Every finding on record at Oakwood Care Center

Based on clinical record review, facility policy review, staff, and resident interviews, the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 7 residents reviewed (Resident #1 and #10). The facility identified a census of 60 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 usually understands and feels understood, with adequate vision. The MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS documented diagnoses including anemia (low red blood cells), heart failure (weakened heart muscle), renal failure (kidney failure), non-Alzheimer's dementia (memory loss), and depression (mood disorder). The MDS documented Resident #10 required staff dependence for toileting hygiene and dressing, and setup help for personal hygiene. Resident #10's Care Plan dated 8/19/26 identified a focus area for behavior problems related to dementia. Interventions directed staff to approach and speak in a calm manner, assure Resident #10 staff validate concerns and stand willing to address legitimate concerns, and communicate clearly. The Investigation Summary dated 7/19/26 documented Staff B, Registered Nurse (RN), reported overhearing Staff C, Certified Nursing Assistant (CNA), tell Resident #10 to just wet her pants while Staff B stood at the medication cart outside Resident #10's closed bedroom door. Staff B reported overhearing Staff C tell Resident #10 to just wet her pants from behind the closed door approximately two weeks prior. The summary documented Staff D, CNA, remained in the room during the statement, though Staff D reported no recollection of the event or hearing Staff C tell Resident #10 to just wet her pants. On 7/21/26 at 11:50 AM Resident #10 stated feeling upset about an incident where two aides entered the room getting the roommate up for the day. Resident #10 stated needing to go to the bathroom, but Staff C stated Staff C and Staff D remained in the middle of a transfer, telling Resident #10 to urinate in the brief and promising cleanup after finishing with the roommate. Resident #10 stated feeling embarrassed to urinate in a brief and noted staff repeatedly tell Resident #10 to urinate in the brief for later cleanup. Resident #10 stated working with therapy to transfer independently so staff won't need to help with bathroom trips, emphasizing staff need to treat all residents with dignity and respect. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 holds the ability to be understood and understand others with no vision problems, behaviors, or resistance of care. The MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented diagnoses including anemia (low red blood cells), cerebral palsy (brain disorder affecting movement), depression (mood disorder), and chronic pain (long-lasting pain). The MDS documented Resident #1 required staff dependence for toileting, personal hygiene, bathing, and dressing, using a wheelchair for mobility. Resident #1's Care Plan dated 8/12/26 identified a focus area for behavior problems, noting Resident #1 tends to reject care, food, medications, and repositioning, consistent with resident values. Interventions directed staff to assure Resident #1 staff validate concerns and stand willing to address legitimate concerns, maintaining respect for Resident #1's rights to make lifestyle choices. The Interdisciplinary Team (IDT) Meeting Notes dated 4/27/26 at 8:25 AM documented Resident #1 expressed disliking new staff and preferring familiar staff as a normal response for Resident #1. On 7/17/26 at 2:00 PM Resident #1 stated Staff A, CNA, isn't nice and doesn't treat Resident #1 with dignity and respect. On 7/23/26 at 12:44 PM the Administrator and Staff E, RN, acknowledged staff must treat all residents with dignity and respect at all times as a facility expectation. The Resident Rights-Dignity and Respect policy dated April 2024 directed staff to lay the foundation for treating all residents with dignity and respect, maintaining and enhancing self-esteem and self-worth. The policy directed each resident holds the right to considerate and respectful care, receiving treatment with honesty, dignity, respect, and reasonable accommodation of individual needs.

Based on clinical record review, staff and resident representative interview, the facility failed to notify a resident representative/family following a resident's fall for 1 of 6 residents reviewed (Resident #4). The facility reported a census of 60 residents. Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented short and long-term memory problems with moderately impaired decision-making abilities, the ability to understand and receive understanding from others, and no present behaviors. Resident #4's MDS documented staff dependence for toileting hygiene, upper and lower body dressing, personal hygiene, transfers, and ambulation, alongside two falls without injury. Resident #4's MDS documented medical diagnoses including cancer (malignant growth), diabetes mellitus (high blood sugar), and hypertension (high blood pressure). Resident #4's Care Plan with a cancellation date of 6/30/26 identified Resident #4 at risk for falls, noting Resident #4 doesn't remember to use a walker for long-distance ambulation (walking) and needs reminders. Interventions instructed keeping the bed in a low position, placing the call light within reach, providing new non-skid shoes, and placing a sign reminding Resident #4 to take the walker when ambulating. An Incident Report in progress notes dated 6/17/26 at 11:55 PM documented staff hearing a loud crash. Upon staff entering Resident #4's room, staff discovered Resident #4 lying on the floor on Resident #4's back, positioning Resident #4's head in the corner by the bathroom door, feet toward the middle of the room, and walker beside the end of the bed. Two staff members assisted Resident #4 to standing, placed Resident #4 into a wheelchair, transported Resident #4 to the north lounge, and transferred Resident #4 to a recliner. Staff observed Resident #4 10 minutes prior to the fall and documented plans to notify Resident #4's Family Member in the morning. General Progress Notes dated 6/18/26 at 7:13 AM documented calling Resident #4's wife to provide an update regarding Resident #4's fall. On 7/23/26 at 9:45 AM Resident #4's Family Member stated expecting notification following the fall occurring on 6/17/26 at 11:55 PM. On 7/23/26 at 12:44 PM the Administrator, and Staff E, Registered Nurse (RN), stated nursing staff must notify family members regarding a resident's change of condition, including falls and new or discontinued medications. The Notification for Change of Condition policy dated June 2023 instructed staff to immediately inform the resident and notify the resident's legal representative or an interested family member when an accident involving the resident occurs resulting in injury or holding potential to require physician intervention.

Based on clinical record review, facility investigation, facility policy, staff and resident interview, the facility failed to report all alleged violations involving mistreatment and misappropriation of resident's property to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 2 of 2 residents reviewed (Resident #10 and #11). The facility reported a census of 60 residents. Findings include:1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented adequate vision and a Brief Interview for Mental Status (BIMS) score of 5, indicating severely cognitively impaired. Resident #10 usually understood others and others sometimes understood Resident #10. Resident #10 required staff dependence for toileting hygiene and dressing, setup help for personal hygiene, and experienced frequent urinary incontinence (loss of bladder control). Diagnoses included anemia (low red blood cells), heart failure (weakened heart), renal failure (kidney failure), non-Alzheimer's dementia (memory loss), and depression (mood disorder). Resident #10's Care Plan focus target dated 8/19/26 identified Resident #10 at risk for falls related to confusion. Interventions instructed staff to provide frequent toileting, encourage toileting before and after meals, keep personal care items and call light within reach, and assist Resident #10 with a stand-pivot transfer using 1 staff member and a front-wheeled walker. The Care Plan noted Resident #10 couldn't always express needs due to confusion. The Investigation Summary dated 7/19/26 documented Staff B, Registered Nurse (RN), overheard Staff C, Certified Nursing Assistant (CNA), tell a resident to just wet her pants while Staff B stood at the medication cart in the hallway outside Resident #10's closed bedroom door. During staff interviews, Staff B informed the Director of Nursing of witnessing potential abuse by Staff C toward Resident #10. Staff B reported overhearing Staff C tell Resident #10 to just wet her pants from behind Resident #10's closed door a couple of weeks prior, but couldn't recall the exact date of the incident or report. The summary documented Staff D, CNA, remained in the room when Staff C made the statement to Resident #10, though Staff D reported no recollection of the event or hearing Staff C tell Resident #10 to just wet her pants. The facility suspended Staff C on 7/19/26 pending investigation and provided staff education regarding abuse and reporting procedures. The Statement of Events dated approximately 7/19/26 at 8:00 AM documented on an unknown date approximately 6/25/26 at 9:00 AM, Staff B stopped the Director of Nursing at the nurse's station while Resident #10 sat in a wheelchair nearby. Staff B spoke vaguely, stating Resident #10 reported having to urinate in her pants that morning because an aide did it again, and Staff B assumed Staff C caused it. The Director of Nursing educated Staff B regarding assumptions, clarifying situations, and offering immediate toileting due to Resident #10's cognition. The Director of Nursing returned to the office, then visited Resident #10 in her room to ask if Resident #10 had to pee her pants. Resident #10 stated making it to the bathroom that morning, and the Director of Nursing offered toileting assistance again. The Director of Nursing documented not recalling Staff B's reported statements and denied ever stating being too busy to deal with the situation, recalling instead stating having just arrived from a meeting and needing a moment to gather thoughts for the day. On 7/19/26 at 8:00 AM the Director of Nursing called Staff B for follow-up questions regarding interview responses. Staff B reported notifying the Director of Nursing in person 1 to 2 weeks prior to taking a week off. The Director of Nursing responded not recalling the conversation and requested details. Staff B stated informing the Director of Nursing at the nurse's station about Staff C telling Resident #10 to urinate in her pants, claiming the Director of Nursing responded not having time for it. The Director of Nursing noted not recalling the interaction that way, but agreed to review and take notes. Staff B stated during a prior incident while passing medications outside Resident #10's closed room door, Staff B overheard Staff C tell Resident #10 from inside the room with Staff D to just pee your pants or similar words. Staff B stated pulling Staff C aside later that day to explain making such statements constituted abuse. Staff B further stated informing the Director of Nursing later when Resident #10 came to the nurse's station stating an aide said Resident #10 had to urinate in her pants again, claiming the Director of Nursing stated an inability to do anything at that time. The Director of Nursing reviewed the conversation with Staff B to confirm accuracy and signed the document. On 7/19/26 at 9:00 AM the Director of Nursing interviewed Staff C over the phone. The Director of Nursing asked Staff C if Staff C ever heard staff or a resident state just pee in your pants. Staff C acknowledged telling Resident #10 approximately a month or longer prior while Staff C and Staff D transferred Resident #10's roommate. Staff C stated Resident #10 expressed an urgent need to use the bathroom, and Staff C responded remaining busy assisting the roommate. When Resident #10 stated an inability to hold urine, Staff C told Resident #10 it felt okay to urinate in her brief and Staff C would clean Resident #10 up after completing the transfer. Staff C stated Staff B stopped Staff C later to explain making such statements constituted abuse. Staff C reported telling Staff B about not telling Resident #10 to just pee in your pants, but rather reassuring Resident #10 about cleaning her up if she couldn't hold it, as Staff C couldn't stop operating a mechanical lift during a transfer. The Director of Nursing reviewed the interview to confirm understanding, determined further investigation felt necessary, and signed the document. On 7/21/26 Staff B provided a written statement documenting during a morning medication pass at the medication cart parked between two rooms, Staff B overheard Staff C tell Resident #10 from behind a closed door to just go to the bathroom in your pants. Staff B noted both Resident #10 and the roommate required two-person assistance for transfers. After passing medications, Staff B entered Resident #10's room and observed Resident #10 sitting on a shower chair draped with a cover while aides finished assisting the roommate. Staff members transported Resident #10 to the shower room for a scheduled shower and then to the dining room for breakfast. Following breakfast, Staff B entered Resident #10's room to administer medications, and Resident #10 repeatedly stated needing to use the bathroom. Staff B informed an aide, who claimed Resident #10 likely used the bathroom during her shower, but Staff B requested the aide assist Resident #10. Later that morning, Staff B informed the Director of Nursing at the nurse's station about Staff C telling Resident #10 to go to the bathroom in her pants. Staff B documented the Director of Nursing asked if Resident #10 used the bathroom, and upon Staff B confirming yes, the Director of Nursing responded caring only about Resident #10 receiving toileting assistance and stating an inability to manage everything personally. Early that afternoon, Staff B pulled Staff C aside privately to report overhearing the statement and explaining telling a resident to go in her pants constituted abuse. Staff B documented Staff C denied making the statement, claiming Staff D made it instead. A written statement by Staff C with no date or time explained approximately 4 weeks prior, Staff B pulled Staff C aside near the medication cart regarding comments made to Resident #10. Staff C attempted to explain Staff B misunderstood the context, but Staff B didn't listen. Staff C explained prior to Resident #10 utilizing a stand-pivot transfer, Staff C and Staff D used a mechanical lift to assist Resident #10's roommate while Resident #10 sat on the bed waiting to transfer to the toilet. When Resident #10 expressed an urgent need to toilet, Staff C and Staff D explained assisting as soon as they finished placing the roommate in a chair. When Resident #10 began urinating in her brief and expressed embarrassment, Staff C reassured Resident #10, noting she wore a brief and staff would clean and change her as soon as they finished with the roommate. On 7/21/26 at 11:50 AM Resident #10 stated feeling upset about an incident occurring on an unknown date and time when two aides entered the room to get the roommate up for the day. Resident #10 stated expressing a need to use the bathroom, but Staff C responded remaining in the middle of a transfer, telling Resident #10 to urinate in her brief and promising cleanup after finishing with the roommate. Resident #10 stated feeling embarrassed to urinate in a brief, noting staff repeatedly tell Resident #10 to urinate in her brief for later cleanup. Resident #10 stated working with therapy to transfer independently so staff won't need to help with bathroom trips, emphasizing staff need to treat all residents with dignity and respect. 2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented adequate vision and a BIMS score of 13, indicating intact cognition. Resident #11 possessed the ability to understand others and make self understood. Resident #11 required staff dependence for toileting hygiene, partial to maximal assistance for dressing and personal hygiene, and experienced frequent urinary incontinence (loss of bladder control). Diagnoses included anemia (low red blood cells), heart failure (weakened heart), renal failure (kidney failure), non-Alzheimer's dementia (memory loss), and depression (mood disorder). Resident #11's Care Plan focus target dated 8/1/26 identified Resident #11 required assistance with Activities of Daily Living (ADLs) related to impaired mobility and noted Resident #11 might become upset without warning, exhibiting suspiciousness toward staff and tearfulness. Interventions instructed staff to use a gait belt (safety belt) during transfers and ambulation (walking) and assist with toileting according to Resident #11's routine. The Investigation Summary dated 7/17/26 documented Resident #11 alleged Staff F, Certified Nursing Assistant (CNA), stole collector coins from her drawer and retaliated by bumping Resident #11's wheelchair with another resident's wheelchair and kicking her chair during mealtimes. On 7/17/26 staff overheard Resident #11 telling others about Staff F stealing her coins and retaliating. Staff E, Administrator, submitted a self-report to the state agency regarding potential theft and abuse. Resident #11 informed a police officer about Staff F stealing 50-cent coins totaling at least $20.00 while Resident #11 used the bathroom around 7/1/26, later changing the date to after 7/4/26 when she stored two shirts in the drawer. Resident #11 stated checking the drawer the next morning after hearing clinking sounds and noticing the coins missing. Resident #11 reported Staff F bumped her wheelchair on 7/10/26 or 7/11/26 and kicked her chair on 7/17/26. On 7/20/26 Staff E called Resident #11 Representative to verify bringing coins to the facility a couple of months prior. Resident #11 Representative inspected coins held by Staff E and denied they represented the missing ones. The summary documented conflicting dates, Resident #11's history of making misplaced property accusations, no resident concerns regarding Staff F, and a lack of evidence identifying Staff F as the source of missing coins. On 7/21/26 at 11:15 AM Resident #11 stated approximately 3 weeks prior, Staff F assisted Resident #11 to the bathroom and closed the door. Resident #11 reported hearing jingling sounds from Staff F's pocket while sitting on the toilet. Resident #11 explained returning to a card game and telling another resident about the jingling sounds, prompting the resident to suggest checking the pink coin purse in Resident #11's room. Resident #11 returned to her room, discovered all coins missing from the coin purse, and didn't mention it initially, but grew angrier over time. On 7/21/26 at 4:00 PM Staff G, Registered Nurse (RN), stated Staff F informed Staff G about Resident #11 accusing Staff F of taking coins from a coin purse. Staff G acknowledged not reporting the allegation to Staff E or the Director of Nursing because Resident #11 frequently made accusations of staff stealing. Staff G explained instructing Staff F to stay away from Resident #11. On 7/21/26 at 4:22 PM Staff E confirmed other residents brought to her attention Resident #11 accusing Staff F of stealing coins from a room drawer. Staff E stated expecting staff to separate involved parties and initiate an investigation immediately, estimating the incident occurred approximately 6/23/26 or 6/25/26. On 7/23/26 at 11:11 AM Staff E and the Director of Nursing stated they expected all staff to report resident allegations immediately, requiring reports to the Department of Inspections, Appeals and Licensing (DIAL) within a 2-hour timeframe. The Patient Protection Guidelines for Abuse Prevention, Reporting, and Investigation policy dated September 2025 directed staff to provide professional care and services in an environment free from abuse, neglect, misappropriation (theft) of resident property, and exploitation. The policy instructed staff to report all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation to DIAL immediately and no later than 2 hours.

Based on record review and interview, the facility failed to ensure staff treated residents with dignity and respect, failed to document allegations of personal degradation and misappropriation (theft) of property in clinical records, and failed to investigate allegations of potential abuse and misappropriation of property for 2 of 2 residents (Resident #10, Resident #11) reviewed for abuse. The facility reported a census of 60 residents. Findings include:1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented adequate vision and a Brief Interview for Mental Status (BIMS) score of 5, indicating severely cognitively impaired. Resident #10 usually understood others and sometimes others understood them. Resident #10 required staff dependence for toileting hygiene and dressing, and setup help for personal hygiene. Diagnoses included anemia (low red blood cells), heart failure (weakened heart), renal failure (kidney failure), non-Alzheimer's dementia (memory loss), and depression (mood disorder). Resident #10's Care Plan focus target dated 8/19/26 identified Resident #10 at risk for falls related to confusion. Resident #10's Clinical Record lacked documentation regarding the allegation of personal degradation. The Investigation Summary dated 7/19/26 documented Staff B, Registered Nurse (RN), reported overhearing Staff C, Certified Nursing Assistant (CNA), tell Resident #10 to just wet her pants while Staff B stood at the medication cart in the hallway outside Resident #10's closed bedroom door. Staff B informed the Director of Nursing about witnessing potential abuse by Staff C toward Resident #10. Staff B reported overhearing Staff C tell Resident #10 from behind the closed door to just wet her pants approximately two weeks prior, though Staff B couldn't recall the exact date of the incident or report. The summary documented Staff D, CNA, remained in the room during the statement, though Staff D reported no recollection of the event or hearing Staff C tell Resident #10 to just wet her pants. Facility leadership suspended Staff C on 7/19/26 pending investigation and provided staff education regarding abuse and reporting procedures. The Statement of Events dated approximately 7/19/26 at 8:00 AM documented on an unknown date approximately 6/25/26 at 9:00 AM, Staff B stopped the Director of Nursing at the nurse's station while Resident #10 sat in a wheelchair nearby. Staff B spoke vaguely without clearly describing a situation, stating Resident #10 reported having to urinate in her pants that morning because an aide did it again, and Staff B assumed Staff C caused it. The Director of Nursing educated Staff B regarding assumptions and clarifying exact situations. The Director of Nursing returned to the office, then visited Resident #10 to ask if Resident #10 had to pee her pants. Resident #10 stated making it to the bathroom that morning. The Director of Nursing documented not recalling Staff B's reported statements and denied ever stating an inability to handle the situation due to being too busy. On 7/19/26 at 8:00 AM the Director of Nursing called Staff B for follow-up questions regarding interview responses. Staff B reported notifying the Director of Nursing in person approximately 1 to 2 weeks prior to taking a week off. Staff B stated informing the Director of Nursing at the nurse's station about Staff C telling Resident #10 to urinate in her pants, claiming the Director of Nursing responded not having time for it. Staff B stated during a prior incident while passing medications outside Resident #10's closed room door, Staff B overheard Staff C tell Resident #10 from inside the room with Staff D to just pee your pants or similar words. Staff B stated pulling Staff C aside later that day to explain making such statements constituted abuse. Staff B further stated informing the Director of Nursing later when Resident #10 came to the nurse's station stating an aide said Resident #10 had to urinate in her pants again, claiming the Director of Nursing stated an inability to do anything at that time. On 7/19/26 at 9:00 AM the Director of Nursing interviewed Staff C over the phone. Staff C acknowledged telling Resident #10 approximately a month or longer prior that it felt okay to urinate in her brief and Staff C would clean Resident #10 up after completing a transfer. Staff C stated Staff B stopped Staff C later to explain making such statements constituted abuse. The Director of Nursing determined further investigation felt necessary. On 7/21/26 Staff B provided a written statement documenting during a morning medication pass, Staff B overheard Staff C tell Resident #10 from behind a closed door to just go to the bathroom in your pants. Later that morning, Staff B informed the Director of Nursing at the nurse's station about Staff C telling Resident #10 to go to the bathroom in her pants. Staff B documented the Director of Nursing asked if Resident #10 used the bathroom, and upon Staff B confirming yes, the Director of Nursing responded caring only about Resident #10 receiving toileting assistance and stating an inability to manage everything personally. Early that afternoon, Staff B pulled Staff C aside privately to report overhearing the statement and explaining telling a resident to go in her pants constituted abuse. A written statement by Staff C with no date or time explained approximately 4 weeks prior, Staff B pulled Staff C aside near the medication cart regarding comments made to Resident #10. Staff C explained telling Resident #10 staff would clean and change her as soon as staff finished with a roommate transfer. On 7/21/26 at 11:50 AM Resident #10 stated feeling upset about an incident where Staff C told Resident #10 to urinate in her brief during a transfer. Resident #10 stated feeling embarrassed to urinate in a brief, noting staff repeatedly tell Resident #10 to urinate in her brief for later cleanup. 2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #11 possessed the ability to understand others and make themselves understood with adequate vision. Resident #11 required staff dependence for toileting hygiene, and partial to maximal assistance for dressing and personal hygiene. Resident #11's MDS documented diagnoses including anemia, heart failure, renal failure, non-Alzheimer's dementia, and depression. Resident #11's Care Plan focus target dated 8/1/26 identified Resident #11 required assistance with Activities of Daily Living (ADLs) related to impaired mobility. Resident #11's Clinical Record lacked documentation regarding the allegation of misappropriation (theft) of personal property. The Investigation Summary dated 7/17/26 documented Resident #11 alleged Staff F, CNA, stole collector coins from her drawer. On 7/17/26 staff overheard Resident #11 telling others about Staff F stealing her coins. The Administrator submitted a self-report to the state agency regarding potential theft. Resident #11 informed a police officer about Staff F stealing 50-cent coins totaling at least $20.00 while Resident #11 used the bathroom around 7/1/26. On 7/20/26 the Administrator called Resident #11 Representative to verify bringing coins to the facility. The summary documented conflicting dates and a lack of evidence identifying Staff F as the source of missing coins. On 7/21/26 at 11:15 AM Resident #11 stated approximately 3 weeks prior, Staff F assisted Resident #11 to the bathroom, and Resident #11 heard jingling sounds from Staff F's pocket. Resident #11 discovered all coins missing from the pink coin purse in her room. On 7/21/26 at 4:00 PM Staff G, RN, stated Staff F informed Staff G about Resident #11 accusing Staff F of taking coins from a coin purse. Staff G acknowledged not reporting the allegation to the Administrator or the Director of Nursing because Resident #11 frequently made accusations of staff stealing. Staff G explained instructing Staff F to stay away from Resident #11 rather than initiating an investigation. On 7/21/26 at 4:22 PM the Administrator confirmed other residents brought to her attention Resident #11 accusing Staff F of stealing coins from a room drawer. The Administrator stated expecting staff to separate involved parties and initiate an investigation immediately, estimating the incident occurred approximately 6/23/26 or 6/25/26. The Administrator confirmed staff must start an investigation immediately and keep the resident safe. On 7/23/26 at 11:11 AM the Administrator and the Director of Nursing stated expecting all staff to report resident allegations immediately, requiring reports to the Department of Inspections, Appeals and Licensing (DIAL) within a 2-hour timeframe. The Patient Protection Guidelines for Abuse Prevention, Reporting, and Investigation policy dated September 2025 directed staff to provide professional care and services in an environment free from abuse, neglect, misappropriation (theft) of resident property, and exploitation. The policy instructed the facility to maintain evidence of thoroughly investigating all alleged violations and preventing further potential abuse while investigations remain in progress. The policy directed the center to conduct a timely, thorough, and objective investigation of potential abuse indicators once reported.

Based on observation, staff, and resident interviews, the facility failed to have two staff always available to use the EZ-stand (sit-to-stand mechanical lift) to transfer residents for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 60 residents. Findings include:Based on observation, record review, and interview, the facility failed to ensure staff members utilized two staff members during mechanical lift transfers for Resident #2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #2 possessed adequate vision, the ability to understand others, and the ability to make self understood, and didn't exhibit behaviors or resistance to care. Resident #2 required staff dependence for toileting hygiene, dressing, and transfers, alongside setup help for oral and personal hygiene. Resident #2's MDS documented diagnoses including hypertension (high blood pressure), non-Alzheimer's dementia (memory loss), depression (mood disorder), and muscle weakness (loss of muscle strength). Resident #2's Care Plan with a target date of 8/12/26 identified a focus area for assistance with Activities of Daily Living (ADLs) related to a history of stroke (brain blood flow blockage) impacting the left dominant side of the body. Interventions instructed staff to transfer Resident #2 using an EZ-stand (sit-to-stand mechanical lift) with two staff members. On 7/21/26 at 10:45 AM an observation revealed Staff H, Certified Nursing Assistant (CNA), and Staff I, CNA, attached the EZ-stand to Resident #2 by the loops on the sling. Staff H and Staff I transferred Resident #2 from the recliner to the wheelchair. On 7/21/26 at 11:00 AM Resident #2 stated staff members sometimes use the EZ-stand with only one staff member present. On 7/22/26 at 10:00 AM Staff J, Licensed Practical Nurse (LPN), confirmed staff members sometimes use the EZ-stand with residents using only one staff member. Staff J confirmed the facility requires two staff members at all times when using mechanical lifts and EZ-stands. On 7/22/26 at 12:00 PM Staff B, Registered Nurse (RN), stated hearing staff members sometimes transfer residents using the EZ-stand with only one staff member. Staff B stated plans to educate staff members regarding the requirement for two staff members when using facility lifts. On 7/22/26 at 1:40 PM Staff D, CNA, confirmed staff members sometimes use the EZ-stand on residents with only one staff member. Staff D confirmed the facility requires two staff members at all times. On 7/22/26 at 3:00 PM the Director of Nursing confirmed facility expectations require staff members to utilize two staff members for EZ-stand or mechanical transfers at all times. On 7/23/26 at 12:44 PM the Administrator and Staff E, RN, confirmed facility expectations require staff members to always utilize two staff members when transferring residents using mechanical lifts and the EZ-stand.

Based on observation, staff interviews, and policy review the facility failed to cover 3 garbage containers with lids. The facility reported a census of 64 residents. Findings include:On 12/29/25 at 1:30 PM observed the kitchen garbage next to the meal preparation table not actively in use, touching the surface of the table. The garbage can had the lid off and rested next to the garbage on the floor. On 12/31/25 at 10:40 AM observed the lid to the kitchen garbage on the floor propped up against the prep table near the storage of the disposable foam dishes. Witnessed the garbage by clean dishes and snack carts with 2 other garbage cans with the lids off by the drink cart. On 12/31/25 at 11:10 AM the Dietary Manager (DM) acknowledged the facility had an issue with the Dietary Staff not keeping the lids on the garbage cans in the kitchen. The DM informed the [NAME] and Dietary Aide of recommendations from the Corporate Dietary Consultant to keep the garbage cans covered and away from the food prep areas. The DM indicated they had a problem and that he should place a sign on the garbage cans. He added he would provide education on the garbage cans. On 12/31/25 at 11:50 AM the Administrator (ADM) reported she expected the staff to cover the garbage cans with lids in the kitchen. In addition, the ADM added she expected the staff to store the garbage cans and lids away from food preparation areas when not in use. The facility's Food Handling policy, revised October 2023, lacked direction related to covering the garbage cans when not in use.

Based on clinical record review, policy review and staff interviews, the facility failed to ensure code status between, the Iowa Physician Orders for Scope of Treatment (IPOST), the Electronic Medical Record (EMR) and the Care Plan were congruent for 1 of 1 resident reviewed for Advanced Directives (Resident #10). The facility reported a census of 64 residents.Findings include: The Care Plan Focus with a target date of [DATE] listed Resident #10's Advanced Directives Status - as a full code (provide life-saving measures if the heart stopped beating). The Intervention directed staff to go to the Electronic Medical Record (EMR) chart to identify their code status. Resident #10's EMR documented on the Profile tab, Orders tab and [DATE] Medication Administration Record (MAR) documented their code status as full code.Resident #10's Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] signed by her and their physician, listed a DNR (no life-saving efforts done to save their life) status in the event her heart stopped beating.During an interview on [DATE] at 2:50 PM Staff A, Licensed Practical Nurse (LPN), reported she looks for a resident's code status in the EMR on the Profile Tab because it is on there and that is where to look. During an interview on [DATE] at 3:04 PM Staff B, Registered Nurse (RN), reported she looked for a resident's code status, in the MAR in the EMR.On [DATE] at 9:10 AM the Minimum Data Set (MDS) Coordinator reported they try to update the Care Plans within a week of changes. She reported any nurse could change the Care Plan to update the code status of a resident.On [DATE] at 9:13 AM the Administrator reported the Social Worker addresses the residents' code status at care conferences. In addition, the staff are to update the code status timely in the chart. The Administrator verified staff are to look for the resident's code status in the EMR in the Profile Tab. The facility policy titled Code Status Identification and CPR revised [DATE] directed the staff, the clinical record will maintain each residents' resuscitation status.

Based on clinical record review, observation, policy review, staff interview, resident interview, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for infection control (Resident #5). The facility reported a census of 64 residents. Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of pressure ulcers to left heel and sacral region, osteomyelitis (bone infection), and diabetes. Resident #5's Electronic Health Record (EHR) listed diagnoses of an unspecified open wound to the left lower leg. The Care Plan Focus with a target date of 2/12/26 indicated Resident #5 needed EBP related to wounds and a urinary catheter. The Interventions directed the staff to use EBP precautions (wear a gown and gloves while performing wound care). On 12/31/25 at 10:20 AM observed Staff C, Licensed Practical Nurse (LPN), gather supplies and go into the Resident #5's room and provide wound care on the left lower leg on the shin. The outside of Resident #5's doorway had an EBP sign and EBP supplies (gowns and gloves in a 3-drawer plastic container). Staff C failed to use EBP while providing Resident #5's wound care, as they didn't wear the required gown. She only wore gloves for the process. During an interview on 12/31/25 at 10:30 AM Staff C reported Resident #5 is on EBP and she forgot to wear a gown during their wound care. On 12/31/25 at 10:32 AM the Director of Nursing (DON) acknowledged Staff C didn't follow EBP as they didn't wear a gown while doing wound care. The facility policy titled Infection Control Manual Surveillance dated September 2023 lacked direction for EBP. The Centers for Disease Control and Prevention (CDC) directed to review document dated June 2021 titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities that 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. In the Quality and Safety Oversight (QSO)-22-08-NH, dated 3/20/24, the Centers for Medicare and Medicaid Services (CMS) indicated in July 2022, the CDC released EBP recommendations and CMS updated its infection prevention and control guidance accordingly. The F880 Infection Prevention and Control would incorporate the new guidance related to EBP to assist long-term care (LTC) surveyors when evaluating the use of enhanced barrier precautions in nursing homes. Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized.

Based on clinical record review, staff interview, and facility change in condition form, at the time of the investigation, the facility failed to assess lung sounds, after a resident had an emesis for which resulted with the resident being admitted to the hospital on [DATE] with septic shock (a life threatening condition that occurs when an infection spreads throughout the body and causes a drop in blood pressure that cannot be corrected with fluids alone) related to aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) for 1 of 3 residents reviewed (Resident #4). The facility identified a census of 62 residents. Findings include:Findings include:The Minimum Data Set (MDS) for Resident #4 with an assessment reference date of 9/8/25, documented diagnoses for which included hypertension, seizure disorder, anxiety, depression and dysphagia (difficulty swallowing and can affect a person ability to safely and easily move food or liquid from the mouth to the stomach). The MDS revealed the resident had short- and long-term memory impairments and moderately impaired for decision making abilities, rarely understands and rarely makes self-understood. The resident required dependent assistance for activity of daily living (ADL) for which included eating assistance. The MDS documented no behaviors.The Plan of Care with a target dated 12/1/25, revealed the resident requires assistance with activity of daily living and potential/actual risk for altered nutritional status, provide diet as ordered, monitor weights, the resident requires one-to-one (1-1) feeding assistance, the resident is dependent on staff for oral care/personal hygiene. The Alert Note dated 10/6/25 at 8:21 PM, revealed Resident #4 was found with emesis (the action or process of vomiting) on her gown, her hair, face, mouth swept (an act to attempt to clear the mouth) to assist her, she continued to cough and have emesis for several minutes, once emesis stopped, vitals were with in normal limits, cleaned her up, she is in recliner resting with eyes closed, even respirations, continue 72 hour follow up report after choking.The Alert Note dated 10/7/25 at 10:18 AM, revealed, overnight nurse reports that resident had no further emesis during the night. This AM, resident did not swallow medications. She also refused to drink her supplement. Resident was not making eye contact with staff. She was not reacting to voice. No coughing noted since resident got up in rock-in-go wheelchair. Lungs have crackles in the bases bilaterally. Respirations are 46 breathes per minute and somewhat labored. Nail beds are cyanotic (a bluish color caused by inadequate oxygen level in the blood). Fingers are cool to touch. The Transfer to Hospital Summary dated 10/7/25 at 10:48 AM, revealed that the reason for transfer is tachypnea (abnormally fast breathing rate)(can be a sign of a serious medical issue like sepsis) not responding, vomited while laying down last night. The Shift Follow up to Incident Note dated 10/7/25 at 12:22 PM, revealed vomiting/choking while laying down, resident transferred to the Emergency Department. Respirations 46 breathes per minute, crackles in the bases of lungs, non-responsive.The Interact Transfer Form dated 10/7/25 at 10:48 AM, revealed reason for transfer: possible aspiration pneumonia.The Progress Notes with date of service 10/13/25 at 7:20 AM, documented, principal problem of septic shock. Resident #4 was admitted to Critical Care Unit (CCU) on 10/7/25 for Septic Shock. Per nursing staff the patient was found with vomit in her mouth and was not at her baseline. They also report that she was hypotensive (condition where the blood pressure is significantly lower than normal). Transition to comfort care. Sepsis secondary to pneumonia.Interview on 10/8/25 at 2:00 PM, Staff A, License Practical Nurse (LPN), acknowledged that the expectation of the nurses are to start a change in condition form in the computer software program for the resident that shows symptoms that are abnormal from their baseline and that form will generate for the next shift to document on that resident.Interview on 10/14/25 at 3:24 PM, Staff B, Registered Nurse (RN), verified that the clinical record lacked documentation of the change in condition form that needed to be completed on Resident #4. The change in condition form will generate follow up documentation of the condition that is charted. The staff are expected to follow the change of condition form.Interview on 10/14/25 at 3:50 PM, Staff C, LPN, verified that the clinical record that documentation of the resident lung sounds after the emesis and acknowledged that the expectation of the nurses is to generate a change in condition form in the computer software.The Change in Condition Form with no date, stated that a change in condition for an assessment of abdominal/gastrointestinal with nausea and/or vomiting needs to be charted on and followed up per guidelines.Emesis in elderly or medically complex residents is a common occurrence and can be triggered by a variety of factors, including medication side effects, acute illness, or even minor GI upset. When emesis occurs, nursing staff must prioritize immediate safety concerns such as airway protection, monitoring for further vomiting, and ensuring the resident is stable. In the absence of overt signs of GI distress or abdominal pain, the initial nursing response may focus on supportive care and observation rather than a full GI assessment.Nursing staff are trained to use clinical judgment to determine when further assessment is warranted. If the emesis episode was isolated, with no associated abdominal pain, distension, or changes in bowel habits, the staff may have deemed it appropriate to monitor the resident for evolving symptoms rather than perform a comprehensive GI assessment at that moment. This approach helps prevent unnecessary interventions and distress for the resident, especially if their overall condition appeared stable following the episode. It is not uncommon for aspiration pneumonia to develop several hours after an aspiration event. At the time of the initial emesis, the resident may not have displayed clinical signs of pneumonia, such as fever, productive cough, or respiratory distress. The development of these symptoms may have occurred later, prompting the decision to send the resident to the hospital for further evaluation and management. Thus, the absence of a GI assessment at the time of emesis does not necessarily represent a lapse in care but rather reflects the evolving nature of the clinical picture.

Based on observation, interviews and record review, the facility failed to ensure the chlorine in their dishwasher was at the correct level for sanitizing dishes. The facility reported a censure of 60 residents. Findings include: On 11/4/24 at 10:20 AM, the dishwasher was tested with a strip. The strip read between 25 Points Per Million (ppm) and 50 ppm. The kitchen staff stated they were going to look into this more. On 11/5/24 at 1:40 PM, the Housekeeping/Laundry Supervisor tested a new dishwasher strip. She stated it was between 50 ppm and 100 ppm. When the surveyor pointed out that the strip read between 25 ppm and 50 ppm, the supervisor concurred that it read between 25 ppm and 50 ppm. On 11/5/24 at 1:45 PM, the facility's Dietitian stated they have a new dishwasher which was probably placed in the last 2-3 weeks. The Dietitian stated that all of the corporation's facilities changed over to new dishwashers. The Dietitian stated she would need to check with their corporation to see what they are doing to ensure the dishes are getting sanitized. On 11/5/24 at 2:49 PM, the Housekeeping/Laundry Supervisor ran the dishwasher again. Observed steam to be coming out of the dishwasher. The temperature gauge revealed a temperature of 134 degrees Fahrenheit (F). She then tested a new strip and it still read between 25 ppm to 50 ppm. She acknowledged that the strip was showing that the chlorine level was not high enough. The Supervisor was using a different strip on this day that was made by the same manufacturer of the dishwasher. On 11/5/24 at 2:53 PM, the Sales Technician for the dishwasher and it's chemicals, stated that the dishwasher is a low temperature dish machine. The Technician stated that the temperature for the dishwasher should be between 120 degrees Fahrenheit (F) and 150 degrees F. He stated that the temperature of the dishwasher should go no higher than 150 degrees F because it would burn the sanitizer. The Sales Technician stated he did not install the dishwasher at this facility. He stated that maybe the guys that did install the dishwasher ran it a few times and then left. He stated maybe the water is getting too hot and if so, it could burn off the sanitizer, he stated this was just speculation. He stated that there was a sticker right on the top panel of the dishwasher with what parts per million the chemical strips should read. He stated the parts per million (ppm) should be at least 50. The Sales Technician stated they could turn the dishwasher up to be sure it reaches at least 50 ppm. He stated someone would come to the facility in 2 days to adjust the dishwasher. When told the facility stated they were using the wrong chemical strip, this technician said that wouldn't matter, either strip could be used. The Sales Technician called back and stated that they would send a technician out to the facility on this night. The sticker on top of the dishwasher reads required 50 ppm available chlorine rinse. On 11/06/24 at 10:46 AM, the corporate dietitian stated that the kitchen staff were using the wrong strips and now they have the right strips. This Dietitian tested the dishwasher and the strip read between 50 ppm and 100 ppm. When told the technician stated that it didn't make a difference what strip was used, this dietitian acknowledged this. The dietitian acknowledged that the strips ran yesterday were the strips that should be used. A Service Manual dated 5/2008; for the facility dishwasher directed: Sanitizer should be 6% solution of sodium hypochlorite. The initial setting is 5cc (cubic centimeters) and this should be checked regularly with a Chlorine Test Kit. Free chlorine in the final rinse should be 50 ppm or more. However, high concentrations can cause deterioration of metal.

Based on clinical record review, policy review and staff interviews, the facility failed to ensure code status between, the Iowa Physician Orders for Scope of Treatment (IPOST), the electronic health record (EHR) and the Care Plan were congruent for 1 of 1 residents reviewed for advanced directives (Resident #3). The facility reported a census of 60 residents. Findings include The Care Plan for Resident #3 with a revised date of [DATE] had a focus area for Advanced Directives with a goal for the Advanced Directives to be Full Code. The Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] for Resident #3 indicated the resident desired to be Do Not resuscitate (DNR) status in the event his heart stopped beating and was signed by the resident and physician. A review of the Resident #3's Electronic Health Record (EHR) profile tab and Orders tab documented code status as Full Code (cardiopulmonary resuscitation (CPR) status). During an interview on [DATE] at 10:41 AM Staff A, Registered Nurse (RN) reported she finds code status on the main part of the profile in the EHR. During an interview on [DATE] at 10:45 AM Staff B, Licensed Practical Nurse (LPN) reports he finds code status on the main part of the profile in the EHR under code status. In an interview on [DATE] at 11:47 AM Staff C, LPN/Care Plan Nurse reported staff should look at the IPOST book for code status. She reported Resident #3's status should have been changed in the EHR to match the IPOST. The facility policy titled Resuscitation for SNF and ICF Setting with a revised date of ,d+[DATE] directs staff the code status election from the IPOST shall match the code status designation in the PointClickCare (EHR) Orders tab of the medical record.

Based on clinical record review and staff interview the facility failed to notify the state ombudsman for 1 of 2 residents (Residents #9) reviewed. The facility reported a census of 60 residents. Findings include: Resident #9 Emergency Care (ED) Physician Notes 4/17/24 document the resident arrived at the ED by ambulance at 4:31 PM and was admitted to the hospital after evaluation in the ED. The Progress Note written on 4/22/24 at 3:41 PM for Resident #9 documented the resident readmitted from the hospital. Review of the facility's Ombudsman report for April 2024 lacked documentation of Resident #9 transferring to the hospital on 4/17/24. On 11/06/24 at 09:46 AM the Administrator confirmed Resident #9 should have been on the Ombudsman report.

Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessments for 2 of 15 residents reviewed (Resident #50 and #62). The facility reported a census of 60 residents. Findings include: 1. The MDS for Resident #50 dated 10/06/24 documented a Brief Interview for Mental State (BIMS) score of 8 indicating moderate cognitive impairment. The MDS further documented the resident had a 5 percent or more weight loss in the past month or 10 percent or more in the last six months. Review of Resident #50's weights revealed the weight on 9/29/24 of 137 pounds and weight on 10/08/24 of 169.2 pounds was struck out documenting it was incorrect documentation. Review of the other weights lack documentation of a weight loss. During an interview on 11/05/24 at 1:45 PM the Dietician reported she most likely recorded it on the MDS due to the weights at the time but documented in the notes that she was unsure of weight loss at the time due to possible inaccurate weights. If the weight was inaccurate the MDS should have been modified. She reported after speaking with the nursing staff Resident #50's weights were inaccurate and that is why they were crossed out and she should have modified the MDS. During an interview 11/05/24 at 2:45 PM the Administrator reported the facility had moved the weight stand and so they had issues with weights during that time and staff should have reweighed the resident. 2. The MDS for Resident #62 dated 8/31/24 documented a BIMS score of 14 indicating intact cognition. The MDS further documented the resident discharged to a short-term general hospital. The Progress Note for Resident #62 dated 8/31/24 at 12:45 PM documented the resident being discharged to home with family. During an interview on 11/05/24 at 2:48 PM Staff D, MDS coordinator reported the MDS was coded incorrectly. It should have been coded Resident #62 discharged to home. Record review of the current RAI Manual dated 10/2023 on page 1-4 instructed the assessment accurately reflects the resident's status.

Based on observation, record review, family and staff interview the facility failed to assess and follow up on a significant weight loss for 1 of 2 residents (Resident #21) reviewed. The facility reported a census of 60 residents. Findings include: Resident #21 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severe cognitive impairment. The MDS documented Resident #21 as needing 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.) with eating. The MDS further documented diagnoses anemia, atrial fibrillation, coronary artery disease, diabetes mellitus and non-Alzheimer's dementia. The Nutrition assessment dated [DATE] revealed Resident #21 received a general diet with cut meat and regular portion sizes. It documented the resident receives supervision at meals in the north dining room and is able to feed himself. A nutrition goal to avoid significant weight changes with diet and interventions in place. The Care Plan initiated on 9/29/2023 identified a focus area for nutritional risk due to diabetes mellitus, fragile skin, dementia and heart disease. The goal in place is to not have a significant weight change in the next 90 days. The Resident Assessment Instrument (RAI) manual states weight loss can result in debility and adversely affect health, safety and quality of life. Weight loss is defined as a 5% or greater weight loss within 30 days. Resident #21 weight records revealed a 12 pound or 6.03% weight loss in a 30-day time frame. The record documented a weight of 199.0 pounds on 10/6/2024 at 10:24 AM for Resident #21. On 11/3/2024 at 1:54 PM the record documented a weight of 187.0 for resident #21. During an interview on 11/5/2024 at 2:12 PM Staff E, Certified Nursing Assistant (CNA) reported Resident #21 eats independently and he does not eat much. Staff E, did not recall how often Resident #21 is weighed. In an interview on 11/6/2024 at 10:36 AM Staff F, CNA reported Resident #21 is able to feed himself and is weighed weekly. Staff F acknowledged if there is a 5 pound difference from the previous weight to the current weight the nurse will instruct the resident to be reweighed. On 11/6/2024 at 12:15 PM Resident #21 was observed in the dining room. The facility provided Resident #21 with a cup of coffee, one 8-ounce glass of orange juice, two 8-ounce glasses of milk, a hot beef sandwich with mashed potatoes with gravy, and peaches. Observed Resident #21's spouse sitting at the table beside him. Following the meal, Resident #21 spouse verbalized Resident #21 consumed his milk and orange juice, and ate only his peaches and meat. Resident #21's spouse stated he has not had a tremendous appetite lately and she had not been notified of any fluctuation in his weight this week. On 11/06/2024 at 12:43 PM, Staff A, Registered Nurse (RN) verbalized residents are weighed weekly on Saturdays unless ordered differently by the physician. She reported the nurse reviews the weights for discrepancies and if more then 3 pounds, the resident is reweighed. Staff A, RN verbalized that the physician and family are to be notified when significant weight loss/gain occur. Staff A, RN reported she was unaware of any significant weight loss for Resident #21. On 11/06/2024 at 1:46 PM Staff A, RN recorded a weight of 203.5 pounds for Resident #21. This is an increase of 16.5 pounds or 8.82% in weight gain from the most recent recorded weight. The Electronic Health Record lacked any further documentation. During an interview on 11/6/2024 at 2:28 PM Staff C, Care Plan Nurse/Licensed Practical Nurse (LPN) revealed the Care Coordinators, MDS Coordinator and the consultant dietitian review the 24-hour reports on Monday for significant weight changes. Staff C, LPN verbalized she is unaware of the significant weight loss recorded for Resident #21. A review of the Food/Fluid Intake record for Resident #21 for the past 30 days revealed the following: 10/9/2024 1:03 PM lunch meal - 25% of meal consumed 10/12/2024 evening meal - no record of meal consumed or refused 10/14/2024 6:26 PM evening meal - 10% of meal consumed 10/15/2024 12:50 PM lunch meal - 50% of meal consumed 10/16/2024 12:48 PM lunch meal - 25% of meal consumed 10/19/2024 evening meal - no record of meal consumed or refused 10/20/2024 13:52 PM lunch meal - 0% of meal consumed 10/22/2024 13:47 PM lunch meal - 0% of meal consumed 10/22/2024 7:00 PM evening meal - 0-25% of meal consumed 10/26/2024 1:54 PM lunch meal - 26%-50% of meal consumed 10/26/2024 evening meal - no record of meal consumed or refused 10/27/2024 evening meal - no record of meal consumed or refused 10/30/2024 12:35 PM lunch meal - 0-25% of meal consumed 10/30/2024 evening meal no record of meal consumed or refused 10/31/2024 9:10 breakfast meal - 0-25% of meal consumed 10/31/2024 12:53 PM lunch meal - 26%-50% of meal consumed 11/2/2024 1:00 PM lunch meal - 26%-50% of meal consumed 11/4/2024 12:48 PM lunch meal - 0%-25% of meal consumed 11/5/2024 12:15 PM lunch meal -26%-50% of meal consumed 11/5/2024 evening meal - no record of meal consumed or refused The facility Weight Monitoring Policy undated revealed weights will be communicated to the physician and family immediately as significant changes occur. The policy designates the Director of Nursing (DON) or designee in the facility will determine significant weekly and monthly weight changes (5% or greater in 30 days and 10% or greater in 180 days) and communicate this information to pertinent staff. Residents weighed weekly will need to have their 30-day and 180-day weights calculated weekly. For example, week 1 will be compared to week 1 of the subsequent month and that same week 6 months ago. The medical records computer program or spreadsheet may be used to calculate this if completed in a timely manner. Weekly weights are to be reviewed by the DON or designee and Consultant Registered Dietitian to identify weight change trends that need to be acted upon quickly. Residents weighed monthly will be weighed at approximately the same week of each month to ensure weights can be compared with previous 30 day and 180 day periods. A significant unintentional weight change is one of two factors that can trigger the need to complete a full MDS and update the care plan. Weight changes attributed to flu or changes in a diuretic be will be documented to indicate cause and whether this is an acute or chronic problem. The physician and family are both to be notified immediately of any significant unintentional weight changes, whether expected or not. Documentation of this notification must be present in the medical record within 24 hours of documenting the weight change and be kept in the medical record. Notification should include a brief assessment of the resident ' s condition and factors that may be contributing to the weight change, as well as proposed or implemented interventions for MD review. A review of the Nurse Progress Notes revealed the facility lacked assessment of Resident #21 for the significant weight change and failed to notify the physician and failed to notify the family.

Based on observations, staff interviews and the Assure Prism Manual, the facility failed to perform proper hand hygiene, appropriately sanitize the blood sugar meter and use barrier when doing blood sugar checks and insulin for 2 of 2 residents reviewed (Resident #21 and #53). The facility reported a census of 60. Findings include: 1. The Minimum Data Set (MDS) for Resident #21 dated 9/06/24 documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS documented Resident #21 has a diagnosis of diabetes and received insulin injections. During an observation on 11/05/24 at 7:52AM, Staff B, Licensed Practical Nurse (LPN) reported he was checking Resident #21's blood sugar. Staff B had already gathered the Assure Prism blood sugar meter (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip) and supplies in a basket and went into his room. Staff B set supplies down on the bed, applied gloves, and cleansed Resident #21's finger with alcohol and poked the finger with the lancet. Staff B picked up the meter and got the blood on the test strip. The resident's blood sugar was 252. Staff B then took out the test strip and placed the blood sugar meter in the basket. After Staff B performed the blood sugar check, then returned to the medication cart. Staff B then placed the blood sugar meter in the basket back in the cart without cleaning the meter or the outside of the plastic basket. Staff B then looked up what amount of Novolog to give to the resident. Staff B then gathered the Novolog pen and alcohol, wiped the tip and applied a needle cap. Staff B then measured up 26 units of Novolog and went into the residents room. He then cleansed the right lower quadrant on Resident #21's abdomen and gave the Novolog injection without applying gloves. Staff B left the room, took the secure needle cap off and put it in the sharps container. Staff B went on the computer and signed out the medications. He then started to gather for the next resident he was going to pass medication for without doing any post hand hygiene from working with Resident #21. During an interview on 11/06/24 at 11:18 AM, Staff A, Registered Nurse (RN) reported staff are to clean the blood sugar machines between each resident. She reported the staff use Sani-cloth (it is a brand of germicidal wipes). During an interview on 11/06/24 11:25 AM Staff B, LPN reported Sani-cloth wipes are to be used to clean the blood sugar meter between residents. He reported he also should wear gloves when giving insulin. He further reported hand hygiene should be done between residents, with glove changes and if his hands get soiled. In an interview on 11/07/24 at 7:25 AM the Director of Nursing reported staff are to use Sani-cloths to clean the blood sugar meter between residents and a barrier should be under supplies. Staff are to wear gloves when giving insulin and should be doing proper hand hygiene before, with gloves changes and after working with residents for care. 2. The MDS for Resident #53 dated 7/29/24 documented she has severely impaired cognitive skills and memory problems. The MDS documented Resident #53 has a diagnosis of diabetes and received insulin injections. During an observation on 11/05/24 at 7:52AM, Staff B, Licensed Practical Nurse (LPN) reported he was checking Resident #21's blood sugar. Staff B had already gathered the blood sugar meter and supplies in a basket and went into his room. Staff B set supplies down on the bed, applied gloves, and cleansed Resident #21's finger with alcohol and poked the finger with the lancet. Staff B picked up the meter and got the blood on the test strip. The resident's blood sugar was 252. Staff B then took out the test strip and placed the blood sugar meter in the basket. Staff B returned to the medication cart, and placed the blood sugar meter in the basket back in the cart without cleaning the meter or the outside of the plastic basket. Staff B then looked up what amount of Novolog to give to the resident. Staff B then gathered the Novolog pen and alcohol, wiped the tip and applied a needle cap. Staff B then measured up 26 units of Novolog and went into the residents room. He cleansed the right lower quadrant on Resident #21's abdomen and gave Novolog injection without applying gloves. Staff B left the room and took the secure needle cap off and put it in the sharps container. Staff B then went on the computer and signed out the medications. He then started to gather for the next resident he was going to pass medication for without doing any post hand hygiene from working with Resident #21. On 11/05/24 at 8:05 AM observed Staff B, LPN gather supplies and get the medications ready for Resident #53. Staff B reported he was going to check Resident #53's blood sugar and she will get 18 units of Lantus which he also gathered the supplies with the medications. Staff B set the glucometer in the basket with the insulin down on the nightstand with no barrier under the basket. Staff B gave Resident #53's the medications crushed in applesauce and went to the sink in the room to wash his hands. Staff B put soap on his hands and washed for 20 seconds and rinsed the soap off. Staff B then with his right hand shut the sink off with his clean hand. Staff B noticed no paper towels in the room so he grabbed a wash cloth hanging on the towel rack by the sink and dried his hands with the wash cloth then hung the wash cloth back up. Staff B then applied gloves and checked the blood sugar on Resident #53. The blood sugar was 225. Staff B then gave Lantus (long acting insulin) after alcohol swabbing the area. Staff B removed his gloves and went out of the room taking the Lantus pen and basket with the blood sugar meter. Staff B put the basket with the meter in the cart without sanitizing either. Staff B removed the secured needle cap and put it in the sharps container and placed the lid on the insulin pen and put it back in the plastic bag with the pharmacy label in the med cart. Staff B gathered Novolog sliding scale 4 units for the resident after comparing it with the Medication Administration Record. Staff B then went back into the room and applied gloves and used an alcohol wipe to cleanse the area. Staff B gave the Novolog and then removed his gloves and left the room. Staff B then threw the gloves in the garbage, took the secure needle cap off the insulin and put it in the sharps container. Staff B recapped the Novolog and placed it back in a plastic pharmacy labeled bag and put it in the medication cart. Staff B then signed off on the medications on the computers without completing hand hygiene. Staff B then proceeded with the med cart down the hallway to the next room. The undated Assure Prism Glucose Manufacturer's Quality Assurance/ Quality Control Reference Manual for use documented the following: Before performing a blood glucose test, observe the following safety precautions: All components that come into contact with blood samples should be considered to be biohazards capable of transmitting viral diseases between patients and healthcare professionals. Before testing each patient, a new pair of clean gloves should be worn by the user. Wash hands thoroughly with soap and water before putting on a new pair of gloves and performing the next patient test. Use only an auto-disabling, single-use lancing device for each patient. After use on each patient, the meter should be cleaned and disinfected. CLEANING AND DISINFECTING THE METER: To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The Assure Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. Cleaning and Disinfection The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. Cleaning : Step 1: Wear appropriate protective gear such as disposable gloves. Step 2: Open the towelette container and pull out 1 towelette and close the lid. Step 3: Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other body fluids. Step 4: Dispose of the used towelette in a trash bin. Disinfecting (The meter should be cleaned prior to disinfection.): Step 5: Open the towelette container and pull out 1 towelette and close the lid. Step 6: Wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens. Step 7: Dispose of the used towelette in a trash bin. Step 8: Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth. Step 9: After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV- a serious liver infection) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. The CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: a. Fingerstick devices should never be used for more than one person b. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include: a. Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. Blood glucose meters are devices that measure blood glucose levels. a. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. b. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

Based on clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed for a Level 2 PASRR evaluation, (Residents #5). The facility reported a census of 58 residents. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] documented Resident #5 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further documented the resident had diagnoses including bipolar disorder and obsessive-compulsive disorder and the residents behavior compared to his last assessment had worsened. Review of the Medication Administration Record (MAR) dated September 2023 for Resident #5 revealed the resident received Lamotrigine (antiseizure) 125 milligrams (MG) two times daily related to bipolar disorder and Fluvoxamine Maleate (antidepressant) 50 MG at bedtime for mood disorder and obsessive-compulsive disorder. The Care Plan for Resident #5 revised 9/13/2018 revealed Resident #5 had mental illnesses including bipolar disorder and directed staff to always approach the resident with positive, kind and patient mannerisms and the resident responded best to that approach. Clinical record review in the Electronic Health Record (EHR) revealed Resident #5 had a Level 2 PASRR completed 3/18/2014 and documented diagnoses including schizoaffective disorder, pervasive developmental disorder, psychotic disorders and mild intellectual disability. Review of Resident #5's diagnoses in the EHR documented the resident had diagnoses of bipolar disorder dated 4/3/15 and obsessive-compulsive disorder dated 12/13/18. 44972 In an interview on 9/26/23 at 3:28 PM, the Social Worker stated a new PASSR evaluation should be submitted with each new mental health diagnosis. She further stated she was to submit the evaluation after being notified by nursing staff or reading the physician progress notes. On 9/26/23 at 3:57 PM via email the Administrator stated if notified of a new diagnosis during a resident's stay, the facility would complete a new PASSR if the diagnosis required it to be done. The Social Worker was to review the progress notes and complete updates from that information. The facility lacked a policy related to Level 2 PASSR evaluation submissions with new mental health diagnosis.

Based on clinical record review, resident and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 2 residents reviewed (Resident #21). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documented the resident had diagnoses of muscle weakness, difficulty in walking, pain, hypertension, and muscle spasms. The Care Plan for Resident #21 with a focus area of risk for falls documented Resident #21 had a history of falls and transferred with assistance of one with a front wheeled walker to ambulate to/from the bathroom. The Care Plan further documented the resident had a focus area for Activities of Daily Living (ADL) and directed one staff to assist the resident with toileting and peri care as needed. During an interview on 9/25/23 at 10:45 AM, Resident #21 reported she had to have assistance to the restroom due frequent falls. The resident further revealed she had come from assisted living to the facility due to falling frequently. Review of Resident #21's Electronic Health Record (EHR) revealed an Incident Report (IR) dated 8/24/23 at 4:10 PM documented the resident was found on the floor in the bathroom doorway due to self-transferring. It further documented the Certified Nursing Assistant (CNA) reported 5 minutes prior to the fall the resident was seen and the CNA assisted the resident to the bathroom and gave the resident the call string to pull. The IR documented the resident reported that she didn't want to wait for staff to assist her. Further review of the EHR revealed Resident #21 fell on [DATE] and 7/14/23 not using her call-light for staff to assist her. Incident on 6/3/23 the resident fell when getting up from the toilet to come out of the bathroom. During an interview on 9/26/23 at 12:17 PM, the Director of Nursing (DON) and Administrator reported they expect staff to follow resident's plan of care on the Care Plan. The Administrator further revealed the facility had documentation of education to the CNA in regards to leaving Resident #21 unsupervised in the bathroom. On 9/26/23 at 12:45 PM, the Administrator and Staff B, Licensed Practical Nurse (LPN)/ Unit Manager reported the facility did not have documentation of education in regards to leaving Resident #21 unsupervised in the bathroom. Staff B, LPN/Unit Manager verbalized she verbally educated the CNA but did not have documentation of completing the education. During an interview on 9/26/23 at 1:30 PM, Staff C, Occupational Therapist (OT) reported she assisted Resident #21 when she admitted to the facility with toileting. Staff C further reported that due to the resident's impulsiveness and poor safety awareness the resident needed to have assistance of one staff with toileting at all times. During an interview on 9/26/23 at 1:46 PM, Staff D, CNA reported if a resident was assistance of one staff then the resident cannot be left unattended in the restroom.

Based on clinical record review and resident and staff interview the facility failed to develop a person-centered care plan that addressed the resident's comprehensive medical needs for 2 of 16 residents reviewed, (Resident #29 and #58). The facility reported a census of 59. Findings included: 1.The Medicare Part A stay Minimum Data Set, dated dated dated [DATE] for Resident #29 reported a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition for daily decision making and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS document she received [CONDITION(S)] as a resident. Resident #29's Care Plan dated 4/21/22 and reviewed on 6/1/22 at 1:00PM lacked a focus area related to [CONDITION(S)] and lacked interventions to provide care to a resident that received [CONDITION(S)]. Resident #29's Care Plan updated and reviewed on 6/1/22 at 1:45PM, update with date of 5/31/22 included a focus area she received hemodialysis treatments related to renal failure. The updated Care Plan included interventions she received [CONDITION(S)] on Monday, Wednesday and Fridays at an outside facility and she had port in her right upper chest that is used for [CONDITION(S)] and mapping to be completed for a fistula. The Care Plan directed staff to do the following; Monitor labs and report to doctor. Monitor her for dry skin and apply lotion as needed. Monitor for effects and side effects related to [CONDITION(S)] treatment. Monitor and document sign and symptoms of depression and obtain and order mental health consult if needed. Monitor and document any signs and symptoms of infection to access cite (redness, swelling, warmth or drainage). Monitor, document and report signs and symptoms of [CONDITION(S)] (changes in consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds). Monitor, document and report signs and symptoms of bleeding, hemorrhage, bacteremia, septic shock. Monitor, document and report new or worsening peripheral [CONDITION(S)]. The document titled Clinical Summary dated 4/1/22 included the following information: First [CONDITION(S)] appointment 4/4/22 at 12:10 PM. [CONDITION(S)] port right chest inserted 3/29/22. During an interview on 6/1/22 at 3:09 PM the Director of Nursing (DON) stated she expected the Care Plan to have been updated or things added within 24 hours of a change. During an interview on 6/2/22 at 8:02 AM the DON stated she talked to the Administrator and she wanted to let me know they had until the next review to update the Care Plan. The Administrator joined the conversation and stated they were talking about the [CONDITION(S)] policy and they go by the pathway and they do have the dash board they follow for appointments. 2. The Minimum Data Set (MDS) dated [DATE], for Resident #58, revealed a BIMS score of 3, indicating severe cognitive impairment. The MDS documented extensive assistance of 1 person physical assistance required in toileting, and limited assistance required with walking and personal hygiene. Mobility aides of a walker or wheelchair utilized. The resident was assessed as frequently incontinent of bowel and bladder. The MDS identified the resident utilized a diuretic medication (increases production of urine and rids body of fluids). The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diuretics can produce side effects including electrolyte and metabolic abnormalities, [CONDITION(S)], and worsening kidney function. A review of the clinical record revealed Daily Skilled Assessments dated 5/16/22 through 5/30/22 consecutively, with daily documentation of a swollen right lower extremity, with 4 to 3+ pitting [CONDITION(S)] (5-6 cm depression, with a rebound of 10-30 seconds) and indentation remaining for a long time. On 6/2/22 at 9:22 AM, in an interview and joint review of the Care Plan, dated 5/14/22, with Staff A, revealed the lack of a focus, goal or interventions for the resident's use of a diuretic medication and lower extremity [CONDITION(S)]. Staff A stated the use of a diuretic medication and the resident's [CONDITION(S)] should be included in the resident's Care Plan.

Based on record reviews, observation and staff interview, the facility failed to provide respiratory care and services that is in accordance with professional standards of practice, as reflected in the absence documentation for oxygen tubing change, for 1 of 1 residents reviewed for oxygen tubing changes (Resident #5). The facility reported a census of 59 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], for Resident #5, documented primary medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident was receiving oxygen as a special treatment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 5/11/22, identified a focus of respiratory illness, with a goal of not showing poor oxygen absorption, and directed staff to maintain humidified oxygen administration continuous, per nasal prongs. On 6/1/22 at 3:13 PM, in a joint inspection, with Staff A, of the resident's oxygen equipment, revealed the absence of any date on the oxygen tubing or humidification, attached to the room and portable oxygen concentrators, (filter and concentrate room air). Staff A confirmed the resident's Treatment Administration Record (TAR), lacked any orders and documentation of tubing changes. On 6/1/22 at 3:30 PM, in an interview with the DON and Administrator, stated the facility practice is to change oxygen tubing every week on Sunday evenings and mark the tubing with tape, initials and date changed. The DON stated she expected the tubing changes to occur and be documented on the resident's TAR. The Administrator stated the facility had no policy directing oxygen tubing changes and expected best practice to be followed.

Based on clinical record review, facility guidance, resident and staff interviews the facility failed to complete the required assessments to communicate the information of the residents status to the [CONDITION(S)] facility prior and post [CONDITION(S)] for 1of 1 residents (Resident # 29). The facility reported a census of 59. Findings included: The Medicare Part A stay Minimum Data Set, dated dated dated [DATE] for Resident #29 reported a Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition for daily decision making and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS document she received [CONDITION(S)] as a resident. Resident #29's Care Plan dated 4/21/22 and reviewed on 6/1/22 at 1:00PM lacked a focus area related to [CONDITION(S)] and lacked interventions to provide care to a resident that received [CONDITION(S)]. Resident #29's Care Plan updated and reviewed 6/1/22 at 1:45PM, updated with date of 5/31/22 included a focus area she received hemodialysis treatments related to renal failure. The updated Care Plan included interventions she received [CONDITION(S)] on Monday, Wednesday and Fridays at an outside facility and she had port in her right upper chest that is used for [CONDITION(S)] and mapping to be completed for a fistula. The Care Plan directed staff to do the following; Monitor labs and report to doctor. Monitor her for dry skin and apply lotion as needed. Monitor for effects and side effects related to [CONDITION(S)] treatment. Monitor and document sign and symptoms of depression and obtain and order mental health consult if needed. Monitor and document any signs and symptoms of infection to access cite (redness, swelling, warmth or drainage). Monitor, document and report signs and symptoms of [CONDITION(S)] (changes in consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds). Monitor, document and report signs and symptoms of bleeding, hemorrhage, bacteremia, septic shock. Monitor, document and report new or worsening peripheral [CONDITION(S)]. The document titled Clinical Summary dated 4/1/22 included the following information: First [CONDITION(S)] appointment 4/4/22 at 12:10 PM. [CONDITION(S)] port right chest inserted 3/29/22. The facility document Clinical Assessment printed 6/1/22 at 12:57 PM lacked 2 assessments done prior and/or post [CONDITION(S)] for the following dates: 4/4/22, 4/15/22, 4/20/22, 4/25/22, 4/27/22 and 5/13/22. The Facility used the [CONDITION(S)] Critical Element Pathway dated 5/2017 for their [CONDITION(S)] policy and procedure that included the following: For a resident receiving [CONDITION(S)] at a certified [CONDITION(S)] facility, did the nursing home: Assess and document vital signs, including the blood pressure in the arm where the access site is not located, weights if ordered and communicate the information including the resident's status with the [CONDITION(S)] facility prior to and post [CONDITION(S)]; Provide assistance and safe transportation to and from [CONDITION(S)]; Administer meds or meals before or after [CONDITION(S)] as ordered; Provide direct visual monitoring of the access site before and after [CONDITION(S)]; and Provide ongoing monitoring and care of the resident's vascular access (fistula, graft, or central venous catheter) for HD, catheter for PD as ordered, and provide ongoing monitoring for [CONDITION(S)] related complications (e.g., bleeding, access site infection, or [CONDITION(S)]). During an interview on 6/1/22 at 2:55 PM with the Administrator she provided the [CONDITION(S)] pathway and stated they do not have a policy or procedure they follow the pathway. During an interview on 6/1/22 at 3:09 PM the Director of Nursing (DON) stated she expected the Care Plan to have been updated or things added within 24 hours of a change. During an interview on 6/2/22 at 7:55 AM with Staff B License Practical Nurse (LPN) when asked about [CONDITION(S)] process she explained the facility had a print out at the desk that shows the appointments for the day. When asked how you know what to do with a [CONDITION(S)] appointment, she stated she had worked for the company for years and new what assessments needed to be done prior and post [CONDITION(S)], we get weights and vital signs. During an interview on 6/2/22 at 8:02 AM the DON stated she talked to the Administrator and she wanted to let me know they had until the next review to update the Care Plan. The Administrator joined the conversation and stated they were talking about the [CONDITION(S)] policy and they go by the pathway and they do have the dash board they follow for appointments. During an interview on 6/2/22 at 10:27 AM the DON brought in items the Administrator asked her to, they included the following: Skilled assessments done 4/4/22. The Emergency Diet for People on [CONDITION(S)] dated 2019. Skilled assessment 4/15/22.

Based on observation/photographs, record review, interviews, and video camera footage, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of four (4) residents reviewed. On 4/26/15, Resident #1 exited the facility without staff knowing the resident's whereabouts and walked 0.8 tenths of a mile in the street. A community member then drove Resident #1 to his/her prior home location & then called the nursing home to alert staff of Resident #1's location. When Resident #1 exited the nursing home, the resident's Wanderguard device activated the door alarm which sounded to alert staff. Staff turned off the alarm without looking outside and another staff approached the area. The video camera showed neither Staff A or Staff D exited the door/s or exited outside to check for anyone. Staff interviews revealed they did not look outside as they assumed the alarm had been for another resident (Resident #2) who just returned with their family member. Neither staff checked whether or not Resident #2 used a Wanderguard alarm device when the Wanderguard alarm had been turned off. Record review identified Resident #1 at risk for elopement and used a Wanderguard at all times for his/her safety. The findings constitute an immediate jeopardy to resident's health and safety. The facility identified a census of 63 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 4/1/15, Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, with no delirium. The MDS identified the resident did not have any behaviors or episodes of wandering. The resident did not require staff support with ambulation in his/her room and corridor as well as locomotion on and off the unit. The assessment revealed the resident ' s balance as unsteady but able to stabilize self without staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet and any surface-to-surface transfer. According to a Care Plan with goals target dated at 4/19/15, the resident required assistance with his/her activities of daily living (ADL'S) related to his/her dementia. The approaches included the following: a. Wanderguard at all times. Check every shift. b. Resident #1 is up independently throughout facility without assistive devices. c. Staff will assist the resident with remembering things correctly. d. Staff will help the resident by re-orientating him/her to reality. Sometimes the resident just needed a few hints to remember something accurately. According to an Elopement Risk Assessment and Interventions form dated 3/26/15, the resident had been at risk for elopement. According to treatment record form dated 4/1/15 through 4/30/15, staff had been directed to check the resident's Wanderguard device every shift, three times a day (TID) related to pre-senile dementia with depressive features (start date of 4/21/14 at 2 p.m.). Review of the facilities Residents at Risk to Elope, 3-ring binders maintained at the North and South nurse stations, identified Residents #1, #3 and #4 had been identified as residents that used Wanderguard alarm devices and at risk for elopement. Each of these residents had pictures to identify who they were and a list identified they had a Wanderguard device placed on their ankles. Review of the facilities camera video footage dated 4/26/15 at approximately 5:10 p.m., showed Resident #1 standing in the hallway, approaching the exit door slowly. At approximately 5:12 p.m., Resident#2 and a family member entered the door, with Resident #1 standing nearby the door. Within a few seconds Resident #1 promptly exited out of the same door. Staff A went to the door within 10-12 seconds & the video showed Resident #2 and his/her family member still located at the door. The video showed Staff D also approached the area (where the alarm had sounded) & stood further back from the door, then turned around and left the area. (Staff A responded to the Wanderguard device alarm sounding and silenced the alarm.) Staff A remains at the door for a few seconds then walked behind Resident #2 and his/her family member as they move further from the exit doors. In the video neither staff appeared to check whether or not Resident #2 used a Wanderguard alarm device (Resident #2 is not listed on the facility list for wearing a Wanderguard device). In the video, neither Staff A nor Staff D exited the door or walk past the first door to the second exit door, or exited outside to check for anyone. (The video camera footage exact times were identified by facility staff as not accurate.) According to an Oakwood Care Center Nurse Call Log form dated 4/26/15 at 4:40 p.m., the East parking lot Wanderguard alarm box had been gone off and sounded for 0:34 seconds. An observation on 4/29/15 between 11:00 a.m. & noon showed the East Exit door had a door alarm box with a key pad (bottom box) and a Wanderguard Alarm with a key pad (top box). During an interview 4/29/15 at 2:55 p.m., Staff A (housekeeping staff/(laundry)) confirmed on 4/26/15 she responded to the sounding East door alarm and observed Resident #2 and his/her son enter the building through the door. Staff A stated she assumed Resident #2 and his/her family set off the alarm. Staff A reported she looked out the door and did not see anyone and silenced the Wanderguard door alarm. The staff member confirmed she did not go outside of the door because she never observed anyone and assumed it had been Resident #2 and his/her family member who set off the alarm. On 4/28/15, a quality assurance (QA) nurse (RN) documented her interview with Staff A (housekeeping staff) after regarding the elopement. According to that document, Staff A repeatedly stated she did not always know which keypad was alarming, but had a better understanding of alarms today after an in-service. According to an In-Service Training Report form dated 5/6/14 at 1:30 p.m., Staff A participated in an in-service with topics that included the facilities missing resident procedure and an elopement update and procedure review. According to a Missing Resident Drill form dated 5/15/14 at 10:40 a.m., Staff A participated in the drill. According to an In-Service Training Report form dated 7/8/14 at 1:30 p.m., Staff A participated in an in-service with topics that included the door systems and alarms. During an interview 4/29/15 at 4:30 p.m., Staff D, Licensed Practical Nurse (LPN) indicated somewhere around 4:40 p.m. on 4/26/15 p.m. Resident #1 approached her and asked her where East Gate Court had been. Then a little after 5 p.m. she heard the East door alarm sound, responded and found Staff A shutting off the Wanderguard alarm system as Resident #2 and his/her family member entered the facility so she went back to her job duties. At approximately 5:34 p.m. Staff E, RN received a telephone call from an unknown person (from the community ) who asked if Resident #1 had lived at the facility because she noticed a (GPS type) device on the resident when she dropped him/her off at his/her house. At that point the staff initiated the missing person policy and procedure, and started looking for Resident #1. Staff D reported the resident returned at 6:20 p.m. to the facility. Staff D reported the facility changed the policy for the charge nurse to deactivate the alarm. During an interview 4/29/15 at 1:54 p.m., the family member of Resident #2 confirmed he returned his/her parent via the east door of the facility. The family member recalled a person at the door who had on a coat and carried purse but he thought the person (Resident #1) had been a visitor. The family member of Resident #2 stated the door alarm sounded when they entered and he attempted to disarm the alarm, but the alarm would not turn off. At that time, a staff member (Staff A) approached the door and disarmed the upper alarm box/ (the Wanderguard alarm). The family member of Resident #2 stated he did not see anyone entering/exiting the parking a lot when he arrived. The family member stated he signed in/ (checked in) his family member (Resident #2) and stayed for about half an hour (1/2). The family member stated he did not see anyone walking in the parking lot or down towards Highway 18 when he left. According to an Oakwood Care Center form Release Of Responsibility For Leave Of Absence form signed on 4/29/15 at an unknown time, Resident #2 had been signed back into the facility on [DATE] at 4:45 p.m. During an interview 4/29/15 at 4:05 p.m., Staff F, Certified Nurse Aide (CNA) indicated she never heard the East door alarm sound however when it came through the pager system it had been canceled. During an interview 4/29/15 at 2:25 p.m., Staff B, Registered Nurse (RN) indicated she provided personal cares to Resident #2 when he/she arrived back to the facility on [DATE] with the assistance of Staff C, Certified Nursing Assistant (CNA). Upon completion she punched out of the facility at 5:13 p.m., exited through the East door of facility, walked straight to her car and left the grounds but was not looking for any residents and or visitors outside. Staff B reported she did not see anyone outside. During an interview 4/29/15 at approximately 3:55 p.m., Staff C, CNA indicated Resident #2 returned back to the facility around 5 p.m. with his/her son at which time she assisted Staff B with personal cares which took approximately 15 minutes. The staff member confirmed she heard the door alarm sounding when the resident returned to the facility but she had been on break and assumed everyone else would take care of the alarm. During an interview 5/1/15 at 8:08 a.m., the resident's Power of Attorney (POA) indicated if the door alarm sounded he/she could not understand why the facilities staff had not checked all of the residents who wore a Wanderguard device. Additionally, the POA confirmed the resident had always tried to get out of the building when he/she came to visit and set off the door alarms. Observations: Onsite observations/photographs taken on 4/29/15 between 11:00 a.m. & noon showed the following: a). At the first (1st) of 2 doors at the east exit where Resident # 1 left the nursing home, had both a door alarm and a Wanderguard Alarm (box on top). b). The 2nd door at the same east exit did not have an alarm/and no alarm sounded. c) The likely area the resident walked along included but is not limited to the following: sidewalk, parking lot, uneven paths of grass/dirt & the street where the resident walked. Onsite observation/photographs taken on 4/30/15 starting at 5:11 p.m., showed the area the resident likely walked a distance of 0.8 of a mile down the street (no sidewalks) and rested upon a mailbox. (The resident was seen prompted up against a community member ' s mailbox, which is located right next to the road.) d). The area passed the mailbox, further down the road included, Road Construction, Railroad Tracks, and a busy intersection for Highway 18. An observation/photograph taken on 4/30/15 at 5:22 p.m., showed the home where Resident #1 had been dropped off by the member of the community. The home included multiple concrete steps (and a hand railing next to the steps) before arriving at the front door. During an interview 4/30/15 at 2:40 p.m., a community member confirmed she observed Resident #1 outside of her home leaning up against her mailbox with the appearance of having been really tired and having trouble. (The distance from the nursing home to the community member ' s mailbox measured at a distance of 0.8 miles from the road presumed traveled.) The community member stated she approached Resident #1 and he/she had been able to give his/her name, spouses name and stated he/she lived at East Gate Court. The community member and his/her spouse drove the resident to his/her home and the resident pointed to his/her home. She dropped Resident #1 off, drove around the cul-de-sac and as they drove back in front of the house, they noticed the resident walked back down the front steps of the home. The resident did not enter the house. The community member found that situation odd along with the fact when she observed Resident #1 exit her car she noticed the resident wore an ankle type device. When the community member returned home she called Oakwood Care Center and shared her observation about the resident with Resident #1 (to the nursing home staff). According to a telephone log form dated 4/26/15 at 5:30 p.m., the facility received a telephone call from a community member (asking if an individual (Resident #1) lived at the nursing home). During an interview 4/30/15 at 6:20 p.m., Staff E (Registered Nurse)/RN indicated on 4/26/15 at 4:30 p.m. she started her break and gave her pager to a training nurse's aide so she did not hear the East door alarm sound. The staff member indicated Resident #1 wandered up to her earlier that afternoon and had set off the Wanderguard alarm at the front door a couple times because he/she had gotten to close to the device. The staff member confirmed around 5:30 p.m. she received a telephone call from an unknown caller (a community member) who asked if Resident #1 lived at the facility. The unknown caller (community member) informed the staff member he/she picked up Resident #1 and took him/her to his/her home (and gave the address). The called indicated she became suspicious when Resident #1 had not gone into the house and when she observed an ankle bracelet on him/her. Staff E asker the caller what she did after that and the caller reported she left Resident #1 at the location (prior home). Staff E stated she immediately called 911 and gave the name and description of the situation to the police dispatcher hung up the telephone and proceeded with the facilities missing person protocol. During an interview 4/29/15 at 12:27 p.m., Resident #1 ' s neighbor (prior to moving to the nursing home) reported on 4/26/15 he and his family had been outside of their house located across the street from Resident #1 ' s prior residence (home) and noticed him/her standing between a (parked) car and the retaining wall of the home. He did not see who dropped Resident #1 off at the house. As he approached the resident he/she seemed happy to see him/her however, after some conversation the resident refused to return to nursing home so he/she called the resident's friend who arrived and returned the resident to the facility. During an interview 4/29/15 at 12:53 p.m., the resident's friend confirmed on 4/26/15 around 5-5:30 p.m., she received a call from Resident #1's neighbor who informed her the resident had been at his/her prior residence and he/she had been unable to get the resident into the car to return to the nursing home. The resident's friend arrived to the location of Resident #1's prior residence and stated the police were also present. She reported she took Resident #1 for a drive around the cemetery and then returned through the North door with Resident #1. According to an Oakwood Care Center Nurse Call Log form dated 4/26/15 at 6:02 p.m., the North entrance Wanderguard alarm box sounded for 0:17 seconds when Resident #1 returned to the nursing home with a friend. According to a police incident report form dated 4/26/15 at 5:34 p.m., the police received a telephone call related to a missing adult person named as Resident #1. The Supplemental Report section modified 4/26/15 at 6:22 p.m. a police officer documented the following: The officer found (Resident #1) outside his/her old home that had been for sale. His/her neighbors who watched the home and saw him/her and came over to him/her. They called his/her friend to come take him/her back to Oakwood as he/she would not get into the car with them. (Resident #1's) husband/wife passed away in the last 6-8 months, they were at Oakwood together and he/she had dementia and had been unable to realize that his/her spouse had been gone and was just going home to look for him/her. His/her friend arrived and took him/her back to Oakwood. According to an Employee Safety & Health Guidelines form (not dated), #22 on the list of guidelines included the following information: Pager System and Door Alarms. All employees must have knowledge of the facility pager and door alarm system. Once initial training had been completed, the employee had been responsible to report any concerns regarding the pager or door alarms to the maintenance supervisor or administrator. When a door alarm goes off, the pager will read, 'door canceled'. That only meant that the door had been shut, NOT that a resident had not gone out of the building. ALL employees had been expected to respond to door alarms immediately, going around the building if necessary, account for residents in your area and communicate via walkie to other staff in the building if a resident had been located OR missing. Missing resident protocol would have been initiated immediately if a resident had been missing, as well as notifying the administrator and DON. The Daily Door check list for the week of April 26 (2015), showed 10 (ten) nursing home exit doors which included the East Parking and North Entrance doors. An interview with the QA RN on 5/1/15, at 11:02 a.m., identified the facility checked the prior door alarms. During an interview with the same QA RN on 5/1/15 she reported the facility made adjustments on 4/30/15 to (now) include the Wanderguard (WG) door alarms on the Daily Door check list. (Prior to 4/30/15, the daily door check list did not specify which door alarm had been checked, Wanderguard or door alarm.) The facility sent the Department the following: On 4/26/15, all staff working during the elopement on the 2-10 shift were educated by the Administrator via 1:1 education. The education given was listed and documented and staff signed acknowledging they received education. The Administrator remained in the facility until the night shift arrived on that night (4/26/15) and educated those staff, again having them sign that they received education. The next Day shift arrived on 4/27/15 and again were educated, which also occurred for the 4/27/15 night & evening shift educated by the Administrator and or DON. On 4/28/15 prior to the day shift, the DON verified all staff had received the education and that there had been signed verification of the education provided. Staff that had not yet worked in the facility since the elopement on 4/26/15 received education regarding following elopement policy/procedure. The facility placed a sign off sheet beside each door alarm directing staff to list when they responded to the and silenced unwitnessed door alarms, why it sounded, and what was the staff person ' s response when sounding. On 4/26/15, Wanderguard residents ' locations will be verified with all unwitnessed door alarms. The facility found alternative placement for Resident #1 with plans to move the resident out of the nursing home on 4/28/15. The facility monitored Resident #1 every 15 minutes until his/her move on 4/28/15. On 4/27/15, the facility staff working was given verbal counseling and education regarding proper policy and procedure, door alarm types, recognition of exit seeking and wandering and appropriate supervision and interventions. Care plans for other residents with Wanderguard were reviewed. Entrance doors with signage to prompt visitors to enter code to disarm alarms were removed. Visual code prompts for alarms were posted were removed. Exit codes were changed on doors alarms to be current with month and year. Ongoing education given to staff regarding the process in place, responding to door alarms by all staff to determine triggering for alarms sounding. If staff is visualizing the door prior to the alarm triggering, visualizing who and how the alarm was triggered, as it ' s happening, and verification that the proper procedure has been followed " all clear " will be given. If the cause of the alarm is not visualized staff will initiate a missing resident drill. If the trigger of the WG alarm was not observed by staff, staff are to start the missing resident drill. The first person to the door of an alarming door will automatically go outside while staff inside are verifying the location of residents. Direct Care Nursing staff are the only staff allowed to reset or cancel the sounding alarm and document on the form. Staff were provided education during the All Staff Education on 4/28/15 of how to reset the time/date on pagers. The time/date needs to be reset on pagers when the batteries are changed. The facility abated the IJ on 4/28/15 when they educated all staff at a mandatory in-service. On 4/28/15, the staff were educated at an in-service and the facility Elopement Policy/Procedure had been discussed along with the recent elopement. New interventions were reviewed by the DON. On 4/28/15 at the In-service- staff were educated what the Wanderguard looks like/monitoring of device. Staff were educated regarding the alarms/codes/beepers and correct time/dates were updated. Staff were educated on Relias course on Elopement, which included triggers for resident. The facility contacted Telligen for ongoing education and training for F323 support/education. On 4/29 the Administrative staff monitored effectiveness and appropriateness of the interventions. On 4/30/25, the Daily Door checklist form now showed all other Wanderguard door alarms on the checklist ; for example and North Entrance WG & North Entrance. On 5/1/15, Staff D (RN) received a written counseling for failure to follow the Door Alarm protocol & supervision of staff/residents. The facility terminated Staff A (housekeeping (laundry)) staff for failing to follow door alarm protocol. These actions lowered the IJ from J to D with the need for ongoing monitoring of door alarms and responses to ensure residents safety.

Based on observation, record review and interviews, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of four (4) residents reviewed. On 5/3/14 Resident #2 exited the facility without staff knowing the resident ' s whereabouts and walked approximately 230 feet. The facility identified Resident #2 at risk for elopement and had cognitive impairments which would affect his/her ability to make safety decisions. When the resident exited the door on 5/3/14, the exit door alarmed, however the nearby staff reported the alarm was hardly audible. When the door alarmed, the facility ' s pager system alerted staff of the open door then cancelled out. Staff reported the facility ' s pager system normally alerted staff when a door opened, but would cancel out within a minute. Staff relying on the pager system to alert them of an open door would not know whether the open door had been addressed by another facility staff or not. In addition, the facility staff turned off the door alarm without looking outside for the resident. The findings constitute an immediate jeopardy to resident ' s health and safety. The facility identified a census of 57 residents Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 3/3/14, assessed Resident #2 with [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which revealed he/she had cognitive impairments for daily decision making skills. The assessment identified Resident #2 had delusional thinking, inattention and disorganized thinking that fluctuated. The resident transfers independently with used a walker for ambulation. The resident had impairment on one side of his/her lower extremity. According to a Care Plan (not dated), the resident required assistance with activities of daily living (ADL's) and as at risk for falls related to a gait/balance problems, advanced age ([AGE] years old), unsteadiness, hearing, visual and cognitive deficits along with medication usage and due to his/her history of wandering and elopement on 5/3/14. The approaches included the following: a. During periods of wandering, (especially when he/she had changes or when he/she had an infection), staff should monitor for presence of infections. b. Continue wearing a wanderguard alarm device and staff should check it for function every shift. c. Frequent visual checks of the resident. d. Motion sensor placed outside of room door in Hollyhock in hallway by outside the west door. Staff monitor function and alert staff of potential need for assistance. e. Resident #2 had a built up shoe on his/her right foot. f. A wanderguard alarm device placed on the resident on 1/30/14. A Wandering and At Risk For Elopement Assessment form dated 3/18/14, indicated the resident as at risk and with a wanderguard alarm device in place. During a picture taking tour on 5/14/14 at 10:45 a.m., the surveyor had been accompanied and taken along the suspected path of the resident by the Administrator, DON and Corporate Nurse. During the tour there had been variable terrain changes that included the following: a. An approximate 1-2 inch gap just outside the Bayside door between the 1st and 2nd slabs of cement. b. An approximate 1-2 inch gap between the sidewalk area the grass. c. A steady slop down and back up from the area where the Northwest cement side walk stopped, through the grassy area and back up to where the Southwest cement sidewalk had started. d. At the base of the slop a man hole had shrunk into the ground leaving an approximate 6 inch deep hole surrounding the area. According to an Oakwood Care Center, Camera Time Sequence form, the Administrator documented the following information: a. 10:48:08 AM - Resident #2 had been walking down the Cottonwood neighborhood in the direction of the Bayside Room. b. 10:49:38 AM - Resident #2 had been visible and walking towards The Bayside Room in the Cottonwood neighborhood and then not visible on camera. c. 10:50:16 AM - Resident again became visible as he/she entered the Bayside Room and in the direction of the Bayside Room door. d. 10:51:44 AM - Resident #2 not visible on camera. e. 10:52:38 - Staff D, RN in room 210. f. 10:53:54 - Staff D at cart by room 202. g. 10:54:44 - Staff D out of room 210 and in to room 211. h. 10:55:28 - Staff D in to room 211. i. 10:57:09 - Staff D out of room 211. j. 10:58:05 - Staff D in to room 209. k. 10:58:25 - Staff E, CNA came down Meadowview towards the Bayside Room responding to the alarm. l. 10:58:53 - Staff D at the medication cart. m. 10:59:01 - Staff E visible in the Bayside Room and went to the door. n. 10:59:04 - The arm of Staff E had been visible by the Bayside Room door. o. 10:59:15 - Lost sight of Staff E as she opened the Bayside Room door. p. 10:59:45 - Staff D observed going into the Bayside Room. q. 11:00:23 - Staff D observed looking out the south windows of the Bayside Room with Staff E also looking, just behind Staff D. r. 11:00:29 - Staff D continued looking out the window. s. 11:01 - Staff E going back down the Cottonwood neighborhood looking into resident rooms. t. 11:01:23 - Staff D back at medication cart. u. 11:01:47 - Lost sight of Staff E. v. 11:05 - Staff B, LPN and Staff C, CNA observed coming towards the front door after checking the South neighborhoods. w. 11:06 - Staff B and Staff C back in the facility with Resident #2. During an interview 5/16/14 at 8:40 a.m. - Staff L, Maintenance indicated the resident ambulated and 231 feet from the Bayside door to the area he/she had been found in the front of the building. Staff Interviews: During an interview 5/14/14 at 12:52 p.m., Staff E confirmed she worked on 5/3/14 on the 6 a.m. to 2 p.m. shift on the Cottonwood hallway (Northwest/area of Bayside). At the time of the elopement she had been down Meadowview (Northeast/area of Bayside) assisting another CNA with a resident. While assisting the resident she had been alerted through her pager system that she had a call light on her assigned hallway (Cottonwood). As she came down the hallway, Staff D had been standing in the hallway between room 209 and 210 and asked her what that noise had been which the Staff E described as a faint beep. The staff member confirmed it had come through the pager system the Bayside door opened and then canceled out so she went to the Bayside door, opened it, stepped out looked North and South, did not see anybody, came back into Bayside, looked out the window, utilized the walkie talkie system and asked Staff C, CNA to check his residents on the South side of the building while she checked Cottonwood and Meadowview. When all her residents had been accounted for she let everyone know via her walkie talkie that all of the residents had been accounted for in Cottonwood and Meadowview then she answered a call light and heard Staff B say the resident had been found outside and in front of the building. The staff member indicated the approximate time from when she heard the faint beep of the door and when the resident had been found as around 10 minutes but the alarm could have been going off longer than that time element. The staff member indicated she felt just stepping outside the door to check for a resident as appropriate because she had not seen anyone, the alarm had canceled and not one else (meaning staff) responded. During an interview 5/14/14 at 1:17 p.m., Staff C confirmed he worked 5/3/14 on the 6 a.m. to 2 p.m. shift on the Hollyhock hallway (Southeast). While he had been receiving report from another aide before break the Bayside door came through the pager system as open and then canceled in less than a minute. He indicated there had been no response so he thought someone had taken care of it and no one communicated with the walkie talkie system at that time so he continued to get residents ready for lunch. Approximately 10 minutes later someone came over the walkie talkie and requested they account for the residents down South. Staff B directed him to check on Resident #2 so he did and reported back to her the resident had not been in his/her room. Both of the staff members went back to the area of the nurse's station and observed the resident outside through the front bay windows of the facility. The staff members responded to the resident who had not appearance of any distress and/or any indications he/she had fallen. The resident had been utilizing a walker, wearing a blue jacket, black pants and wearing velcro strapped shoes with a built up sole. The staff members assisted the resident to the lunch table while Staff B assessed him/her and found he/she had been fine and with no cuts. At that point the staff member accompanied the surveyor outside to where the resident had been found which had been indicated as in the middle of the front porch at the end of the sidewalk area facing the east with his/her walker and wearing shoes. When the staff member and surveyor returned into the facility the resident had been sitting in the front/south lounge area. Upon encouragement to go for a walk the resident stood independently from the chair using his/her walker and ambulated through the lounge area, past the nurse's station and down the hallway with a built up shoe on his/her right foot, the foot abducted and walking on the ball of his/her foot and with a limp. During an interview 5/16/14 at 8:08 a.m., Staff B confirmed she worked on 5/3/14 on the 6 a.m. to 2 p.m. shift on the South wing of the facility as the charge nurse for both hallways. On that day, later morning she confirmed a page came through their system the Bayside door had been opened and then canceled so the staff assumed everything had been OK. While preparing for the noon medication pass they received a page through the walkie talkie system to make sure their residents had been accounted for so Staff C, CNA and herself began to check the South end of the building. Staff C indicated the resident as not in his/her room and that he/she had been a resident with a wanderguard device and as active throughout the facility. The staff members went to the South lounge area and observed the resident as outside in the front of the building on the sidewalk facing the East looking around. The staff member indicated the resident with no appearance of distress and/or any indication of a fall. The staff members redirected the resident into the facility and without difficulty while she assessed the resident for any injury. The staff member confirmed when they found the resident outside of the facility she paged over the walkie talkie but could not recall her exact words. During an interview 5/14/14 at 12:35 p.m., Staff D, RN confirmed she worked 6 a.m. to 2 p.m. on the day of the elopement on the Cottonwood hallway (area of Bayside). At the time of the elopement she had been performing a treatment as far East in the hallway as she could have been from Bayside and when she came out of the room Staff E, CNA came down Cottonwood from the East towards Bayside. The staff member asked Staff E if she heard something at which time the staff member replied, yes, I think it is an alarm. Staff D described the alarm as faint and hardly audible. Staff E went into Bayside and then Staff D followed. When she arrived Staff E informed her no one had been outside as she stepped outside, looked around and spotted nothing and/or no one. Staff E utilized the walkie talkie system and requested the south staff account for their residents and that all of the North residents had been accounted for. Staff D indicated that had been when Staff B, LPN utilized the walkie talkie system and informed staff the resident had been outside and in front of the building. The staff member confirmed she had not walked around the outside of the building because all of her residents had been accounted for and the resident had been observed outside. The staff member confirmed when the Bayside door opened it came through her pager system then canceled self out. Lastly the staff member denied having called a code purple as directed in the 1st process of a missing person drill. During an interview 5/14/14 at 1:40 p.m., Staff A, CNA confirmed she worked from 6 a.m. to 2 p.m. on the weekend of the elopement on Meadowview hallway and never heard the door alarm sound and that staff could not hear that door alarm on Meadowview. The staff member could not recall if the door alarm came through the pager system. The staff member indicated she heard a page go through the walkie talkie system that someone had checked the door but no more directives had been given to check on the residents. The staff member confirmed the elopement occurred during the first break time in the facility so there had been only 1 CNA on each hallway. The staff member confirmed she later heard over the walkie talkie system the resident had been found outside but could not recall how many minutes had elapsed. She did recall hearing Staff B announce on the walkie talkie system if someone checked the door how can you explain the resident having been outside. During an interview 5/14/14 at 1:52 p.m., Staff F, CNA confirmed she worked on 5/3/14 from 6 a.m. to 2 p.m. on the Cottonwood hallway. At the time of the incident she had been in the break room on the back porch of the building (north side) when her pager vibrated and she saw the Bayside door had been canceled. At 10:45 a.m. to 10:50 a.m. Staff E announced on the walkie talkie all of the residents on the North had been accounted for and requested the staff on the South check their residents as she continued on her break. Staff B responded by stating OK and then said the resident had been found outside shortly thereafter. The staff member indicated she heard Staff B announce on the walker talkie something to the effect of if you checked the doors how come the resident had been found outside. The staff member indicated staff could not hear any alarms in the break room. The staff member confirmed if a pager says cancel she thought someone had been taking care of it and when she heard Staff E on the walkie talkie she assumed everything had been under control. During an interview 5/16/14 at 2:37 p.m., Staff G, LPN confirmed she had been unable to hear the alarm sounding on the day of the incident when she had been sitting at the North nurse's station talking on the telephone. The staff member did hear Staff D say an alarm had been going off and observed her ambulating down Cottonwood hallway so she knew the staff member had been looking at it. Staff G indicated she should have gotten off of the telephone but did not because Staff D responded. Later she observed Staff D walking up the hallway so she asked what had been going on. Staff D told her they had checked Cottonwood for all of the residents, that they needed to check Westwood and they also utilized the walkie talkie and requested the South end check for their residents. The staff member indicated she never paid attention to alarms that did not go off very often (Bayside) especially when they are cancelled out right away. According to a written statement (not dated), Staff J, housekeeping documented the following: a. 5/3/14 around 10:45 a.m. to 10:50 a.m. I was finished with Meadowview Drive, turned the corner and observed Staff D and Staff E going down Cottonwood. The staff said an alarm had been going off but they had taken care of it. According to a written statement dated 5/3/14, Staff K, CNA documented the following: a. I had been standing at the South nurse's station when my buzzer went off and I looked at my pager and it said Bayside room cancel. I remember thinking Bayside room cancel, that's weird. I got my food for lunch at 10:45 a.m. right after and went to lunch. During an interview 5/20/14 at 10:54 a.m., Staff K indicated she thought the situation had been weird because no one utilized the Bayside door and that she had not responded to the alarm because it had been canceled and she assumed someone else had taken care of the door. Additionally the staff member indicated she never heard anything announced over the walkie talkie. During an interview 5/16/14 at 3 p.m., Staff H, LPN confirmed if she observed through the pager system that a specific door had opened and then canceled out right way she would have checked it out especially if a door is not normally utilized for example the Bayside and Cottonwood doors. During an interview 5/16/14 at 3:14 p.m., Staff I, CNA confirmed if she observed through the pager system that a specific door had opened and canceled out staff were required to check it. During an interview 5/14/14 at 2:45 p.m., the DON confirmed the facility had just found out that all of the exit doors in the facility had been fire doors so they automatically shut after opened which canceled out the pagers but the alarms would have kept sounding. During an interview 5/14/14 at approximately 4:20 p.m., the Administrator confirmed she would have expected the staff to respond to all door alarms even if cancelled out. According to a Residents with Wanderguards/At Risk For Wandering/Elopement form, the facility identified 11 residents at risk which included the resident. According to the facilities layout map (not dated), the facility identified the following: a. 3 doors with a wanderguard alarm device. (there were actually 4) b. 14 cameras throughout the facility. c. 10 monitored (alarmed) doors. A facility tour and observation on 5/14/14 starting at approximately 3:25 p.m., revealed 1 of the 4 doors that contained the wanderguard alarm system as not function. During an interview at the same time Staff L confirmed the system as nonfunctional. During an interview 5/16/14 at 7:45 a.m., the Director of Nursing (DON) indicated the resident had an elopement risk prior to the incident and the reason the wanderguard had been originally placed. According to an Elopement Prevention Program form dated 3/27/09, the policy had been resident safety promoted by minimizing the risk for elopement. The Information read as follows: a. Elopement occurred when a resident left the premises or a safe area without authorization and/or any supervision. A resident who left a safe area may have been at risk of (or had a potential to experience) heat or cold exposure dehydration, medical complications, drowning, or having been struck by a motor vehicle. According to the facilities Procedure for Missing Resident form (not dated), a prompt response to all door alarms had been essential by all staff - treat each alarm as an emergency. According to A Matter of Rights booklet dated 2013, each resident had the right to have been assured their surroundings were save, clean and comfortable. Written notices for Staff D and E dated 5/8/14 identified at approximately 10:55 a.m. on 5/3/14, a resident (Resident #2) went out the door of the Bayside, however viewing the camera, staff shut off the door alarm but did not go outside to look for the resident. Staff did not exit the building to ensure the resident ' s safety. The facility did not have any documentation of when the pager system had alarmed and or cancelled out. The facility abated the IJ on 5/4/14: On 5/3/14, the facility monitored the resident ' s whereabouts every 30 minutes. On 5/3/14, the facility added a visual barrier/stop signs to exit doors. On 5/4/14, the facility abated the IJ when they educated all staff on the following: a. Staff respond to door alarms immediately. b. Available staff respond to the door alarm until " cancelled " is announced over the walkie talkie and the charge nurse will initiate an internal search for a missing resident and outside perimeter search. When determined all residents are accounted for, an announcement must be made on the walkie as needed. c. A floor mat alarm was added to the bayside door. Staff tested the alarm for functioning. d. Staff were educated on outside perimeter checks when an alarm goes off. Staff demonstrated their understanding of outside perimeter checks. e. On 5/6/14, education was provided to all employees where the facility ' s missing resident drill (Policy) was reviewed. On 5/12/14 the facility obtained an estimate for installing wanderguard system on eleven doors. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring to ensure safety provisions are being followed.

Based on observation, staff interviews and record review, the facility failed to provide adequate supervision to ensure against hazards from self and failed to supervise the implementation of the health care plan to decrease the resident's risk for falls for one of four residents reviewed. The facility reported a census of 55 residents. (Resident #2) Findings include: 1. The Admission Record for Resident #2 revealed an admission date of [DATE]. The Admission Record identified this resident's medical [DIAGNOSES REDACTED]. A Level of Care Certification for Facility report dated 5/4/12 noted this resident required assistance with walking, bathing and grooming. A Pre-Admission assessment dated [DATE] noted this resident required the assistance of a walker due to unsteady and legs felt weak, with dizziness when getting up. A Short Portable Mental Status Questionnaire dated 12/6/12 assessed this resident with severe intellectual functioning. A Re-Admission assessment dated [DATE] noted this resident's acute active medical [DIAGNOSES REDACTED]. The resident required assistance of one person with bed mobility, toileting, transfers and walking. A Resident Status Sheet dated 12/29/12 noted this resident required assistance with bed mobility, transferring, walking, bathing and toilet use. The resident had short-term memory loss and modified cognitive function. The resident suffered from moderate pain on a daily basis. An Initial Pain assessment dated [DATE] noted this resident suffered from aching pain, 50% (percent) of the time. An Admission/Readmission Fall Risk assessment dated [DATE] noted this resident's risk factors for falls included anxiety diagnosis, congestive heart failure, a decline in functional status, diabetes, medication changes, oxygen use, pain, use of nine or more medications and environmental factors. The list of interventions included: educate on call light use, encourage call light use, grab bars, frequent monitoring by staff members, OT occupational therapy, PT physical therapy, pain medication, and a room free of clutter/well lit. An Admission Nursing Evaluation dated 1/4/13 noted this resident returned from the hospital with admitting [DIAGNOSES REDACTED]. The resident required assistance with bed mobility, transfers, walking and dressing. A hospital Discharge Summary dated 12/29/12 noted this [AGE] year old resident was admitted to the hospital to evaluate his/her back pain. The resident's prior history included lumbosacral spine and thoracic spine disease treated with chronic narcotics. This resident's discharge [DIAGNOSES REDACTED]. A History and Physical dated 12/27/12 noted this resident's past medical history included osteoarthritis, lumbar compression fracture, chronic pain, and osteoporosis, history of uterine cancer, and [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] of the skin, right total knee arthroplasty, left elbow arthroplasty, left hip arthroplasty and back surgery. A Physician's note/order dated 1/10/13 assessed this resident with a lot of right upper quadrant pain and some chest pain. The physician ordered the facility to increase this resident's narcotic pain patch, "Will bump up (his/her) fentanyl patch to 25 mcg daily." A communication sheet sent to this resident's physician on 1/15/13 noted this resident got up without assistance after eating supper in his/her bedroom and staff heard a loud bang. Staff found this resident on the floor, with the resident's chest/head/neck leaning against the wall. A communication sheet sent to this resident's physician on 1/24/13 noted this resident complained, "my heart hurting" after being up in his/her room without assistance. Staff assisted the resident back to bed and gave Nitro with relief. A physician's note/order dated 1/24/13 noted the physician examined this resident for chest pain and emergency room follow up. The resident had been taken to the emergency room several times recently with chest pain. The resident had been found to have a myocardial infarction; however the resident declined any aggressive treatment. The resident had moderate dementia. The physician assessed this resident with end-stage dementia and chest pain with coronary artery disease and ordered Hospice services. A Hospice Certification of Terminal Illness dated 1/25/13 noted this resident [AGE] year-old with a hospice [DIAGNOSES REDACTED]. The resident lived in a nursing home primarily due to dementia and heart disease. The resident was hospitalized twice since December 28, 2012. The patient also had recent myocardial infarction. The patient has had worsening in cognition and ability to communicate as well as worsening confusion. The patient requires assistance with all daily cares of living as well as bed mobility. The patient is incontinent of urine and bowel. An Interdisciplinary Progress Note dated 1/24/13 at 7:20 p.m. noted staff found this resident walking in the hallway without assistance. The resident complained of heart pain. An Interdisciplinary Progress Note dated 1/20/13 at 1:00 p.m. noted resident required one to two person assistance with transfers and walking. At 3:30 p.m. on 1/20/13 the nurse documented this resident thought he/she was in Florida. C.N.A.'s (certified nursing assistants) to monitor more frequently. A Physical Therapist Progress and Discharge Summary report dated 3/31/13 noted this resident was able to safely complete transfers requiring moderate assistance. A Rehabilitation/Restorative Summary dated 2/8/13 noted this resident required the assistance of one person for bed mobility and the assistance of one to two persons for transfers and walking. A Minimum Date Set (MDS) assessment with a reference date of 2/5/13, reflected this resident with cognitive impairment with a score of 3 out of 15. The resident required extensive assistance of two persons for transfers, walking and toilet use and extensive assistance of one person for bed mobility. This resident experienced moderate pain on a frequent basis. The resident weighed 136 pounds. The resident sustained [REDACTED]. A Social Service Interdisciplinary Progress Notes dated 2/6/13 noted Social Service significant change assessment completed. BIMS score is 3/15, suggesting severe impairment. Resident indicated he/she slept a lot and was tired with little energy; this is attributed to recent health problems and decline. An Interdisciplinary Progress Note dated 2/8/13 at 4:30 p.m. noted a significant change for this resident. Resident and family chose Hospice Services for comfort, shortness of breath and end of life concerns. Resident required staff assistance with walking and transfers. Resident had some incontinence of bowel and bladder. Staff provided all perineal cleansing related to incontinence. A CAA report dated 2/8/13 noted this resident was at a high risk for falls related to confusion, chronic pain, unsteady gait, at times desired to be independent, urinary frequently and a history of night sleep walking. Staff will assist with transfers and walking with one to two assistants based on fatigue levels. Resident has periods of fluctuating confusion and forgetfulness. CAA report identified problems with delirium and had delusional occurrences. An Interdisciplinary Progress Note dated 2/9/13 at 5:50 a.m. noted this resident continued to complain of left lower rib pain. A narcotic medication, Percocet had been given at 4:30 a.m. Attempted to reposition resident for comfort with little success. This resident's plan of care dated 1/25/13 identified this resident's self-care deficit related to dementia, chronic neck, chest and back pain and need for increased assistance. The approaches included to transfer and walk with assistance of one. This resident's ability to walk independently in his/her room with a walker was discontinued from the plan of care on 1/23/13. The plan of care also noted this resident's risk for injury related to [DIAGNOSES REDACTED]. The approaches instructed the staff to use a motion sensor alarm on the floor beside the bed to alert staff when resident was out of bed unassisted beginning on 2/19/13. Alarm Audit Assessments dated 5/25/12, 6/22/12, 7/23/12 and 8/23/12 noted the staff used a motion sensor alarm across door of bedroom at night to alert staff if resident was up sleep walking. An Interdisciplinary Progress Note dated 2/19/13 at 3:30 a.m. noted staff found this resident sitting on the floor next to bed. Resident had been incontinent of urine. Resident complained of chronic back pain. Pain medication, Percocet given for pain control. A Quality Assurance Investigation Form dated 2/19/13 noted at 3:30 a.m. this resident slid out of bed. The nurse implemented a new approach to utilize a motion sensor alarm in this resident's room. The Incident Report Form noted resident was found sitting on floor next to bed. States that he/she slid out of bed. No injuries noted. Resident had been incontinent of urine. Call light was within reach. A Communication Sheet sent to this resident's physician dated 2/19/13 informed the physician of noted bruises to right arm and right thigh. The physician wrote, "Most likely from fall last night. Monitor." An Interdisciplinary Progress Note dated 2/19/13 at 7:30 a.m. noted staff gave this resident education to please use call light or hand bell for assistance. Doesn't always use either one despite education and is noted to transfer/walk without assistance. Review of the C.N.A. (certified nursing assistant) communication book revealed an entry dated 2/19/13 instructing the staff to utilize a motion sensor alarm for this resident due to a fall on 2/19/13. On 2/19/13 the Director of Nursing added to use the Sensor Alarm at all times for this resident. An Interdisciplinary Progress Note dated 2/24/13 at 3:40 a.m. noted resident on the floor in front of television/nightstand. Resident's left eye was swollen shut and purple. Measured 5 cm (centimeter) across by 3.5 cm down. Small (1 cm) laceration to the lateral side of the eye. Resident stated he/she hit his/her head on the floor. Resident admitted to trying to walk to bathroom without assistance. Resident also bleeding from nose and spitting out some blood. Unable to assess left pupil. Pressure applied to cut on eye and nose. Resident stated he/she needed to go to the hospital. A Quality Assurance Investigation Form dated 2/24/13 noted the staff found this resident on the floor, by the bed at 3:40 a.m. The fall related injury caused the resident to complain. The resident stated, "I think I need to go to the hospital." A CT Final Report dated 2/24/13 noted this resident had a left orbit inferior wall blowout fracture with 7 mm (millimeter) orbital (eye) floor fragment depression into maxillary sinus. Lamina papyracea (medial orbital wall) nondisplaced fracture. Ventral wall left maxillary sinus fracture depressed 3 mm. Nondisplaced fracture at posterolateral left maxillary sinus wall. Complete opacification of left maxillary sinus with blood, gas, and herniated retro-orbital fat. Suspect involvement of infraorbital nerve (V2) Pronounced left periorbital and fascial soft tissue swelling. A Mercy Medical Center physician's orders [REDACTED]. A Physician's Progress Note dated 2/25/13 noted the facility called the physician to the facility to examine this resident due to severe eye swelling. The resident had fallen and was sent to the emergency room and they diagnosed him/her with orbital fractures, but nursing was concerned because of so much eye swelling and pain. By the time the physician got to the facility they had already bumped up his/her pain medication. A Physician's Progress Note dated 2/28/13 noted this resident had fallen on Sunday and had an orbital fracture. The eye was actually markedly improved compared to Monday. The fentanyl had been increased. Left eye and face has a lot of bruising. The edema has gone down nicely. Assessment included: status [REDACTED]. A Physician's Progress Note dated 3/7/13 noted this resident was on Hospice. The staff have noticed every time they get this resident up he/she seems to have excruciating pain and does not want to put weight on the left side. When interviewed on 3/27/13 at 10:05 a.m. a Licensed Practical Nurse, Staff A stated she worked as a nursing assistant on the overnight shift from 10:00 p.m. on 3/23/13 through 6:00 a.m. on 2/24/13. She stated she alone was assigned to care for Resident #2. She stated there was a charge nurse on duty and two other staff members working on the other side of the building. She stated she "peeked" in on Resident #2 during her midnight and 2:00 a.m. rounds. She stated she did not provide any care for this resident. She did not assist the resident to the bathroom and she did not check to see if this resident was incontinent or not. She stated she had received written directions instructing her what to do and the only direction she had received for this resident was that the resident was a wanderer and to make sure to check on him/her prior to 6:00 a.m. She stated she was not aware this resident was to utilize a motion sensor alarm and also stated an alarm was not used for this resident that night. Staff A stated she was passing fresh ice water about 3:15 a.m. and she saw this resident was in bed and the television was on. She did not recall if the resident was awake or not. Staff A stated the next time she went to this resident's room, she saw the resident sitting on the floor. No alarms were in place and no alarms were sounding. The call light was not activated. She noticed blood coming from the resident's face. Staff A touched the resident's face and immediately knew it was broken. Staff A described this resident's injury, "It was horrid looking." The resident's eye was swollen shut. She then called for the charge nurse to come to this resident's bedroom. When interviewed on 3/25/13 at 10:00 p.m. a Registered Nurse, Staff B stated Resident #2 had a history of [REDACTED]. Resident #2 would at times sit on the side of the bed. The resident would forget to ask for assistance. At times the resident would use the call light, however that was becoming less frequent. The resident would sit on the side of the bed and then try to get up unassisted. On 2/19/13 she was called to the resident's bedroom. She found the resident on the floor. The resident had pulled the covers off the bed, over him/herself and just wanted a pillow and to be left on the floor. The resident was incontinent of bladder. After assessing the resident they assisted the resident to the bathroom, provided personal cleansing and assisted the resident back to bed. The nurse then completed an incident report and documented the incident. She asked the nursing assistant to check on the resident more frequently. Resident #2 was more confused than when he/she was admitted to the facility. The resident had a progression of his/her dementia. Staff B could not recall if there were any new interventions put into place between 2/19/13 and 2/24/13. On 2/24/13 she as paged to this resident's bedroom. She saw this resident sitting on the floor leaning against a chair. She observed blood. It was evident the resident had hit his/her face. The resident's eye was swollen and bleeding. The nurse stated, "I have never seen a black and blue eye that bad." The nurse could not even get the resident's eye open to check the pupil. No alarms were in place that night. Staff B could not recall any alarms utilized for this resident during that period of time. The resident stated he/she hit his/her face on the floor. The resident stated he/she needed to go to the hospital. The resident appeared to be in pain. The resident stated he/she needed to go to the bathroom, so they assisted him/her to the bathroom and then to his/her bed to await the ambulance. It was painful for the resident to be moved. Staff B stated that night there were four people working, herself, Staff A and two nursing assistants. When interviewed on 3/26/13 at 2:15 p.m. a Licensed Practical Nurse, Staff F described Resident #2 as a pleasantly confused resident. Sometimes the resident would use the call light and sometimes he/she would not use the call light. They then tried to use a call bell and again sometimes the resident would use the bell and sometimes he/she would not use the bell. The resident used to be independent in his/her bedroom. The staff implemented the use of the sensor alarm for this resident on 2/19/13 after this resident had fallen during the night due to the resident's gait was less steady and the resident was not asking for assistance prior to getting up. They applied the sensor alarm on the day shift on 2/19/13. She wrote this new intervention for Resident #2 in the facility's Nurse Aide Communication book and on the resident's plan of care. Staff F stated she always stressed the importance of reading the Nurse Aide Communication book to the C.N.A. (certified nursing assistants.) Staff F stated she normally/routinely read the Nurse Aide Communication book. When interviewed on 3/26/13 at 6:15 p.m. a certified nursing assistant, Staff G stated she did recall working with Resident #2 on 2/23/13 on the evening shift just prior to this resident's fall. She stated they did not utilize any alarms on this resident that evening (2:00 p.m. to 10:00 p.m.). She stated the day shift did not report to her any use of alarms for this resident during the routinely shift to shift report at 2:00 p.m. when she reported to work. She stated she was informed the next day that this resident was to have an alarm used and she and the other nursing assistant working that evening, Staff H both stated they were not aware that this resident was to have an alarm. Staff G stated she does read the Nurse Aide Communication book, however she stated she relies on the information given to her during report by the off going C.N.A. Staff G stated she relies on other C.N.A.s to tell her when a resident requires the use of an alarm during their routine walking rounds. Review of the Nurse Aide Communication Book revealed Staff G had initialed the entry dated 2/19/13 educating the staff of the new interventions to utilize a Sensor Alarm for Resident #2. When interviewed on 3/26/13 at 3:15 p.m. a certified nursing assistant, Staff H was asked if alarms are always utilized as planned. Staff H stated approximately 75% of the time; she finds the alarms on and in place as planned. She stated sometimes it just slips their minds. She stated they do not routinely check for alarms. She stated about a year ago they routinely checked for alarms during their walk through rounds between each shift and each nurse aide had to initial that the alarm was in place. She stated they had stopped doing the checks. She stated sometimes the staff will turn the alarms off or turn the alarm around to prevent the alarm from sounding while they provided care and then sometimes they would forget to reactivate the alarms. When interviewed on 3/26/13 at 12:20 p.m. a Registered Nurse, Staff C stated sometimes she will work as a nursing assistant. Staff C stated when she works as a C.N.A. she always reads the Nurse Aide Communication book. When interviewed on 3/25/13 at 4:35 p.m. the Director of Nursing stated Staff F had added the new intervention of using the Sensor Alarm on 2/19/13 to be used on the night shift and then she, the Director of Nursing changed it to be used at all times to decrease the confusion about when it should and should not be used. The nursing assistants are expected to read the Nurse Aide Communication book and to initial it when they read it. They are supposed to read it before each shift they work. The nursing assistants are also supposed to conduct walking rounds between each shift where they go to each resident's room and the off going aide gives a verbal report to the oncoming aide about each resident. The Director of Nursing stated there was a breakdown with the alarm the day of this incident. The Director of Nursing stated she knew it was used on 2/19/13 however due to they were not documenting the use of the alarm and due to the nursing were not documenting if and when they checked the alarm, they were unable to say if the Sensor Alarm was utilized on 2/20/13, 2/21/13, 2/22/13 and on 2/23/13. When interviewed on 3/26/13 at 8:50 a.m. the Director of Nursing stated when she conducted her investigation of this fall she was informed by Staff A that an alarm was not utilized that night and Staff A was unaware the resident was to have an alarm in place. The Director of Nursing also added Staff F failed to add Resident #2 on the report sheet on 2/19/13 to alert the oncoming nurses of this resident's fall and the new intervention of a Sensor Alarm. When interviewed on 3/27/13 at 5:00 p.m. the Director of Nursing stated the facility used to have each nursing assistant visualize each alarm used during their walking rounds and both the off-going aide and the on-coming aide would each visualize the alarm and document the presence of the alarm. This occurred at the change of each shift (three times a day). Then there was a period when they did not utilize any alarms. Then when they began utilizing alarms again, they did not reinstate this check of the alarms. When interviewed on 3/27/13 at 10:30 a.m. Administrator stated they had implemented a new system approximately six months ago. The facility installed "Wall-a-roos" in each resident hall. Each Wall-a-roo contained the resident's plans of care. That way, each aide had easy access to each plan of care and the aide was expected to read these care plans every shift they worked. When interviewed on 3/27/13 at 10:40 a.m. a Unit Manager, Staff E stated they began documenting the use of alarms on the TAR (treatment administration record) on March 1, 2013. Now the charge nurse documents every shift if an alarm is on/in place. Staff E stated she monitors the use/placement of alarms on a monthly basis. Observation on 3/25/13 at 3:50 p.m. revealed two nursing assistants transferred this resident from the lift chair to the commode using moderate assistance of two and a gait belt. At this time the resident stated, "I'm dying." After sitting on the commode a short period of time the resident stated, "Is there anything wrong with the baby?" No one had been talking about a baby and there was no baby in the room. Observation on 3/26/13 at 1:10 p.m. revealed two facility nursing assistants and one hospice nursing assistant transferred this resident from the lift chair to the bed with the use of the mechanical lift. This investigation revealed the facility failed to implement their planned approaches to decrease this resident's risk for injury related to falls. The staff failed to utilize a planned Sensor Alarm to alert them when this resident attempted to walk unassisted. The resident had a history of [REDACTED]. The resident was confused and required the assistance of the staff for transfers. On 2/24/13 this resident attempted to get up without assistance and fell and sustained a major injury and pain.

Based on observation, record review and staff interviews, the facility failed to monitor for the identification, assess and treat pressure ulcers (wound care) for one of one resident reviewed with skin breakdown (Resident #6). The facility reported a census of 62 residents. Resident #6 had a deep tissue injury of the right and left buttock in April and May 2012. The area healed on 5/23/2012. During an initial tour on 6/26/2012 at 9:30 a.m., the resident was identified as having no pressure ulcers abrasions or open areas. At 2:44 p.m. on 6/26/2012, observation revealed the resident had an abraided area on the left buttock. On 6/27/2012 at 8:01 a.m. the staff performed perineal area and wiped over the open area with a wipe and did not apply the barrier cream. At 9:00 a.m. on 6/27/2012 the staff transferred the resident to a wheelchair. The resident sat in the wheelchair until 10:30 and requested to use the bed pan. The resident sat on the bed pan until 11:28. The staff removed the bedpan and cleansed the buttock area with wet wipes. The staff wiped over the open area. At 12:10 p.m. the resident sat in the wheelchair. At 2:15 p.m. the staff transferred the resident to the recliner. The resident voiced the wheelchair seat too hard to sit in. The staff confirmed the resident had stated the resident voiced discomfort with buttocks. On 6/28/2012 the resident sat in the wheelchair. At 9:52 a.m. the staff transferred the resident from the wheelchair to the bed. The resident used the bed pan. Observation revealed open areas on the right and left buttock. The facility had not identified the open area to the right buttock timely, even when the resident voiced discomfort at the site. The resident ' s record lacked documentation of the area until 6/28/2012 and the physician provided an order on 6/29/2012. Since the resident had a history of [REDACTED]. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 with [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assist of two for bed mobility and total assistance of two for transfers, toilet use and personal hygiene and frequently incontinent of bowel and bladder. The MDS indicated the resident had no pressure ulcers on the prior assessments, and had been at risk for pressure sore development and moisture associated skin damage. A wound clinic progress note dated 4/25/2012 indicated the resident had a deep tissue injury on the right and left buttock. On 5/23/2012 the wound clinic identified the areas as healed. The Resident Care Plan with a team conference dated 05/21/12 identified a problem for bowel and bladder incontinence with potential for urinary tract infection and impaired skin integrity. A goal had been established on 06/07/12, that the resident skin will heal over the next 90 days. The following approaches were included: a. Treatment to buttocks per orders. Certified nursing assistants may apply b. Have resident lay down one hour every morning. c. Follow with the ET ([MEDICATION NAME][MEDICATION NAME]) nurse as needed. d. Staff will assess the skin with dressing and undressing and notify nursing/physician of any concerns. e. Alternating air flow mattress to bed. Check function every shift. f. Monitor skin around peg tube weekly and as needed g. Pressure reduction cushion to wheelchair. h. Staff will provide all pericares every morning and afternoon plus after every incontinent episode. i. Staff will use the urinal for voiding and the commode for bowel movement. j.Wears briefs to protect his dignity as he is incontinent at times of bowel and bladder. k. Monitor bowel movements and any signs of constipation. l. Staff assist for proper positioning in the bed. During the initial facility tour on 6/26/12 at 9:36 a.m., Staff E (Registered Nurse) reported the resident had no pressure sores or skin abrasions or open areas. Observation on 06/26/12 at 2:44 p.m., Staff H (Certified Nursing Assistant, CNA) and Staff K (CNA) proceeded to perform incontinent cares on the resident. Observation revealed the resident had a superficial abrasion on the left buttock. Observation on 06/27/12 at 8:01 a.m., Staff G (registered nurse and Staff F (CNA) performed morning cares for the resident. Staff proceeded to position resident on his/her right side; Staff G proceeded to take wet wipes and clean over the open area on the left buttock four times and applied no barrier cream to the resident ' s bottom. On 6/27/12 at 9:15 a.m., Staff G and Staff F was interviewed and stated the resident wanted to get up for the morning so they transferred the resident into his/her wheelchair at 9:00 a.m. Observation on 06/27/12 at 10:30 a.m. revealed Staff G and Staff F proceed to transfer the resident from the wheelchair to the bed. Staff proceeded to place resident on a bedpan. Observation revealed an open area on the left buttock. Observation on 06/27/12 at 11:22 a.m. revealed the privacy curtain remained pulled around the resident. Observation on 06/27/12 at 11:28 a.m. revealed Staff G and Staff F to remove the bed pan from underneath the resident. Staff F cleaned over the open area on the left buttock with wet wipes. Observation on 06/27/12 at 12:10 p.m., revealed the resident sitting in the wheelchair at the nurses ' station. Observation on 06/27/12 at 1:11 p.m., revealed the resident sitting in the north lobby area in the wheelchair. Observation on 06/27/12 at 2:15 p.m., Staff H (CNA) and Staff M (CNA) transferred the resident from the wheelchair to a blue recliner in the resident ' s room. The staff provided no cares at that time. Resident #6 expressed the wheelchair seat too hard to sit in. On 06/27/12 at 3:01 p.m., Staff H was interviewed and stated the resident was transferred from the blue recliner to the wheelchair because the resident voiced his/her bottom was sore and wanted to sit in the wheelchair again. Observation on 06/28/12 at 8:14 a.m., revealed the resident sitting by the nurses ' station in his/her wheelchair. Observation on 06/28/12 at 9:52 a.m., Staff F and Staff J (CNA) proceeded to transfer the resident from their wheelchair to their bed to be placed on the bed pan. Observation revealed an open area on their right and left buttock, at that time the surveyor pointed the areas out and asked Staff B (registered nurse) if he/she had been aware of the open areas. Staff B replied, only the one open area on the resident left buttock, but now the resident has one on their right buttock. Staff B informed this surveyor that he/she would go get the charge nurse and have them measure the areas and do the appropriate notifications and treatments. At 10:10 a.m., Staff I (Licensed Practical Nurse) measured an open are on the resident ' s left buttock to be 2.9 centimeters (cm) by 2.2 centimeters and also measured an open area on the resident ' s right buttock to be 1.4 centimeters by 0.7 centimeters. Staff I stated had looked at the resident ' s bottom on 06/27/12 and did not see any skin issues. Clinical record review revealed no documentation, assessment or physician notification of any open area for the resident in the nurse ' s notes. The facility skin assessment book had no skin assessments for the resident. A non-pressure skin condition record dated 06/28/12, documented the right cheek, excoriated area measures 1.4 centimeters by 0.7 centimeters with partial thickness. The surrounding skin had a reddened and purplish appearance. A non-pressure skin condition record dated 06/28/12, documented the left cheek, excoriated area measured 2.9 cm by 2.2 cm with partial thickness. The surrounding skin had a reddened and purplish appearance. A physician's order [REDACTED]. On 06/29/12 at 9:00 a.m., Staff D (Director of Nursing) was interviewed and stated the nurses needed to be checking the resident ' s bottom every shift due to his/her disease process and a history of open areas.