22 - Hallucinations classified as admission. The clinical record didn't reveal a new PASRR screening. On 12/11/24 at 2:19 PM Staff C, Licensed Practical Nurse (LPN), explained they knew of the expectation to resubmit a PASRR with a new mental health diagnosis and would complete a new submission. On 12/11/24 at 3:11 PM The Administrator reported they follow the regulation and didn't have a specific policy for PASRR's.

Based on interviews, observations, and record review, the facility failed to provide appropriate nursing supervision to ensure safety for 1 of 3 residents sampled (Resident #1). Resident #1 required assist of 1 for transfers and ambulation. The facility failed to provide the assist of 1 resulting in Resident #1 falling in her room and fracturing her hip. The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #1 included: malignant neoplasm of right breast (breast cancer) and age related cognitive decline. A Brief Interview for Mental Status (BIMS) was not assessed. Resident #1 required extensive assist of 1 for transfers, toilet use, and ambulation. This MDS documented that Resident #1 was admitted to the facility on [DATE]. An MDS dated [DATE], documented that a BIMS score for Resident #1 was 10 out of 15, which indicated moderately impaired cognition. It documented that Resident #1 required an extensive assist of 2 for transfers, toilet use, and ambulation. This MDS documented that Resident #1 was a reentry to the facility on [DATE], after an acute hospitalization . A Care Plan for Resident #1 documented: A Focus area revised on 7/18/23, directed staff that Resident #1 was at an increased risk for falls related to weakness. It documented that she had a fall on 6/5/23 with no injury, a fall on 6/18/2023 with no injury, and a fall on 7/18/2023 that resulted in a hip fracture that required Resident #1 to be admitted to the hospital. A Progress Note dated 7/18/23 at 8:30 a.m., documented that the nurse was called into Resident #1's room. She observed this resident sitting on the floor near the bathroom on her bottom with her head against the wall. This resident's pants were down around her ankles and her right shoe was off. This resident stated she did hit the back right side of her head. This resident's right leg had external rotation and was painful with movement. This resident's range of motion (ROM) was within normal limits with the exception of her right leg and hip. Per nursing judgement this resident was sent to the ER for evaluation. A call was placed to 911 and a report was called to the ER. This resident's daughter was aware and would meet this resident in the ER. A Progress Note from 7/18/23 at 8:45 a.m., documented that the EMT's (Emergency Medical Technician's) were at the facility to transport this resident to the ER. She was assisted on to the gurney. She had a neck brace and leg immobilizer placed. A message was sent to the on-call provider. A Progress Note dated 7/18/23 at 11:43 a.m., documented that a call was received from the ER and this resident had a fracture of the right hip. She was going to be admitted and was to be evaluated for surgery. A Progress Note dated 7/23/23 at 1:17 p.m., documented that a call was received from the hospital's medical surgical unit reporting that this resident was to be discharged back to the facility on this day. The facility's nurse informed the caller that they had not received a call about readmission at all that weekend. The nurse asked if this resident was to be skilled care and she said yes. The nurse informed the caller that this resident would have to return on the following day. The caller stated that the facility nurse did not need to be rude and the caller will not be rude back, but she would let the provider know that the nurse was refusing to take this resident back and the caller would be reporting this to state. The nurse called the Director of Nursing (DON) and the DON stated that on Friday the Social Worker said the plan was for this resident to return on Monday. The nurse also called the daughter, and the daughter stated that she had been with this resident all day and the daughter had heard nothing about her being discharged on this day. The daughter said that she also had talked with the Social Worker and the plan was to have this resident discharged back to the facility on Monday. A Progress Note dated as a late entry on 7/25/23 at 3:30 p.m., documented that this resident was readmitted to the facility. This resident was transported to the facility by this resident's family and was brought into the building by wheelchair (w/c). This resident had been at the hospital and was post operative for a right hip pinning on 7/19/23. The surgical dressing was dry and intact. This resident voiced her pain level to be at a 4 on a scale from 0-10 (with 10 being the worst pain). It documented that this resident was to be an assist of 1. It documented that this resident was happy to be back and was in a pleasant mood. A Final Result for an X-ray of Resident #1's right hip dated 7/18/23 at 10:20 a.m., documented that the impression was a right hip fracture. The reason for the X-ray was documented as right hip pain, fell that morning. On 9/14/23 at 10:53 a.m., the DON, when asked what interventions the facility had put into place to keep this resident form falling again, stated that the facility has signs up in this resident's room to remind her to ask for assistance when transferring or ambulating. The DON stated that they have asked Resident #1 to keep her door open in her room when she is in there. The DON stated that Resident #1 really liked to change clothes and look at her clothes. The DON stated the biggest thing the facility was doing was to make sure Resident #1's door was open as before she liked to keep her door shut. The DON stated that the facility had also sent out letters to families asking them not to have their loved ones wear Croc shoes. The DON stated this resident was wearing Croc shoes at the time of her fall. The DON stated that everyone was aware that Resident #1 needed to be assisted, and checked on. The DON stated that if staff see Resident #1 up in her room they know to go into the room. The DON stated that therapy was working with Resident #1. The DON stated that this resident did not like to use her walker appropriately. Resident #1 liked to grab the bars down low, so the staff encourage her to use her walker appropriately. The DON stated that this resident would take her walker and move it with one hand. The DON stated that her expectation was that the staff leave her walker in front of her (in her room). The DON stated that Resident #1 would become very frustrated with staff trying to help. The DON stated that she felt Resident #1 viewed staff trying to help her as staff trying to stop her from doing things. The DON stated that staff offer Resident #1 assistance to the toilet, before and after meals, and if they see Resident #1 in her room trying to go to the bathroom they go in and help her. The DON stated they also do rounds before and after meals for toileting and night shift does rounds. The DON stated this resident is toileted before bed and in the morning. The DON stated that she didn't see a lot of documentation on Resident #1 getting up at night, so the DON didn't know if this resident was continent through the night or if it was a routine rounding. The DON stated that Resident #1's falls had been during the day. On 9/14/23 at 11:58 a.m., the MDS Nurse stated that non-compliance should have been documented on this resident's Care Plan. The MDS nurse stated she was going to add it to this resident's Care Plan right away. The MDS nurse stated that Resident #1 was non-compliant with transfers and ambulation with assist of 1. She stated that the tasks (direction for the Certified Nurse Aides(CNAs) regarding resident care needs) would not say anything about non-compliance either as the tasks flow from the resident's Care Plan. She acknowledged that the CNAs would not know by looking at the Care Plan that this resident was non-compliant. On 9/14/23 at 12:15 p.m., the MDS Nurse stated that Resident #1 was non-compliant at the time of her fall. The MDS nurse stated that she knew that the report was submitted saying Resident #1 was independent but she was not. Resident #1 required an assist of 1 but was non-compliant with asking for assistance. On 9/14/23 at 12:16 PM, the DON stated that she was the one that submitted the report to DIA stating that this resident was independent in her room at the time of her fall with fracture. She stated that she wasn't the only one who thought that this resident was independent and did not know where she heard that this resident was independent in her room. The DON stated that she honestly thought that Resident #1 was independent in her room up to the point of her fall with fracture. The DON stated she had went to therapy and asked them about it, and therapy told this DON that this resident was not independent in her room and hadn't been since admission. Both the MDS Nurse and the DON, acknowledged during the above 2 conversations, that this resident should have been Care Planned to show that she was non-compliant with the interventions for assist of 1 for transfers and ambulation. On 9/14/23 at 12:23 p.m., Staff A, Physical Therapy Aide (PTA), stated that she had been working at the facility full time for over a year. Staff A stated that when Resident #1 first came in to the facility, Resident #1 was on Hospice, so they did not know Resident #1's abilities. Staff A stated that rehabilitation had picked Resident #1 up on their caseload when Resident #1 came off of Hospice for Part B to set her up on Restorative programs for PT (Physical Therapy) and OT (Occupational Therapy). Staff A stated that Resident #1 was a stand by to contact guard assist. Staff A stated that 'assist of 1' would be how nursing would say it for transfers and ambulation. Staff A stated that Resident #1 was using a four wheeled walker at that time. Staff A stated that at the time of this interview Resident #1 was to use a front wheeled walker and remained a stand by to contact guard assist/assist of 1. Staff A stated that this resident's daughter was not happy and had showed Staff A a picture of this resident standing in her room with no one else around. Staff A stated that this resident's daughter also knew that her mom was non compliant. Staff A stated that PT/OT were going to make Resident #1 independent when she came back this last time after her hip fracture, but they didn't because of confusion trying to push the walker backwards and also had tried to push the walker sideways. Staff A stated that was why Resident #1 remained an assist of 1. On 9/14/23 at 12:33 p.m., Staff B, CNA was walking with the resident down the hall to her room. He was using a Gait belt and this resident was pushing her walker. They entered this resident's room and this resident then sat in her recliner and stated she saw a nap in her future and laughed a little. Staff B stated he had worked at the facility for about a month and a half to 2 months. He said that he thought he started after she had the fall. Staff B stated that this resident needed help going to bathroom and walking down to dining. Staff B stated he had not worked with this resident too much. Staff B stated that he believed they were supposed to help her with transfers as well. When asked how he knows what each resident's care needs were, Staff B then apologized and stated that he was still trying to get everybody's routine down. He stated he could check the Care Plan at the nurse's desk if he didn't know. On 9/14/23 at 12:38 p.m., Resident #1's daughter stated that when her mom fell and broke her hip, her mom was trying to get herself dressed when she wasn't supposed to, she was supposed to get assist of 1 from staff. She had her pants down around her legs and that's how she tripped and fell . She will tell you that she slipped on water but that is not true. Resident #1's daughter stated that her mom likes to get dressed on her own and won't wait for someone. This resident's daughter stated that she wished they would alarm her mom's chair but know that can't be done. This daughter stated that staff were supposed to help her mom. This resident's daughter stated she knew staff were checking on her more frequently and intervene when they find her standing. This daughter stated her mom has a will of her own and is a tough one because she thinks she can do everything she used to do [AGE] years ago and she just can't. This resident's daughter stated that staff were doing what they could within their means. She stated that Hospice were using side rails in her mom's bed and an alarm pad on her mom's chair so they could respond immediately. Resident #1's daughter stated that she was at the facility all the time, once or twice a day and this daughter catches her mom doing all kinds of things. This daughter stated her mom goes to the bathroom by herself and her mom will push her walker sideways thinking it will strengthen her legs. This daughter stated that her mom just doesn't know what she is doing. The daughter stated that her mom was completely non-compliant. This daughter stated that her mom wasn't trying to be non-compliant, she just didn't know what she was doing. This daughter stated that her mom doesn't become really upset but she tells this daughter and her brothers that the staff are so nosy and she can do what she wants to in her own room. The daughter stated every nursing home in the history was short staffed but they are handling it well and do a good job. On 9/14/23 at 4:26 p.m., Staff C, CNA stated she had worked at the facility for [AGE] years. Staff C stated she had worked with Resident #1 and Resident #1 was supposed to be an assist of 1. Staff C stated that this resident remained an assist of 1 and remained non-compliant. Staff C stated that upon admission, she believes they thought Resident #1 was independent. Staff C stated that this resident wasn't real steady but did pretty well. Staff C stated that when she looked into this resident's room and the bathroom door is shut, She will go in and 9 times out of 10 this resident would be in the bathroom. 9/14/23 at 4:29 p.m., Staff D, CNA stated she had worked at the facility for 4 years in June. Staff D stated this resident did not need much prior to her fall. Staff D stated this resident really just needed set up and monitored to dress. Staff D stated she was able to transfer herself and ambulate in her room, but quite honestly Staff D did not remember if Resident #1 was independent to ambulate in the hall or not. Staff D stated that since Resident #1's hip fracture staff assist her with her peri cares and brushing her teeth, although some of it Resident #1 will do herself but they stand by her. Staff D stated they are to use a gait belt in her room and walk her in the halls with 1 assist with a gait belt. On 9/14/23 at 4:33 p.m., Staff E CNA/Certified Medication Aide (CMA), stated that she had worked at the facility for almost a year. Staff E stated that she honestly could not say what Resident #1's needs were prior to the fall with fracture because Staff E worked primarily in the Dementia unit. Staff E stated she knew at this time, Resident #1 was a limited assist of 1 with a gait belt and staff were to stand there with this resident. Staff E stated that staff were to assist this resident. She stated Resident #1 could do the majority of the work. Staff E stated that this resident was to use her walker in the room and in the hall too. On 9/14/23 at 4:40 p.m., the DON stated that the facility was a no alarm facility, which meant there were to be no bed alarms and no chair alarms. She stated she had not seen anything about being a no alarm facility in the Admissions packet. She stated she wished they could use alarms. On 9/18/23 at 12:43 p.m., Staff F, CMA stated that what she remembered from the day that Resident #1 fell and broke her hip was that Resident #1's door was closed that day. Staff F believed Resident #1 probably shut the door herself. Staff F stated she usually worked on the other side of the facility. Staff F stated she really did not know what this resident's typical day was like. Staff F just knew she had worked with this resident a few times prior to that, when she walked around. Staff F stated that before the fall Staff F knew that this resident was an assist of 1 on the floor and then in her room she was able to walk around by herself. On the day she fell , Staff F stated she saw that this resident was on the floor and her pants were half down. Staff F stated she then radioed the nurse. Staff F said that Resident #1 was by the bathroom door, the bathroom door was already closed and she was on the bedroom side of the door. Staff F stated that this resident told Staff F that she tried to pull up her pants and it didn't work out as she wanted and she ended up falling down. Staff F stated that Resident #1 was pointing at her hip and said it hurt and she couldn't move it. Staff F thought it was her right hip that this resident was pointing at. Staff F stated that Staff G, Licensed Practical Nurse (LPN) was the nurse that responded. Staff F stated that Staff G assessed Resident #1, took her vital signs as she was supposed to do and then Staff G called the ambulance. Staff F stated the ambulance then came and picked this resident up. On 9/14/23 at 5:10 p.m., the DON and the Administrator acknowledged understanding of this resident not receiving assistance of 1 staff as Care Planned for transfers and ambulation for Resident #1. They acknowledged there was confusion by staff with what assistance this resident required, as some staff believed this resident to be independent with transfers and ambulation in her room. On 9/18/23 at 1:39 p.m., Staff G stated that Resident #1 was an assist of 1 at the time of the fall, but she was non-compliant. Staff G stated that this resident had to have a lot of reminders. Staff G stated that morning Staff G was training another nurse on the memory unit. Staff G stated as soon as they came out of the unit, Staff G got called and went in to Resident #1's room. Staff G said that this resident was sitting on the floor. Staff G stated that she instantly knew not to move her because her right leg was externally rotated. Staff G did not remember what level this resident rated her pain. Staff G said that Resident #1 was talking to us normally and kept saying she hurt there (right hip and leg). Staff G stated that this resident was calm. Staff G believed that this resident had a little stool in her pants and she was trying to change her pants. Staff G stated that this resident's leg looked shorter as well. Staff G stated that the nurse that Staff G was training stayed with Resident #1, and then Staff G went and called 911 and then Staff G called the daughter. Staff G stated the ambulance came and staff G was going to give this resident something for pain. Staff G stated that when this resident was first admitted to this facility she was Hospice and had a morphine order, so Staff G looked to see if there was something she could give Resident #1 for pain, but her morphine order had been discontinued as Hospice had been discontinued. Staff G stated that when Resident #1 returned from the hospital, Staff G wasn't there. Staff G stated she did not remember, but Staff G believed the next time Staff G took care of this resident, this resident was a 1 assist with a walker and a gait belt. Staff G stated that the interventions at this time to prevent falls for Resident #1 were that this resident was still an assist, but she was non-compliant, so she had to be reminded. Staff G stated that this resident has had therapy. Staff G stated that this resident's family rearranged this resident's room so she could get around a little better but other than that Staff G did not know of any other changes. Staff G stated she was not at work so she could not look at this resident's Care Plan at this time. An OT-Therapist Progress & Discharge Summary dated 6/14/23, documented start of care 6/2/23 and end of care 6/14/23. It documented that Resident #1 was to be a stand by assist for safe functional ambulation with a 4 wheeled walker. An OT-Therapist Progress & Discharge Summary dated 8/12/23, documented start of care was 7/26/23 and end of care was 8/12/23. It documented that Resident #1's discharge plans were to discharge to restorative and #1 to remain in Long Term care and wait for staff assistance. A Fall Clinical Protocol policy dated 3/2018, directed the following: Assessment and Recognition l. The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnoses. 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. a. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. b. After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. 4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). a. Falls often have medical causes; they are not just a nursing issue. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often, multiple factors contribute to a falling problem. 2. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. a. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. b. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 5. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underling causes. A Fall and Falls Risk, Managing Policy dated 3/2018, directed the following: Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Definition According to the NOS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/her self is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall. Fall Risk Factors l. Environmental factors that contribute to the risk of falls include: a. wet floors; b. poor lighting; c. incorrect bed height or width; d. obstacles in the footpath; e. improperly fitted or maintained wheelchairs; and f. footwear that is unsafe or absent. 2. Resident conditions that may contribute to the risk of falls include: a. fever; b. infection; c. delirium and other cognitive impairment; pain; e. lower extremity weakness; f. poor grip strength; g. medication side effects; h. orthostatic hypotension; functional impairments; j. visual deficits; and incontinence. 3. Medical factors that contribute to the risk of falls include: a. arthritis; b. heart failure; c. anemia; d. neurological disorders; and e. balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. A Bed/Chair Alarm policy Dated 1/18/23, directed the following: Purpose: In order to keep residents free from restraints, Grandview Heights prohibits the use of bed & chair alarms. Policy: 1. If a resident is a fall risk, Grandview Heights will explore alternative options to keeping the resident safe such as: a. A closer room to the nurse's station to allow for increased supervision b. Leaving the residents room door open c. Camera monitoring at the nurse's station, with consent d. Utilizing the community areas e. Including the resident in daily activities and exercise groups

Based on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to ensure the environment was as free of hazards as possible for a resident with a history of wandering and identified at risk for elopement (when a resident leaves the building without staff knowledge or consent). Resident #1 was identified with cognitive impairment, periods of increased confusion and disorientation, impaired safety awareness, wandering behaviors, and Care Planned for a Wander Management Alarm Bracelet (wander guard). Investigation revealed on 4/20/22 Resident #1 exited the facility at 10:08 p.m., and staff responded to the activated door alarm, but failed to determine the cause and assure that all residents were safe and accounted for. Resident #1 walked across the facility back yard/parking lot, a farm field, crossed a city street, and entered a convenience store parking lot. Resident #1 then called his family to report that he was outside and alone, worried, and unable to find his way back. Resident #1 was located at 11:30 p.m. and returned to the facility. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility identified 4 residents that required the use of the wander management alarm system. The facility reported a census of 59 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) Assessment with a Reference Date of 4/17/2022 that documented an admitted [DATE]. Resident #1 scored a 12 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. The MDS indicated Resident #1 wandered on a daily basis, and was independent for transfer and walking in room. The MDS further documented the resident's diagnoses included hypertension, [CONDITION(S)], disorientation, cerebral infarction, tremor, and syndrome of inappropriate secretion of antidiuretic hormone which can cause confusion. A Wandering Risk Assessment completed on 4/8/22 identified the resident as disoriented, admitted within the last month, independent, taking an antidepressant medication, and a known wanderer. The 4/1/22-4/30/22 the Treatment Administration Record (TAR) for Resident #1 documented wander guard (alarm system) to right wrist, check placement and functioning every shift dated as initiated upon admission, 4/8/22. A Baseline Care Plan initiated on 4/8/22 identified Resident #1 as alert, independent for bed mobility and a stand by assist for transfer, walking and toileting. The Baseline Care Plan directed a wander guard alarm system. Following the Elopement Care Plan, initiated on 4/21/22 documented Resident #1 at risk for injury related to impaired cognition with periods of increased confusion/disorientation, impaired safety awareness, and impulsivity related to frequent wandering, talked of leaving facility with an actual elopement on 4/20/22. The Care Plan listed the following Directives dated as initiated on 4/21/22: a. Door alarms on per facility policy. b. If the resident wandering excessively, encourage to sit and rest to avoid fatigue. Offer snacks, one on one conversation, distraction with activities, etc. c. Picture on wandering board at nurse's stations and in the employee lounge. d. Place on CCDI (Chronic Confusion or Dementing Illness) unit. e. Wander guard in place, check for function every shift. The Progress Notes contained the following entries: a. On 4/21/22 at 5:00 a.m., Staff A, Licensed Practical Nurse (LPN) documented at 11:15 p.m. on 4/20/22 Resident #1's son called to say his dad had phoned and was in a parking lot. Resident not in his room and a building search was initiated by staff and the resident not found. Staff A started looking for resident outside in car with the lights. Searched in lots and fields around the facility, unable to locate Resident #1. At 11:20 p.m. the son called again, reported the resident had said he was in the parking lot at a local convenience store on 12th Street. At 11:25 p.m nurse arrived at the convenience store and called out for the resident who walked up to car. Son informed at 11:30 p.m. that his father had been found and the he was ok. Full assessment completed. Resident was placed on the CCDI unit for the rest of the night for close observation. On call physician was contacted and informed of resident's elopement and condition. No new orders. b. On 4/21/22, the Director of Nursing (DON) documented at 11:38 p.m. on 4/20/21 directed Staff A, LPN to place resident on the CCDI unit. At 00:20 a.m. the DON entered the front door and set off the alarm with a quick response from staff. At 1:00 a.m. reviewed the facility camera footage for 4/20/22 and established a timeline which included the following: a. At 10:08 p.m., Staff A, LPN and Staff B, Certified Medication Aide (CMA) counting narcotics, when Resident #1 walked up the 600 hallway, out therapy doors. b. At 10:08:34 p.m. Door alarm panel sounded. c. At 10:09 p.m., Staff A, LPN responded to the activated door, unable to visualize resident, no suspicion at that time. Alarm panel deactivated by Staff B, CMA. d. At 11:15 p.m., Son calls facility, reported Resident #1 in a parking lot. Later reported to be a convenience store parking lot. e. At 11:30 p.m., Staff A, LPN returned with Resident #1. Resident noted to be wearing long sleeved pocked t-shirt, full zip fleece jacket, blue jeans, long socks, lace up hiking boots, had water pitcher, cell phone, and wallet. The DON further documented resident exited the facility through the therapy doors. Weather was noted to be 48 degrees, 15 MPH wind, no precipitation, and cloud cover. Resident was admitted on [DATE] with a wandering score of 27, wander guard bracelet placed with order on the TAR to check function and placement every shift. Resident has participated in goal directed wandering which initially was determined fulfilled resident's need for exercise and provide sensory stimulation. Resident noted to be conversational with staff having moments of clarity and moments of confusion, but no exit seeking attempts or comments made. Review of an Elopement Incident Report dated as initiated by Staff A, LPN on 4/21/22 at 00:02 a.m. revealed on 4/20/22 at 11:15 p.m. Resident #1's son called to say the resident was in a parking lot. A facility search was completed right away, followed by a search of the parking lots and farm fields around the facility with use of car lights. Resident oriented to person only, and noted to have confusion, impaired memory, and a wanderer. In an observation on 4/27/22 at 2:50 p.m. Resident #1 was observed to be seated in a chair in the facility CCDI unit dining room area. Resident stood independently and ambulated. Wander guard bracelet noted on right wrist. Wander guard bracelet was tested by Staff C, CMA. Resident very hard of hearing. Stated that he had no concerns. During interview and Environmental tour of the facility on 4/25/22 at 10:15 a.m., the DON demonstrated that the Therapy Room exit door audibly alarmed at the door and the alarm stopped sounding when the door was again closed. The alarm was then heard sounding at the West Nurse's station annunciator panel. Surveyor and DON proceeded to the annunciator panel where the DON demonstrated reset of the alarm by simply pushing a reset button. The DON confirmed that Resident #1 had been assessed at risk of elopement and wore a wander guard bracelet on his wrist. The DON confirmed that the only doorway at the facility that was equipped with the wander guard alarm system was the front entrance. The DON responded that the Therapy Exit Door would have no reason to sound unless someone had exited that door as the door is locked to entry from the outside and not used for staff or visitor entrance or exit. The DON clarified that all doors to the facility are locked against entry. Lights were visualized outside the doorway, DON identified that the exterior lights came on automatically at night to light up the periphery of the building. The incident happened after 10:00 p.m., when it would have been dark outside. There is a sidewalk outside the therapy door that only goes to the right identified as North, towards the backside of the facility. It was determined by the DON that the resident exited the therapy doorway, was on the sidewalk, and when he got to the back of the building crossed the facility back yard which is grass and a farm field with corn fodder. The convenience store would have been visible from the back yard. Resident would have had to walk across grass and field, then cross South 12th Ave. with a speed limit of 35 mph to get to the convenience parking lot. It was approximated that the convenience store was 0.5 miles from the facility. The DON stated that she would have expected staff to check the area outside the Therapy Room Exit door for a cause of the door alarm being activated. Further stated, she would have expected to do more than was done. When unable to determine a cause for the door alarm being activated, the DON would have expected to assure all residents were accounted for and safe. The DON responded was unsure if the facility had a specific door alarm response policy, however stated she thought it was common sense to determine the cause of a door alarm activation. In an interview on 4/26/22 at 6:20 p.m., Resident #1's son stated he visited his father daily, and talked to him numerous times a day on the phone. Responded he had been involved in the decision to place the wander guard bracelet because his father talked daily about leaving, was more confused and disoriented, and not safe to make decisions about care. Further stated the family had placed their father at the facility for his safety and felt it was not safe for him to be alone unsupervised. Stated on 4/20/22 he received the first call from his father, who informed that he was outside, in some kind of parking lot. He called the facility to have them check on his father and felt like it took too long, so he called his father back. Again, his father seemed certain that he was outside, but not sure where. The son responded that he was calm, but worried because he had no idea how to get back. The son had him look around and he could describe a convenience store sign. He stayed on the phone with his father and notified the facility of his father's location. He visited the next day and his father had some recall of leaving, but told him he'd gone for a walk. The following day his father seemed to have no recall of the incident. In an interview on 4/26/22 at 10:37 p.m., Staff A, LPN reported on 4/20/22 he arrived for the 10:00 p.m.-6:00 a.m. shift, and was counting medications at the West side Nurse's Station with Staff B, CMA. At approximately 10:08 p.m. the door alarm annunciator panel sounded, which indicated the Therapy Room Exit Door had alarmed. Staff A reported that he went to the therapy room and opened the exit door and looked outside. Stated the area was well lit by outside lighting and he found no reason for the door alarm. He returned to the Nurse's Station and had Staff B, CMA reset the alarm. Around 11:15 p.m. he received a call from Resident #1's son, who reported that he had received a call from his father that he was outside in a parking lot. When Staff A, LPN unable to locate the resident in his room, he initiated a search for resident, inside and outside. Staff A stated he used his car, so that he would have his headlights to try and locate the resident in the parking lot, or farm field behind the facility, but was unable to locate. Staff A then reported he got a radio call from staff inside the facility that the son had called back again and thought that his father was at a local convenience store. Staff A found the convenience store was closed when he arrived, and he couldn't see the resident. Staff A stated that Resident #1 walked over to his car when he yelled his name. Staff A, LPN responded that he was unaware of any expectation or protocol to do an accountability check for residents when unable to find the cause of a door alarm. In an interview on 4/27/22 at 9:45 a.m., the DON confirmed that she had been the nurse who had assessed Resident #1 upon re-entry into the facility and determined based on a history of wandering and an expressed desire to leave the facility he required a wander guard for safety. The DON further stated that the facility failed to have a policy or protocol to check all residents and do a head count if a door alarm went off and the cause couldn't be determined, but she felt that it was just good nursing judgment and all the nurse's that she had interviewed had indicated that is what they would do in this situation. The DON clarified that she would have expected staff to search outside for the cause of the activated door alarm and if unable to find a cause to complete a head count to assure that all residents were safe and accounted for. In an interview on 4/27/22 at 11:05 a.m., the State of Iowa Climatologist reported the temperature in the area of the facility on 4/20/22 between 10:00 p.m. and midnight ranged from 41-42 degrees Fahrenheit with wind chill factored in. There was no precipitation. Sunset was at 8:00 p.m. and the climatologist responded that after 8:00 p.m. without a light it would be considered dark outside. Observation and interview on 4/26/22 at 9:00 a.m., the Convenience Store Clerk reported that the store is open until 11:00 p.m. From the convenience store parking lot 12th Ave South, a city street was busy at this time of day with a factory to the South. Speed limit posted at 35 mph There was a stoplight to the South with commercial/industrial buildings and a raceway, and residential to the North. There were no sidewalks. A ditch was visible across the street from the convenience store, steep in parts and a farm field with corn fodder, which would be difficult to walk through in the dark. Noted a small grassed waterway visible and a large pile of brush. Approximately 0.5 mile away across the field, the back of the facility is partially visible. The facility was unable to provide a Door Alarm Policy. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 4/27/22 at 2:15 p.m. Facility staff removed the Immediate Jeopardy on 4/27/22, 2022 through the following actions: a. Development of a Door Alarm Policy that included the expectation that in the event of a door alarm going off, a check of the door alarming and the perimeter of the building will be completed by assigned staff and an immediate resident head count will be completed by assigned staff. b. A blast technology communication was sent to notify all licensed nursing staff that they are to report to the facility by 5 p.m. on 4/27/22 to review and sign the facility Door Alarm Policy. They will review and sign off that they have reviewed and understand their role in initiating a complete search and resident head count. Staff on duty have been educated. c. A copy of the policy was affixed to the front of each report book and all staff at report were reminded that they need to review and sign for 72 hours to ensure that all employees are educated. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policies and procedures.

Based on observations, record review, staff interviews, and policy review the facility failed to prevent the risk for serious harm, transmission and infecting residents related to failure to separate COVID-19 positive and negative residents for 4 of 64 residents reviewed (Residents #6, #7, #8 and #9) and failed to implement complete and consistent screening of employees. The facility reported as of 7/28/20 that 47 out of 64 residents COVID-19 positive. The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #6 dated 5/13/20, included [DIAGNOSES REDACTED]. The assessment identified the resident with a Brief Interview for Mental Status (BIMS) score of 99, indicating unable to evaluate cognitive status. Review of Resident #6's Care Plan revised 7/16/20, revealed Resident #6 COVID- 19 positive. The Minimum Data Set (MDS) assessment for Resident #7 dated 6/10/20, included [DIAGNOSES REDACTED]. The assessment identified the resident with a BIMS score of 5, indicating severe cognitive impairment. Review of Resident #7's Care Plan revised 7/23/20, documented Resident #7 was COVID-19 positive. Observation on 7/22/20 at 1:00 p.m., revealed Resident #6 and Resident #7 residing together in room [ROOM NUMBER]. Review of Resident #7's Nursing Progress Notes documented: a. 7/17/20 at 8:13 a.m., resident with negative COVID results from 7/13/20. b. 7/23/20 at 9:54 a.m., family member aware of resident's positive COVID result. c. 7/23/20 at 7:02 p.m., physician's orders [REDACTED]. New order received to send resident to emergency room (ER) due to worsening condition and evaluation. d. 7/23/20 at 10:56 p.m., call placed to hospital for update on resident's condition. Resident's chest x-ray and tests reveal the resident diagnosed as COVID-19 positive, having pneumonia, as well as a urinary tract infection [MEDICAL CONDITION]. The resident's temperature at ER reached 104.0 Fahrenheit. Nurse reports resident's family wanted the resident sent to a hospital Intensive Care Unit (ICU) for further treatment. The Minimum Data Set (MDS) assessment For Resident #8 dated 7/20/20, included [DIAGNOSES REDACTED]. The assessment indicated the resident with a BIMS score of 5, indicating severe cognitive impairment. Review of Resident #8's Care Plan revised 7/16/20, revealed Resident #8 COVID- 19 positive. The Minimum Data Set (MDS) assessment For Resident #9 dated 6/14/20, included [DIAGNOSES REDACTED]. The assessment identified the resident had a BIMS score of 13, indicating no cognitive impairment. Review of Resident #9's Nursing Progress Note dated 7/23/20 at 11:29 a.m., documented family aware of resident's negative COVID result. Observation on 7/22/20 at 10:00 a.m., revealed Resident #8 and Resident #9 residing together in room [ROOM NUMBER]. During an interview on 7/22/20 at 12:45 p.m., Staff E, Director of Nursing (DON) confirmed Resident #6 was COVID-19 positive and Resident #7 was COVID-19 negative, residing together in room [ROOM NUMBER]. Staff E, DON also confirmed Resident #8 was COVID-19 positive and Resident #9 was COVID-19 negative, residing together in room [ROOM NUMBER]. Staff E, stated the plan was to move them but confirmed residents had not been separated. The facility failed to cohort or isolate COVID positive and COVID negative residents to reduce the risk of transmission of COVID-19 amongst residents. 2. During an interview on 7/22/20 at 10:08 a.m., Staff A, Certified Medication Aide (CMA) stated the following process for staff screening when entering the facility to work: take their own temperature, use hand sanitizer, ring the doorbell to get in, and hit confirm button on the time clock. During an interview on 7/27/20 at 9:00 a.m., Staff B, Certified Nurse Aide (CNA) stated the following process for staff screening when entering the facility to work: take your temperature, answer the questions on the time clock, and if the answer is yes then have to call a supervisor. Staff B, CNA stated she was falsifying the answers on the time clock questions as she had been exposed to COVID-19 in the building. During an interview on 7/27/20 at 9:55 a.m., Staff C, Licensed Practical Nurse (LPN) stated the following process for staff screening when entering the facility to work: answer questions on the time clock and take her own temperature. Staff C, LPN, stated the process switched to staff checking the documented temperature of the staff before you with the memory on the thermometer. Staff C, LPN stated around 1:30 p.m. on an unknown date, Staff G, CMA reported to Staff C, LPN that she had upper respiratory symptoms and a cough, but no temperature throughout the shift. Staff G, CMA also reported to Staff C, LPN the same symptoms were reported to a nurse at the beginning of her shift and the nurse told Staff G, she was fine to work. Staff C, LPN stated she questioned Staff G regarding the need to go home and Staff G stated she felt okay. Staff C did not report Staff G's symptoms to her supervisor, did not send Staff G home, and reported was unaware if Staff G completed her shift. During an interview on 7/23/20 at 2:50 p.m , Staff G, CMA reported working the whole shift on 7/3/20 with a dry cough, body aches, not feeling well and no temperature throughout the shift. Staff G stated symptoms were reported to Staff C, LPN. Staff G, also reported she tested COVID 19 positive on 7/9/20. During an interview on 7/27/20 at 1:16 p.m., Staff D, Registered Nurse, (RN) stated the following process for staff screening when entering the facility to work: questions on the time clock are answered and take own temperature. If staff temperature was 100.3 or above then the staff had to go home. If staff answered yes on the time clock, the staff had to be seen by a supervisor. Staff D, RN stated she had not screened any staff members due to the time clock questions. Staff D, reported she allowed Staff B, CNA to work an entire shift on an unknown date with knowledge of Staff B having symptoms of a cough, dizziness, and overall not feeling well. Staff D, RN stated Staff B did not have a fever and stated guidance from Administration was staff can work if have no fever. Staff D, RN was unable to verify direct guidance from a supervisor. Staff D explained Staff B's symptoms were not reported to a supervisor. In review of eighteen pages of untitled documents dated 7/21/20 - 7/28/20, noted staff names and temperatures documented only 238 of 660 entries of staff temperatures documented checked or initialed by staff as verified. The facility failed to follow facility policy and procedure. Review of an undated facility policy titled, Covid-19 Screening Policy and Procedure stated the following: a. Staff will self-screen and verify temperatures. b. Take your temperature and write your name and temperature in the self-temperature book. c. The previous staff member will verify the temperature from the memory of the thermometer and initial next to the temperature. d. Answer the questions on the time clock. If you answer yes to any of the questions, a nurse will come to the door to assess the staff member prior to clocking in and entering the building. The nurse will then determine if the staff member may enter the building or be advised to go home. In review of facility's documents titled COVID-19 Employee Time clock Responses the following noted: a. 36 sheets dated 7/1/20 - 7/7/20. b. 37 sheets dated 7/8/20 - 7/15/20. c. 5 sheets dated 7/25/20 - 7/26/20. The facility failed to have all signs and symptoms of COVID-19 in the staff screening process per Centers for Disease Control and Prevention (CDC) guidelines dated 5/13/20 to include: a. Screen all health care personnel at the beginning of their shift for fever and symptoms of COVID-19. b. Actively take their temperature and document absence of symptoms consistent with COVID-19. c. Assess for fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. d. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. e. If health care personnel develop fever (100.0 F) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace. During an interview on 7/30/20 at 10:05 a.m, Staff E, DON, stated, Prior to our Immediate Jeopardy (IJ), staff would enter the front door, take their own temperature, and write it down on the flowsheet (on the table). The next staff to follow staff in would check the memory on the thermometer, circle and initial the employee entry before them. Obviously, that wasn't getting done 100% of the time but my expectations were that staff were doing this as directed. The incident detailed above resulted in determination of Immediate Jeopardy for the facility and notified of such on 7/28/20 at 5:00 p.m The Facility Staff abated the Immediate Jeopardy situation on 7/29/20 through the following actions: a. One COVID-19 positive resident cohorting with a COVID-19 negative resident moved to a private room on the isolation hall in room [ROOM NUMBER]. The other two COVID-19 positive and negative residents that were cohorting are no longer in the same room as the COVID-19 negative resident transferred to the hospital with a COVID-19 positive diagnosis. b. All staff notified on 7/29/20, via a mass text message, thru the facilities Smart Link system, of the change of policy regarding screening of staff upon entrance for a complete list of COVID-19 signs and symptoms and the requirement for a nurse to take all staff temperatures. Based on the results of the corrective measures taken by the facility lowered the scope and severity of the deficiency from a K level to an E level.

Based on clinical record review, observation and staff interviews, the facility failed to ensure completion of initial and/or ongoing assessments and interventions to identify, prevent or promote healing of areas of altered skin integrity for two of two residents reviewed (Residents #291 and #23). The facility identified a census of 92. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #291, dated 5/28/18, recorded [DIAGNOSES REDACTED]. The MDS documented the resident required the physical assistance of two for bed mobility, toilet use and transfer and the assistance of one for dressing and personal hygiene. The resident ate independently following set up. The MDS documented the resident had frequent incontinence of bowel and had an indwelling catheter for urination. The assessment also recorded Resident #291 had three Stage 2 pressure ulcers with one present on resident's admitted , 5/11/18. The resident's care plan dated 5/30/18 included a focus area of actual pressure ulcers and he had the potential of further pressure ulcer development related to impaired mobility, incontinent of bowel, varied oral intakes and low [MEDICATION NAME] and protein levels. The resident received comfort care. The care plan documented the goal that his pressure ulcers would show signs of healing and remain free of infection. Documented interventions instructed to assess, record and monitor the resident's wound healing per protocol, report improvements and declines to the medical doctor and assist resident to turn and reposition frequently. On 6/12/18, staff added the intervention to use a turn sheet and heel boots at all times. A Braden Scale for predicting pressure sore risk dated 6/6/18 documented the resident scored a 13, which identified the resident to be at risk for developing a pressure sore. During observation on 6/12/18 at 8:14 A.M, with Staff C, Registered Nurse Unit Manager /Quality Assurance, Resident #291 lay flat on his back in his bed a pillow had been placed under his knees and his heels lay directly against the mattress. The resident had a square skin dressing in place on the right inner ankle with a date of 6/8/18. His left great toe appeared reddened. The resident also had a bright red rash on his groin area on both buttocks and down the back of both thighs. The observation revealed five skin dressing patches on his back and one on his sacral area. One patch had a date of application of 6/7/18 and the remaining five showed no date. The patch on the sacral area was contaminated with BM. Record review showed the resident had a pressure wound identified on right inner foot and no treatment order could be found on the current Treatment Administration Record (TAR). The TAR also contained no treatment direction for the sacral area or rash to groin and buttocks. During an observation on 6/12/18 at 11:20 AM, the resident lay flat on his back with his heels directly on the mattress. Staff B, Registered Nurse (RN) entered the room, washed her hands and donned gloves. She prepared a clean surface barrier and laid out wound treatment supplies. Staff C, RN Unit Manager/ Quality Assurance entered room as an observer. a. Staff B removed the Kerrafoam (a wound protection dressing) dated as applied on 6/8/18 from the resident's right ankle. Clear drainage ran down the side of the resident's ankle onto the bedding. Staff B measured the ankle wound, identified as pressure wound, with a paper measure strip that she laid against the wound. The wound measured 1.7 centimeters (cm) X 2.7 cm and had a shallow ulcer with a red and yellow wound bed. Staff B moved toward resident's back to start the treatment. On request, Staff B lifted resident's feet and revealed black eschar (a collection of dead tissue that is within a wound, flush with the skin surface and reflects deep tissue damage) on both heels. She touched the reddened left great toe, which had crossed over the second toe and separated them. An open area with a red wound bed and a small amount of drainage was against the second left toe. Staff B replaced resident's heels back directly on the mattress. b. Staff B then removed the Kerrafoam dressing close to resident's right shoulder blade. The dressing covered a linear open area that appeared to be from abrasion, tearing or shearing. Staff B cleansed and re-dressed this open area. c. Staff B removed the next dressing, below the first, which showed two circular areas that appeared to be abrasion, shear or skin tear. Staff B cleansed and re-dressed the open areas. d. The next dressing lower towards his spine was removed and showed a circular open area with a moderate amount of serous sanguineous (watery blood fluid) drainage. Staff B cleansed and re-dressed the open area. e. The next dressing fell on the resident's midback spine and when removed, revealed a softball size reddened area with two eschar areas one on each side of the resident's spine. Staff B cleansed the area and placed Aqaucel (an antimicrobial which inhibits the growth of microorganisms) and Kerrafoam dressing on this area. f. The next dressing lower on the spine recorded an applied date of 6/7/18. Staff B removed the dressing revealing a pink/red wound bed which she cleansed and covered with a new Kerrafoam dressing. g. The bottom dressing showed no date and was on the sacral region (lowest area of spine). Removal of the dressing showed an ulcer with a red wound bed and serous sanguineous drainage present. Staff B cleansed the wound and covered it with a Kerrafoam dressing. Then Staff C stated she was not aware of this last pressure area and the facility did not have a skin tracking sheet for it. Staff B did not measure it and Staff C requested she measure this wound (2.0 cm by 1.7 cm). Staff B then repositioned resident on his back, with his heels directly on the mattress, removed her gloves, washed her hands and left the resident's room. In an immediate interview, Staff C stated she would expect Staff B to measure a wound without being prompted. Staff C stated Staff B failed to assess and measure the three new areas on the resident's heels and between his right great and little toe. Staff C measured the new areas to send information to physician. The resident's left heel wound measured 2.2 by 0.5 cm, his right heel wound measured 3.0 by 1.5 cm and the wound to the second toe of his left foot measured 0.7 cm by 0.7 cm. Review of the Weekly Pressure Ulcer Record revealed resident had a pressure identified area on right inner foot noted on 5/23/18. The resident's TAR documented no treatment order. Review of the current TART revealed no treatment for [REDACTED]. A room care plan utilized by the Certified Nurse Aides (CNA) directed to use heel boots. Staff completed three Weekly pressure ulcer records at this time: a. A weekly pressure ulcer record documented the date of onset for a stage 2 lower spine pressure ulcer as 5/11/18 with the next assessment on 5/23/18 then weekly through 6/6/18. This pressure area measured 0.5 cm by 1.0 cm with a dark purple surrounding area measuring 3.5 cm by 2.4 cm. b. A weekly pressure ulcer record identified a Stage 2 right inner foot with a date of onset on 5/23/18 and listed preventative measures to include heel boots. Weekly assessments were documented with the last one reading measurements of 1.7 cm by 2.2 cm. and the facility would be faxing physician for a new order. c. A weekly pressure ulcer record identified a Stage 2 upper spine pressure area with date of onset as 5/23/18. Weekly assessments completed through 6/6/18. This pressure area measured 1.2 cm by 0.7 cm. d. No weekly pressure ulcer record was in place for the pressure ulcer covered on the resident's sacral area. Staff sent a Routine Physician Notification form dated 4/23/18 (an error as the resident entered the facility on 5/11/18) on 5/23/18. It was returned with the word yes and without the physicians' signature. This notification requested treatment for [REDACTED]. The order showed a notation date of 5/24/18. The TAR showed this order to read foam dressing, apply to open areas topically every other day to promote wound healing, apply to spine, upper right back, and abdominal fold. It failed to include the area of the right inner foot. On 6/13/18, Staff C provided a weekly pressure ulcer record that had been initiated for the sacrum wound. It identified a Stage 2 wound that measured 2.0 cm by 1.7 cm. Weekly pressure ulcer records had also been started for the bilateral heel pressure area and the pressure found on the right foot second toe. She provided a paper faxed to the physician with updated condition of the resident's skin. The physician provided for new orders. The facility's Wound/Dressing change protocol dated 2/27/15 directed to verify treatment on TAR, date and initial any new dressing replaced and conduct weekly measurements to monitor for any changes. On 6/12/18 at 12:39 P.M., Staff C stated she would expect all pressure and open wound areas to have been assessed and the assessment sent to the physician for treatment orders. She would expect skin to be assessed for new and worsening areas of pressure. She would expect a resident's heels to be protected and recommended the patient have a turning sheet for repositioning. She stated she had been gone for three weeks and generally does the skin assessments. She had expected the RN charge nurses to monitor and assess for skin changes while she was off but felt it had not been done effectively. She would expect a barrier cream to be used by CNA staff and or a treatment would be in place for the excoriated areas to his groin and buttock. During an interview with the Director of Nursing (DON) on 6/13/18 at 3:50 P.M., she stated she would expect skin assessments to be timely and accurate even when the Unit Manager was off. She stated she felt there had been a system failure while the Unit Manager was off. She would expect new skin conditions to be assessed and the physician to be informed. During a phone interview on 6/14/18 at 11:55 AM, the resident's primary Physician stated he would expect new skin issues to be assessed by the nurses and treated for [REDACTED]. 2. The MDS assessment for Resident #23, dated 3/21/18, documented her [DIAGNOSES REDACTED]. The MDS documented the resident as at risk for developing pressure ulcers and without ulcers at the time of the assessment. Resident #23 required the physical assistance of two for bed mobility and transfers and the physical assistance of one with dressing. The resident's care plan, initiated on 3/31/17, recorded a focus area of the potential for pressure ulcer development related to decreased mobility and incontinence. Staff added an intervention on 4/23/18 to apply heel boots on at all times and Resident #23 should not wear shoes. A Weekly Pressure Ulcer Record documented the resident developed a pressure sore on the right outer heel on 4/23/18. The record documented the area had been a Stage 2 wound and measured 1.0 centimeters (cm) x 0.7 cm, an intact blister. A Weekly Pressure Ulcer Record documented the resident developed a pressure sore on the left outer heel on 4/23/18. The record documented the area had been a Stage 2 wound and measured 3.5 cm x 3.0 cm, an intact blister. A Weekly Pressure Ulcer Record documented Resident #23 developed a pressure sore on the left inner heel on 4/23/18. The record documented the area had been a Stage 2 wound and measured 2.0 cm x 2.0 cm, an intact blister. On 6/13/18 at 10:18 a.m., Staff C, RN assessed the resident's heels with findings as follows: a. Right outer heel - Stage 2, 0.8 cm x 1.0 cm.; Staff C stated the area had begun as fluid filled blister. b. Left outer heel - Stage 2, dark color, 3.5 cm x 3.0 cm; Staff C stated the wound could be eschar and the resident complained of pain when Staff C touched it. c. Left inner heel - Stage 2 a dry hardened area, 1.4 cm x 1.5 cm. The resident moaned when socks were placed on after Staff C assessed the areas. During interview on 6/13/18 at 10:39 a.m., Staff C stated the heel lift boots were not implemented until after the resident developed blisters to both heels. When asked why the heel lift boots had not placed prior or an intervention to float the resident's heels, Staff C stated the resident had not been at risk for pressure sores. The surveyor and Staff C reviewed the resident's MDS assessment and Braden scale which documented a risk of developing pressure sores. Staff C stated she had not been aware of that. On 6/13/18 at 11:24 a.m., the DON stated the floor nurses completed the Braden assessments and they should have notified the nurse manager.

Based on observation, clinical record review and staff interview, the facility failed to plan nursing services with wound care provisions for two of four residents. The facility failed to ensure that Resident #1 and Resident #4 receive the necessary interventions to promote healing and prevent deterioration of pressure sores. The facility identified a census of 88 residents. Findings include: 1. The MDS assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident as cognitively impaired, had modified decision making abilities and disorganized thinking. The MDS assessment dated [DATE], documented the resident required extensive assistance with transfers and personal cares, occasionally incontinent of bowel, always incontinent of bladder and required extensive assistance with bed mobility. The MDS assessment documented the resident had a Stage II pressure ulcer. Braden scale for predicting pressure sore risk, dated 1/12/11, documented resident with a score of 12, total score of 12 or less represents high risk. A risk factor of friction and shearing requires moderate to maximum assistance in moving. Mobility very limited, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Resident with a history of pressure ulcers. The comprehensive care plan with team conference dated 1/19/11, included a problem with an onset date of 2/4/11, actual impaired skin integrity related to Stage II pressure area, potential related to decreased mobility, urinary incontinence and varied oral intake. The planned interventions included: a. Assist to turn and reposition every two hours. b. Treatment as ordered. c. Pressure relieving device to bed/chair. d. Monitor healing progress or lack thereof. Contact medical doctor for condition update as needed and treatment change as needed. e. Monitor during bathing for signs of skin irritation or breakdown. f. Podiatrist consult as needed. g. Encourage adequate intake of food and fluids. h. Administer medication pass as ordered. i. Encourage to allow staff to place pillow under feet when in bed. j. Turning schedule initiated at night. k. Treatment as ordered to open area on coccyx. l. Administer Z-bec as ordered. m. Diet as ordered. Nurses notes dated 2/4/11, documented staff found a 2 centimeter (cm) by 0.5 cm by 0.1 cm depth open area on the resident's coccyx. A wound assessment dated [DATE], documented suspected pressure ulcer to coccyx area related to immobility, poor nutrition, Braden score and incontinence. Measurements include: a. 2/4/11, the area measured 2 cm by 0.5 cm by 0.1 cm b. 2/10/11, the Stage II area measured 1 cm by 0.2 cm by 0.1 cm c. 2/14/11, the Stage II area measured 1.2 cm by 0.4 cm by 0.1 cm, slightly macerated. d. 2/24/11, the area was unstageable and now had two wounds: 1. First area on coccyx measured 3 cm by 1.4 cm, depth unknown, with macerated edges, with 90 percent yellow slough. 2. Second area on coccyx measured 1.7 cm by 0.6 cm by unknown depth, edges open with 100 percent yellow slough. A facsimile to the physician dated 2/21/11, requested an order to change treatment to the residents buttocks to Manukapli, cover with Allevyn, change every three days and as needed. The physician agreed with the order and returned the facsimile back to the facility on [DATE]. A turning schedule dated 2011, documented 'no back'! During continual observation on 2/22/11 at 1:06 p.m., observation revealed the resident lying on he/she back in bed with a pillow behind he/she head. At 2:22 p.m., resident remained on their back in bed with pillow behind he/she head. At 3:02 p.m., the resident continued to lie on he/she back in bed with pillow behind he/she head. At 4:11 p.m., the resident continued to lie on he/she back in bed with pillow behind he/she head. At 4:41 p.m., or 3 hours and 35 minutes later the resident continued to lie on he/she back in bed with pillow behind he/she head. Observation on 2/24/11 at 1:22 p.m., Staff G (certified nursing assistant) and Staff H (certified nursing assistant) proceeded to transfer the resident to bed from he/she wheelchair onto a nap pad. Staff proceeded to provide peri cares as the resident was incontinent of urine and stool. Staff B (registered nurse) stated the dressing had fallen off the open area and needed to be replaced. Staff B left the room. At 1:45 p.m., Staff B knocked on the door and proceeded to come into the resident room with an over the bed tray table and supplies to complete the dressing change. Staff B applied a treatment to both areas on the residents left buttock and coccyx areas. Staff B and Staff I (registered nurse) proceeded to position the resident on top of a cotton fitted sheet, nap pad and a clean brief. Staff B stated the other open area was new. During the treatment the resident stated "ouch it hurts down there." to the nurse. During interview on 2/24/11 at 2:02 p.m., Staff B stated the one open area noted on 2/04/11 was bigger and they had faxed to the doctor for a treatment change and the other open area was not present on 2/21/11 when an assessment was completed. During interview on 2/24/11 at 2:06 p.m., Staff F (licensed practical nurse) stated the low loss air mattress was less effective when more than a fitted sheet and a brief were over the mattress. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of two for bed mobility and transfer and had a Stage III pressure ulcer. The plan of care dated 9/8/10, documented a problem of potential for impaired skin integrity related incontinence, impaired mobility and impaired cardiovascular status. The problem included an addition of actual, pressure area to coccyx (11/30/10). The problem included an intervention to assist to turn/reposition per turn schedule-see turn schedule in Certified Nurse Aide book. A Braden Scale assessment for predicting pressure sore risk dated 1/26/11, documented the resident to be at a moderate risk. A turning schedule for the resident for the month of February 2011, included a hand written note at the bottom that read "No Back". The schedule revealed the resident had frequently been positioned on his/her back. Nurse notes dated 11/30/10 at 10:00 p.m., documented the resident had an open area measuring 0.2 centimeters (cm) by 0.2 cm x 0.1 cm. The area was found on the residents coccyx. A routine physician notification dated 11/30/10, directed staff to apply [MEDICATION NAME] (protective barrier cream) to the open area two times daily. A routine physician notification dated 12/1/10, documented the wound to the coccyx measured 1.2 cm by 0.5 cm by 0.1 cm, with a request to discontinue the [MEDICATION NAME] and cleanse the area with normal saline, apply Manukapli (honey based wound treatment) to wound bed, cover with a 2 by 2 Allevyn (dressing) and change every three days. The form documented the wound as a Stage III pressure ulcer. The Weekly Pressure Ulcer Progress report dated 12/1/10, documented the resident had a Stage III pressure ulcer on the coccyx that measured 1.2 cm by 0.5 cm by 0.1 cm., with a treatment of [REDACTED]. A preventative measure included to turn the resident every two hours. The Weekly Pressure Ulcer Progress report dated 12/8/10 documented the Stage II area measured 0.5 cm by 0.2 cm by 0.2 cm. The Weekly Pressure Ulcer Progress report dated 12/15/10, documented the Stage III area measured 1 cm by 0.5 cm by .25 cm. A Weekly Wound Progress form documented at the top of the form the coccyx area was a Stage II . The form dated 12/22/10, documented the area measured 0.9 cm by 0.3 cm by 0.9 cm. The Weekly Wound Progress form dated 12/30/10, documented the area measured 0.6 cm by 0.3 cm by 0.1 cm. The Weekly Wound Progress form dated 1/6/11, documented the area measured 0.4 cm by 0.3 cm by 0.1 cm. The Weekly Wound Progress form dated 1/12/11, documented the area measured 0.4 cm by 0.3 cm by 0.1 cm. The Weekly Wound Progress form dated 1/19/11, documented the area measured 0.3 cm by 0.1 cm by 0.1 cm. The facility completed no further assessment of the area until 2/2/11, utilizing a formal wound assessment form. The form dated 2/2/11, documented the area measured 0.3 cm by 0.3 cm by 0.1 cm and was a Stage III pressure ulcer. On 2/8/11, the form documented the area as a Stage III pressure ulcer that measured 0.3 cm by 0.2 cm by 0.1 cm. On 2/16/11, the form documented the area as a Stage II pressure ulcer that measured 0.3 cm by 0.1 cm by 0.1 cm. During observation on 2/22/11 at 12:35 p.m., Staff K (Licensed Practical Nurse) and Staff A (Registered Nurse) assisted the resident to transfer to bed and positioned the resident on his/her back. At 2:10 p.m., the resident remained on his/her back. Staff L (Certified Nurse Aide) and Staff M (Certified Nurse Aide) completed perineal cares as the resident laid in bed. During the observation the resident was turned from side to side to cleanse the perineal area, and upon completion, positioned on his/her back. At 3:07 p.m., the resident remained in bed on his/her back. At 3:50 p.m., the resident remained in bed on his/her back. At 4:19 p.m., the resident remained in bed on his/her back. At 4:30 p.m., the resident remained in bed on his/her back. During observation on 2/23/11 at 5:40 a.m., the resident laid in bed on his/her back. At 6:27 a.m., the resident sat in his/her room in a wheel chair. At 7:15 a.m., the resident remained in the wheel chair in his/her room. At 7:17 a.m., Staff D (Director of Nursing) wheeled the resident from his/her room to the dining room, leaving him/her in the wheel chair at a table. At 7:58 a.m., the resident remained in the dining room in the wheel chair. At 8:17 a.m., the resident remained in the dining room in the wheel chair. At 8:20 a.m., the resident remained in a wheel chair at the dining table and received a breakfast tray. At 8:40 a.m., Staff N (Certified Nurse Aide) pushed the resident to his/her room, and with assistance of Staff D, transferred the resident to bed and positioned him/her on the back. At 9:20 a.m., the resident remained in bed on his/her back. At 10:05 a.m., the resident remained in bed on his/her back. At 10:50 a.m.., the resident remained in bed on his/her back. At 11:11 a.m., the resident remained in bed on his/her back. At 11:21 a.m., the resident remained in bed on his/her back. During interview on 1/24/11 at 3:00 p.m., Staff A stated the resident should not be left on his/her back because of the pressure ulcer on the coccyx, and stated they did not know what the manufacturer recommendations would be for layering clothing or linens over an alternating pressure mattress. During observation of a treatment on 2/25/11 at 9:21 a.m., Staff K (Licensed Practical Nurse) measured the area at 0.4 cm by 0.3 cm by 0.3 cm. At that time Staff K stated the area did not have much of a depth before this but that it now did so he/she would measure it. During interview on 2/25/11 at 10:35 a.m., Staff A stated an in-service was completed with staff on positioning the resident and proper documentation of that. Staff A stated the physician was notified earlier today about changing the treatment to the coccyx. The facility policy titled Decubitus Ulcer/Pressure Sore Protocol (undated), documented if a resident had skin breakdown, staff were to implement a more frequent turn schedule. The policy also documented a weekly progress report must be documented, preferably on the same day each week.