Every finding on record at Ravenwood Specialty Care

Based on observation, clinical record review, emergency medical services (EMS) report review, hospital record review, and staff interviews, the facility failed to ensure door alarm response procedures and resident supervision to prevent elopement (leaving without permission) for 1 of 8 residents reviewed (Resident #23) for nursing supervision. Resident #23, required staff assistance of 1 person with ambulation and transfers, exited the facility undetected through an alarmed door, fell near a roadway, and sustained a subdural hematoma (blood collection between brain and skull), facial fractures, and lacerations (cuts) requiring hospitalization. The facility staff disarmed the sounding alarm and failed to account for the residents in the building for approximately 2 hours. This failure resulted in an Immediate Jeopardy situation. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2026 on July 29, 2026 at 4:37 PM. The facility staff removed the Immediate Jeopardy on July 30, 2026 through the following actions:7/29/26: Education provided to all staff regarding appropriate response to door alarms.Three missing resident drills well be completed randomly over the next week and will continue weekly for 4 weeks on varying shifts. The scope lowered from a J to a D prior to exit after ensuring the facility implemented education. The facility reported a census of 130 residents.The Admit/Re-Admit Note dated 7/25/26 at 4:50 PM documented Resident #23 admitted to the facility on [DATE] at 4:50 PM. The note described Resident #23 as alert and required the assistance of 1 person for transfers. The Care Plan Focus dated 7/25/26 identified activities of living (ADLs) included an Intervention revised 7/29/26 that Resident #23 required assist of 1 person with a front wheeled walker for ambulation and transfers. The Care Plan Focus revised 7/29/26 indicated Resident #23 had a risk for falls due to a Parkinson's diagnosis, poor impulse control, stress disorder, incontinence, and medication side effects. The Intervention dated 7/29/26 directed staff to remind Resident #23 to ask for assistance for all ambulation. The Care Plan Focus revised 7/29/26 reflected Resident #23 had a neurological deficit related to Parkinson's. The CSC - BIMS Evaluation Note dated 7/25/26 at 6:24 PM reflected Resident #23 need a Brief Interview for Mental Status (BIMS) conducted. Resident #23 couldn't report the correct day of the week and couldn't recall bed. He scored a 13, indicating intact cognition. The Occupational Therapy (OT) Assistant Therapy Services dated 7/24/26 indicated Resident #23 had decreased awareness of need for assistance and decreased awareness of need for safety. The OT Participation Limitation for the day involved fatigue, confusion, and safety. The OT impairment identified strength, activity tolerance, balance, cognition, and safety. The OT Clinical Impression listed Resident #23 tolerated his session physically fair with rest breaks. He demonstrated increased difficulty with multi-step directives and decreased safety awareness during mobility and transfers. The SPN-Skilled Evaluation dated 7/26/26 at 2:25 PM reflected Resident #23 transferred with stand by assist, a gait belt, wheelchair/walker. The Progress Note written on 7/26/26 at 2:32 PM documented Resident #23 refused his medication at noon. Resident #23 wanted to speak with the pharmacist. The pharmacist educated him on his medications and the potential side effects of not taking the medications. Resident #23 expressed we will see and that he would risk it and would wait for his son to bring his medications from home. The Progress Note written on 7/27/26 at 7:29 AM documented therapy was recommending Resident #23 have 1 person assistance for all transfers using a walker. The Progress Note written on 7/27/26 at 6:41 PM documented the resident required assistance of 1 person, a gait belt and walker for ambulation (walking). The Progress Note written on 7/29/26 at 2:45 AM documented the hospital called the facility to reported Resident #23 was in their emergency room (ER). The nurse had been on the other side of the building assisting another nurse. Upon returning to her assigned area of the building she heard the door alarm going off. She went to the door she thought was alarming. When she couldn't reset the alarm, she asked the other nurse assigned to the same side of the building for assistance. The other nurse told her which door to go to and assisted with shutting off the alarm. Both nurses looked outside and didn't see anyone, so they returned to their assigned duties. The Progress Note written on 7/29/26 at 3:45 AM documented the facility contact the hospital Emergency Department nurse, who reported Resident #23 was brought to the hospital around 2:30 AM. A passerby had seen the resident with a cut on his head and called EMS. The hospital reported they were monitoring him and might transfer him to a higher level of care hospital. The EMS Patient Care Record dated 7/29/26 documented Resident #23 had a chief complaint of head injury with an initial and final patient acuity of emergent. Upon arrival, the Emergency Medical Services (EMS) found Resident #23 lying on his side, next to the curb in the roadway. The note described Resident #23 as confused and not able to answer orientation questions. He had a large laceration (cut), a hematoma (bruise) above his right eye and an abrasion to his right shoulder. Resident #23 reported to EMS that he fell and was not struck by a car. He wore a hospital scrub top and hospital socks. The EMS didn't know at the time where Resident #23 came from or where he planned to go. The dispatch location listed a street or highway on west 9th Street at 2:14 AM. The transport mode was listed as non-emergent with no lights or sirens at 2:19 AM. At 2:29 AM the response mode was listed as emergent with lights and sirens to the hospital. The destination listed as 0.6 miles. The Incident Report dated 7/29/26 reflected at approximately 11:00 PM, the nurse observed Resident #23 asleep in his room with the lights off. At approximately 12:00 AM, a certified nurse aide (CNA) documented the same observation as the nurse. At approximately 12:30 AM, the staff heard an alarm sound near the therapy area. The nurse initially checked the E-wing door and found it not alarming. She got assistance from another nurse and determined the back therapy door as the source of the alarm. They checked the immediate exterior area, but didn't observe anyone outside. They reset the alarm and resumed their assigned duties and rounds. At approximately 2:30 AM, while conducting rounds, the facility received a call from the hospital. They reported Resident #23 came to their ER with a laceration (cut) on his head. The facility notified the Administrator and Director of Nursing (DON). The Administrator contacted the hospital who reported a passerby found Resident #23 and called for assistance. The hospital was evaluating, treating, and monitoring his injuries. The Action Taken During Investigation indicated staff received immediate education regarding door-alarm response and the missing-resident procedure. The facility would schedule 3 missing-resident drills within 24 hours of the incident. Additional follow-up included reinforcing the resident sign-out process with newly admitted residents and reviewing staff expectations for accounting for residents after a door alarm. The Root Cause Analysis determined Resident #23 was alert and oriented, retained decision-making authority, and scored a 0 on the wander assessment. He failed to follow the sign out process to leave the facility. While away from the facility, he sustained injuries in a reported fall and was transported to the hospital for evaluation and treatment. The conclusion reflected the staff responded to the door alarm by identifying the alarmed door and checking the immediate exterior area. The facility failed to complete a head count at the time to determine if anyone exited. The emergency room Department Physician Note dated 7/29/26 identified Resident #23 eloped from the nursing home and was found on the side of the road by the police department sitting on the curb face down with obvious lacerations to the forehead and right side of the face with confusion. Resident #23 reported he went out for a job and his feet got out from under him because the hill got away from him and he fell down. He denied getting his by a car. The nursing facility didn't know he left, reporting they last saw him around midnight in his room. Resident #23 appeared awake, alert, and oriented to person, place, and time. The CT (specialized imaging) of the head without contrast dated 7/29/26 at 4:09 AM identified an impression of Resident #23 included the following:An acute (new) right-sided subdural hematoma (blood collection between brain and skull) extending from the middle cranial fossa through the cerebral convexity into the anterior cranial fossa with localized mass effect seen.Extracranial soft tissue swelling and hemorrhage in the supraorbital and frontal soft tissues greater on the right than the left extending over the right orbital roof and zygoma.Right-sided nasal bone fracture with subtle depressionMultilevel cervical spondylosis without an acute fractureThe findings indicated Resident #23 had a subdural hematoma which extended from the middle cranial fossa through the cerebral convexity extends into the anterior cranial fossa. Localized effect is seen with no midline shift. Hemorrhage is hyperdense and measured 9.47 millimeters (mm) in thickness with normal gray/white differentiation. He had extracranial soft tissue swelling and hemorrhage in the supraorbital and frontal soft tissues greater on the right than on the left extending on the right over the orbital roof and along the right zygoma. The History and Physical dated 7/29/26 at 6:27 AM identified the police found Resident #23 lying face down on the curb with lacerations to his forehead, abrasions to his shoulder, knee, and feet at approximately 2:30 AM. The nursing facility last saw him around midnight. Per EMS he went out for a job and fell. He eloped from his nursing home. At baseline he apparently alert and oriented but mildly confused. The CT showed a subdural hematoma with mass effect in the right frontal of 9.4 mm with a nasal bone fracture. The secondary review noted a 1 centimeter (cm) by 1 cm bruise or hematoma (blood collection under skin) without bleeding. The record didn't show obvious cuts or bruises on the back of Resident #23's head. An Outside Hospital (OSH) previously repaired Resident #23's prior lacerations (deep cuts). The hospital contacted neurosurgery and facial trauma. The plan listed trauma primary with nothing by mouth and admission to the hospital per neurosurgery. The Neurosurgery Consult Note dated 7/29/26 at 7:50 AM directed to give Keppra (seizure medication) for seizure prophylaxis (prevention) 500 milligrams (mg) twice a day for 7 days. The CT Brain without Contract dated 7/29/26 at 7:57 AM showed a right convexity subdural hematoma measuring up to 0.6 centimeter (cm), previously 0.9 cm. The report noted interval extension of the subdural hematoma to the level of the superior sagittal sinus (large brain vein). The scan didn't show significant midline shift (brain pushing to one side), new intracranial hemorrhage (bleeding inside skull), or large vascular territory infarct (stroke from blocked blood vessel). The report noted stable mild dilation (enlargement) of the supratentorial ventricles (fluid spaces in upper brain). The basal cisterns (fluid spaces at base of brain) showed age-appropriate size and configuration. The brainstem (base of brain) and posterior fossa (back lower skull area) remained within normal limits. The scan again showed a right frontal scalp hematoma (blood collection under scalp) extending inferiorly to the periorbital area (area around eye). The scan didn't show mass effect (pressure on tissue) on the right globe (right eyeball). Facial bones required better evaluation on the dedicated CT Max face (facial bone scan). The CT scan impression included:Right convexity subdural hematoma (blood collection between brain and skull) measuring up to 0.6 cm, previously 0.9 cm. Interval extension of the subdural hematoma to the level of the superior sagittal sinus (large brain vein). No significant midline shift (brain pushing to one side).No new intracranial hemorrhage (bleeding inside skull).Stable right frontal scalp hematoma (blood collection under scalp). The Ortho Progress Note dated 7/30/26 indicated his subdural hematoma remained stable on his repeat CT. The note described Resident #23 as delirious that morning but denied other sites of pain. The Plan reflected no plan for surgical intervention.The Trauma Progress Note written 7/30/26, documented the Level I certified Emergency Department received Resident #23 from the resident's local hospital on 7/29/26. The note documented diagnoses including Parkinson's and dementia. The note describes a 5 cm laceration over his right eyebrow closed with 7 sutures (stitches), a 1 centimeter (cm) laceration over his right cheek with 2 sutures, a 1 cm laceration over his right cheek, below the eye with 2 sutures, road rash abrasion with oozing blood approximately 1 cm by 1 cm to right eye, facial tenderness to right cheek. The top of his forehead had a 2 cm by 1 cm bruise without any bleeding. The lacerations were repaired at the local hospital prior to transfer. Resident #23 remained hospitalized as of 8/3/26. An observation 8/3/26 of the route Resident #23 potentially took on prior to being found by a passerby revealed posted speed limits of: St [NAME] Drive, 25 Miles Per Hour (MPH), [NAME] 9th Street 30 MPH and [NAME] 30 MPH. There was a stop light observed at the intersection of [NAME] 9th Street and [NAME]. Per the State of Iowa Climatologist, the temperature was between 69-71 degrees Fahrenheit between the hours of 12:54 AM and 2:45 AM with a heat index in the 70-72 degrees Fahrenheit range on 7/29/26. During an interview on 7/29/26 at 2:40 PM, Staff B, Registered Nurse (RN), explained around midnight she went over to the other side of the building to assist the nurse on that side. She reported being on that side for about a half hour. She explained when she returned to her assigned side of the building she heard the door alarm sounding. She went to the door at the end of the E hall. When she couldn't silence the alarm on the door, she went to the nurse's station and asked Staff C for assistance. Staff C directed her to a different door, near therapy. Staff B explained Staff C went to the door with her and silenced the alarm. Both nurses looked outside and did not see anyone. Both went to their assigned areas and returned to work. Staff B explained about 2:30 AM, Staff C notified her she had a phone call. It was the local hospital reporting to her they had Resident #23. Staff B explained the procedure should have been to clear the alarm, check outside, and do a room check if there is nothing/no one outside. She explained she should have checked rooms and did not, adding she dropped the ball. During an interview on 7/29/26 at 10:00 AM, the Director of Nursing (DON) explained the staff should have completed a head count when they couldn't find a reason for the door alarm to be sounding. During an interview on 8/3/26 at 4:07 PM the Administrator acknowledged the facility did not have a door alarm policy. The Facility Policy titled Emergency Procedure - Missing Resident, revised August 2018, lacked direction on how and when to respond to door alarms.

Based on clinical record review, resident and staff interview, the facility failed to answer a call light in a timely manner for 1 of 4 residents (Resident # 22) reviewed for call lights. The facility reported a census of 130 residents.Findings include:Resident #22's Clinical Census reviewed 7/27/26 documented an admission date of 7/21/26. On 7/28/26 at 3:41 PM Resident #22 reported she had her call light on from 3:00 AM until 6:45 AM, when she called the facility directly to request assistance. The Behavior Note dated 7/26/26 at 6:45 AM documented Resident #2 called the facility at approximately 6:45 AM using their personal cellphone to report she's had call light on since 3:00 AM. The writer documented they observed Resident #2's call light came on at 5:21 AM, not 3:00 AM, they apologized for her wait time and told her they would pass along her concerns to the correct people. On 7/28/26 at 3:20 PM Staff A, Licensed Practical Nurse (LPN), confirmed Resident #22 had her call light on from 5:21 AM until Staff A entered the room around 6:45 AM. On 7/28/26 at 2:52 PM the Director of Nursing (DON) stated they expected staff to answer call lights within 15 minutes.

Based on clinical review, staff interview, family interview, facility investigation, incident report, hospital record review, and facility policy the facility failed to ensure safe handling of equipment during resident assistance which resulted with a hematoma, laceration, unnecessary pain, 3 units of blood, prolonged hospitalization, wound assessments, and wound care for 1 out of 3 residents reviewed (Resident #2). The facility reported a census of 137. Findings include:Resident #2's Clinical Census printed 6/15/26 listed an admission date of 6/6/26 and a discharge date of 6/9/26. The Care Plan Focus dated 6/8/26 related to Resident #2's activities of daily living. The Interventions listed Resident #2 as independent with bed mobility, ambulation, transfers, upper body dressing, and lower body dressing. The Incident, Accident, Unusual Occurrence Note dated 6/8/26 at 7:30 AM written by Staff B, Agency Registered Nurse (ARN), documented Staff C, Certified Nurse Aide (CNA), told alerted them to Resident #2's complaint of severe right lower leg pain. Upon assessment, they found Resident #2 seated in a recliner with a pale, grayish, tender hematoma on the lateral anterior aspect of the right lower leg. During the assessment, the hematoma began actively bleeding with an estimated blood loss of 300 milliliters (mL). Staff B applied direct pressure with a bandage, but the bleeding persisted. Staff B elevated Resident #2's right limb and contacted 911 for Emergency Medical Services (EMS). Resident #2 indicated Staff A, CNA, hit her twice while lowering the footrest of the recliner. Staff A present in the room, acknowledged lowering the footrest but denied striking Resident #2, stating any contact they made was unintentional. Upon arrival, EMS prepared Resident #2 for transport. During the transfer to the stretcher, the skin over the hematoma split open, requiring the application of additional dressings. Resident #2 was safely moved to the stretcher using a sheet lift and transported to the hospital for evaluation and management of the bleeding hematoma and skin tear. The Incident Report dated 6/8/26 documented Resident #2 reported after using her call light and asking to get up for the day, she asked the CNA to lower the recliner leg rest because she felt weak. Resident #2 stated the CNA attempted to lower the leg rest manually and then used her foot to push it down, at which time the CNA's leg struck the resident's right lower leg. Resident #2 immediately reported pain and requested a nurse. The nursing assessment identified a grayish hematoma on the right lower leg that subsequently opened and bled, prompting emergency transport to the hospital for further evaluation and treatment. Staff B reported Resident #2 stated Staff A struck her while attempting to lower the recliner. The Hospital Discharge Summary documented diagnoses of lymphedema and venous stasis of the lower legs, class 3 severe obesity due to excess calories, and a body mass index (BMI) of 40.0-44.9. It also documented edema in both lower legs, a pulmonary embolism, and a large soft tissue hematoma of the right lower leg. The resident had a history of pulmonary embolisms (PE) and took Eliquis (an anticoagulant that thins the blood). Her hemoglobin dropped to 6.6, and she required a total of 3 units of packed red blood cell transfusions. On 6/16/26 at 7:20 AM, the hospital Case Manager indicated Resident #2 discharged from the hospital and had been there for quite a while. She added the facility that she would send the hospital discharge summary. On 6/16/26 at 11:27 AM, Staff B provided an account of an interaction between Resident #2 and Staff A while she assessed Resident #2. Staff A told Resident #2 she was doing what she asked her to do, she did not have contact with the resident, and if she did, it was not intentional. Resident #2 told Staff A, Yes, it wasn't intentional but yes you hit me twice. Staff B indicated upon her arrival; Resident #2 didn't have her legs elevated. Staff B attempted to ask the CNA how they manipulated the footrest, but she stated this question went unanswered due to Resident #2's bleeding and the urgent need to transfer them to the Emergency Department (ED). Staff B described the CNA as experienced and reported no prior history of rough handling or boundary issues with residents. Following the incident, the Director of Nursing (DON), called Staff B and Staff A their office. Staff A subsequently went home. On 6/16/26 at 1:29 PM, Staff A indicated she couldn't lower the footrest on Resident #2's recliner. She pushed the footrest with her hands, but the footrest did not lock into place. Resident #2 told Staff A that she couldn't lift her legs. Staff A indicated she pushed the footrest down with her foot. She added she removed the first layer of blankets, but the resident still had a blanket wrapped around her legs and tucked under her limbs. Staff A indicated this was the first time she had worked with Resident #2. She also indicated she has always had a difficult time getting the recliner footrest down. Staff A indicated the facility put her on suspension ever since the incident. On 6/16/26 at 3:00 PM, the Administrator indicated she expected the recliner footrest to function properly. She stated she expected staff to remove blankets, ask for help, and alert maintenance that they had a footrest not working. On 6/16/26 at 4:00 PM, Resident #2 indicated an incident occurred on her first morning at the facility (at approximately 5:00-6:00 AM). Resident #2 indicated she had requested assistance from Staff A to lower the recliner footrest because she felt weak. Staff A turned to the right side, picked up her right foot, and attempted to kick the recliner's footrest mechanism. During this action, Staff A struck Resident #2's right leg. Resident #2 reported screaming in pain and telling Staff A that really hurt. Resident #2 indicated the footrest did not go down. On 6/17/26 at 11:28 AM, Staff C, Certified Nurse Aide (CNA), indicated when she went to answer Resident #2's call light, she saw Staff A in Resident #2's room standing to the left side of Resident #2. Staff A indicated Resident #2 needed to use the bathroom but told Staff C to look at the hematoma on Resident #2's right lower leg. Staff C indicated she saw a large, gray-colored hematoma. Resident #2 sat in the recliner with her feet on the ground. Staff C alerted Staff B. Staff C indicated didn't know if Resident #2 took an anticoagulant medication. She also indicated that Resident #2 requested to seek medical attention immediately and grabbed her leg. When Staff B started to apply a dressing to her right lower leg, it started bleeding. Then Resident #2 told her Staff A kicked her and it busted, adding they already had the footrest down and she was not bleeding at that time. The facility's Safe Lifting and Movement of Residents Policy, revised July 2017, instructed staff on the following: Resident safety, dignity, comfort, and medical conditions will be incorporated into goals and decisions regarding the safe lifting and moving of residents.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques.Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.All equipment design and use will meet or exceed guidelines and regulations concerning resident safety and the use of restraints.Safe lifting and movement of residents is part of an overall facility employee health and safety program that involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies, addressing reports of workplace injuries, providing training on safety, ergonomics, and the proper use of equipment, and continually evaluating the effectiveness of workplace safety and injury-prevention strategies.

Based on clinical record review, hospital record review, external clinic record review and staff interview the facility failed to assess a wound and document complete assessments for 1 of 4 residents reviewed (Resident #9). Resident #9 required emergency medical services including a foot amputation. The facility reported a census of 131 residents.Findings include:Resident #9's Minimum Data Set (MDS) dated [DATE] documented an admission date of 3/15/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS had no documentation of rejection of care behaviors. Resident #9 didn't have bowel or bladder incontinence (loss of control). The MDS included diagnoses of a stroke (blood clot in brain), peripheral vascular disease (poor blood circulation), and diabetes (high blood sugar). Resident #9 didn't have pressure ulcers (bedsores), venous ulcers (leg sores), or arterial ulcers (clogged artery sores). Resident #9 had a diabetic foot ulcer (open sore). Skin and ulcer/injury treatments on Resident #9's MDS included a pressure reduction device for his chair, a pressure reduction device for bed, and applications of ointments or medications to areas other than feet. The treatments on Resident #9's MDS for their feet didn't include a dressing, with or without topical medications. Staff E, Registered Nurse (RN), signed Resident #9's MDS as complete on 3/9/26. Resident #9's April 2026 Treatment Administration Record (TAR) recorded treatment and dressing changes daily, with omissions on 4/12, 4/22, 4/23, and 4/27/26. Resident #9's May 2026 TAR recorded treatment and dressing changes daily, with omissions on 5/1, 5/5, and 5/11/26. The SW - Skin Issues dated 4/6/26 at 4:53 PM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The wound measured 4.19-centimeter (cm) length (l) by (x) 3.18 cm width (w) x 0 depth (d) and an area of 9.91 cm squared (cm2). The wound had no undermining or tunneling. The SW - Skin Issues dated 4/10/26 at 11:47 AM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The note lacked measurements with no tunneling or undermining.The Podiatry Clinic (foot care specialist) note dated 4/10/26 documented Resident #9 had necrotic (dead) tissue debrided (cut away) and needed a right fifth toe amputation (surgical removal). The note described the wound as very painful.The SW - Skin Issues dated 4/15/26 at 11:19 AM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The note indicated the wound deteriorated with measurements of 2.48 cm L x 4.34 cm W x 0 cm D with no undermining or tunneling.The SW - Skin Issues dated 4/21/26 at 7:41 AM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The documentation lacked measurements, but listed no undermining or tunneling.The SW - Skin Issues dated 4/24/26 at 7:42 AM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The documentation lacked measurements but listed no undermining or tunneling.The SW - Skin Issues dated 4/24/26 at 8:40 AM documented the right dorsum 1st interdigital space (foot) other skin issue acquired in house. The note listed the wound healed or closed with continued monitoring and no undermining or tunneling. The Podiatry Clinic note dated 4/27/26 documented an amputation of a gangrenous (dead) toe on the right foot. The Podiatry Clinic note dated 4/28/26 documented a post-operative toe check and that Resident #9's condition eventually required a below the knee amputation. The Podiatry Clinic note dated 5/1/26 documented a post-operative toe check and that Resident #9 continued at high risk for a below the knee amputation. The SW - Skin Issues dated 5/2/26 at 2:12 PM documented the right dorsum 1st interdigital space (foot) listed a surgical wound acquired in house with an unknown progress. The measurements listed 4.19 cm L x 3.35 cm W x 0 cm D. Area measured 15.02 cm2 with no undermining or tunneling.The SW - Skin Issues dated 5/5/26 at 10:45 AM documented the right dorsum 1st interdigital space (foot) listed a surgical wound acquired in house with an unknown progress. The note lacked measurements but reflected no undermining or tunneling.The SW - Skin Issues dated 5/13/26 at 6:06 PM documented the right dorsum 1st interdigital space (foot) listed a surgical wound acquired in house with an unknown progress. The note lacked measurements but reflected no undermining or tunneling.The SW - Skin Issues dated 5/14/26 at 8:52 AM documented the right dorsum 1st interdigital space (foot) listed a surgical wound acquired in house with a stable progress. The wound measured 0.71 cm L x 1.61 cm W x 0 cm D. The area measured 1.21 cm2 with no undermining or tunneling.The SW - Skin Issues dated 5/15/26 at 4:07 PM documented the right dorsum 1st interdigital space (foot) listed a surgical wound acquired in house. The wound lacked measurement but reflected no undermining or tunneling.The Hospital records documented staff transferred Resident #9 to the emergency department (ED) on 5/17/26. ED providers diagnosed Resident #9 with sepsis (serious blood infection) with acute renal (kidney) failure and septic shock (dangerously low blood pressure) due to an unknown organism. Resident #9's foot appeared necrotic (dead tissue) and gangrenous (decaying tissue). The medical providers consulted on Resident #9's lower extremity amputation (surgical limb removal) of either a below the knee amputation (BKA) or an above the knee amputation (AKA). He had an obvious gangrenous infection over his lateral (outer side) right midfoot at the site of the previous amputation. When assessed, the provider noted the wound had complete dehiscence (splitting open) with exposed underlying metatarsal (long foot) bones noted along the fourth and fifth distribution. He had slight peri-wound erythema (redness around a wound) with mild lymphangitis (inflamed lymph vessels) up to his ankle with tenderness and 1 plus pitting edema (swelling). The Hospital records included a note on 5/17/26 that Resident #9 required a below the knee amputation in the operating room on 5/18/26. On 5/19/26 at 12:00 PM, the Director of Nursing (DON) explained staff completed no additional in-house assessments for Resident #9's foot.

Based on clinical record review, resident and staff interview and policy review the facility failed to provide an adequate intervention after a resident fell for 1 of 4 residents reviewed for falls (Resident #1). The facility used a mechanical lift to get Resident #1 off the floor and into his bed despite complaints of hip pain and not wanting to move his leg. Upon assessment, the hospital found a fracture in Resident #1's leg. The facility reported a census of 131 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 10/30/25 from home. The MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS indicated Resident #1 had a fall since the prior assessment. He had 1 fall without injury.The Fall Risk Evaluation scores printed 5/21/26 directed to initiate a Care Plan for falls if a 10 or greater. The Evaluations listed the following scores:a.3/16/26: 10b.5/1/26: 11c.5/3/26: 2d.5/8/26: 11The Care Plan Focus initiated 3/16/26 revised 5/11/26 indicated Resident #1 had a risk for falls. The Interventions dated 3/16/26 included the following:a.Encourage Resident #1 to use his call light for assistance.b.Encourage Resident #1 to wear proper footwear.The Care Plan Focus initiated 11/3/25 revised 5/3/26 identified Resident #1 as noncompliant with using his call light and waiting for assistance and would transfer himself. The Interventions directed the following:a.5/3/26: Staff to intervene if they see Resident #1 transferring himself.b.Revised 2/9/26: Ambulation/mobility: None, he required a manual wheelchair for mobility. c.Revised 2/9/26: Resident #1 required an assist of 1 with a front wheeled walker (FWW) per therapy 1/9/25. Encourage wheelchair at time of weakness, unsteady gait, or increased confusion. The Care Plan Focus revised 11/3/25 indicated Resident #1 had a risk for falls related to chronic confusion, shortness of breath, and cardiac impairments, and medication side effects. The Interventions directed the following:a.11/3/25: Anticipate and meet his needs.b.11/3/25: Be sure his call light is within reach and encourage him to use it for assistance as needed. He needed prompt response to all requests for assistance. c.11/3/25: Follow facility fall protocol.d.11/3/25: Review information on past falls and attempt to determine the cause of falls. Record possible root causes. After remove any potential causes if possible. Educate him, his family, caregivers, and the interdisciplinary team (IDT) as to the cause.e.11/7/25: Ensure he wore appropriate footwear when ambulation or mobilizing in the wheelchair. f.11/7/25: Post fall, rearrange room to maximize living space. g.3/18/26: Post fall, offer assistance to the bathroom after meals.h.5/4/26: Post fall, visual cue in room to remind him to use his call light and wait for staff assistance for transfers. The Progress Note written on 5/3/26 at 11:45 AM documented Resident #1 lay on the floor, banging on the door with his foot. He reported to the nurse as he headed to the bathroom, he fell. He rated his pain a 10 out of 10 in his left hip. The assessment showed his left hip had redness and mild swelling. Resident #1 didn't want to bend his left leg due to the pain. The staff transferred Resident #1 to the Emergency Department via ambulance. The Progress Note written on 5/3/26 at 6:09 PM documented the hospital admitted Resident #1 for a hip fracture (broken bone) and possible surgery. In a statement written on 5/5/26 about the fall, Staff B, Licensed Practical Nurse (LPN) documented she last saw Resident #1 eating his breakfast in bed, while passing medications. Resident #1 reported to the nurse he had to go to the bathroom and lost his balance. She assessed him, and he screamed due to pain. The staff used the mechanical lift to get him up. Resident #1 wasn't incontinent and didn't wear shoes or gripper socks. On 5/12/26 at 8:51 AM Resident #1 explained he fell when he headed to the bathroom. He reported he didn't turn on his call light. He further explained there's no point in using it since it can take a couple of hours for staff to answer it. He explained the staff used the mechanical lift to get him off the floor. He added the nurse didn't do range of motion (ROM) (joint movement exercises) to him while on the floor prior to getting him up. On 5/18/26 at 4:37 PM Staff B explained as she passed medications, she heard a banging noise. She found Resident #1 laying on the floor between the door and the dresser. He reported to her he headed to the bathroom. He hadn't used his call light. She explained she went to get the equipment to take vitals and when she came back, he complained of hip pain. He complained of hip pain while on the floor. They used the mechanical lift to get him up off the floor and into bed. Once in bed he continued to complain of pain and didn't want to bend or move that left leg. She explained that she hadn't seen Resident #1 walk so she assumed he required a mechanical lift transfer. She explained normal protocol dictates getting someone up when they fall, even if they complain of pain. On 5/21/26 at 11:58 AM the primary care provider (PCP) explained that while she didn't see the x-rays, she didn't believe this represented a major injury. The fall and the nature of the injury led her to assume the fracture resulted from the fall. On 5/21/26 at 4:22 PM the Director of Nursing (DON) explained she expected an assessment to be completed post fall including vital signs, hand grips, looking for hip rotation, skin alterations, and if it stayed unwitnessed or if they hit their head, neurological assessments. She further explained that if a resident complained of pain and didn't want to move an extremity, staff should make them as comfortable as possible, leave them on the floor, and wait for the Emergency Medical Technicians (EMTs) to arrive. The Falls-Clinical Protocol policy revised March 2018 directed staff to assess, document, and report musculoskeletal function, observing for any change in normal ROM.

Based on observation, policy review, resident, and staff interviews the facility failed to answer call lights in a timely manner. This resulted in residents to not use the call light, being forgotten on the toilet, and unable to seek assistance when needed for 4 of 5 residents (Residents #1, #3, #10 and a confidential source) reviewed for call lights. The facility reported a census of 131 residents.Findings include: 1. On 5/12/26 at 8:51 AM, Resident #1 explained he recently had a fall. He reported he didn't use his call light to call for assistance when he needed to use the restroom. He explained there's no point in turning it on as it can take a couple of hours for staff to answer it. 2. On 5/12/26 at 9:21 AM, Resident #3 reported one night she vomited due to acid reflux (stomach irritation) and turned on her call light. She reported no one came into her room for 4 hours, until the next morning. When she reported it to a nurse and staff, they didn't have an explanation why someone didn't answer her call light. 3. On 5/12/26 at 12:27 PM, a resident during a confidential interview explained they've to use the call light 3 to 4 times to get any help. They explained sometimes they do things for themselves that they aren't supposed to do because help doesn't come. The resident stated, they'd get their butt chewed for it, but if they got to go, they got to go. The resident explained staff forgot them in the bathroom [ROOM NUMBER] times in the last month and a half, long enough for their buttocks to go numb. They explained they're unable to find the call light in the restroom to call for help. An observation of the restroom during the interview revealed a call light with a short string, approximately 5 inches long, at shoulder height behind the armrest. 4. On 5/14/26 at 9:14 AM, Resident #10 explained he didn't use his call light. He added he can see out into the hall and just waves someone down when they go by or he calls out. He reported it's faster than waiting for someone to answer his call light. On 5/14/26 at 11:20 AM, Staff D, Certified Nurse Aide (CNA), explained call lights are to be answered right away but up to 15 minutes if a person's busy with another resident. On 5/18/26 at 2:37 PM, Staff B, Licensed Practical Nurse (LPN), explained call lights should be answered in a maximum time of 10 minutes. She explained if the CNAs are busy, the nurse's supposed to answer the lights. On 5/19/26 at 9:59 AM, Staff C, Registered Nurse (RN), explained she wasn't sure what the maximum time allowed for answering a call light was, just as soon as possible. On 5/21/26 at 4:22 PM, the Director of Nursing (DON) explained the maximum allowable time frame for answering a call light's 15 minutes. The Answering the Call Light policy revised March 2021 instructed staff to ensure timely responses to the resident's requests and needs.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to maintain effective infection control and isolation procedures for 1 of 3 residents reviewed (Resident #7), specifically regarding contact precautions and hand hygiene during care for a resident with an infectious disease. The facility reported a census of 131 residents. Findings include: The Progress Note written on 5/7/26 at 9:35 AM documented the Advanced Registered Nurse Practitioner (ARNP) gave a verbal order to collect a stool sample from Resident #7 for Clostridium difficile (C. diff) (severe bowel infection) due to prolonged diarrhea and a history of C. diff infection. The Provider Encounter Note dated 5/7/26 documented the stool sample came back positive for C. diff. The staff placed Resident #7 on contact precautions, and started them on an antibiotic. The SPN - Focused Evaluation dated 5/11/26 at 9:11 PM reflected Resident #7 received treatment for C-diff and had 1 loose stool that shift. He reported his stomach remained tender.The SPN - Focused Evaluation dated 5/13/26 at 10:23 PM indicated Resident #7 continued to take medication for C-diff. He denied abdominal pain and didn't have loose stools reported on that shift.The Physician Order written 5/11/26 directed Resident #7 to stay in contact isolation precautions, with all treatments, medication passes, therapy, activities, and meals occurring in their room. On 5/13/26 at 8:58 AM, Staff F, Registered Nurse (RN), entered Resident #7's room wearing a gown and gloves. After explaining the plan to Resident #7, she began their dressing change. The procedure included filling the sink with soapy water and placing clean washcloths in the sink, without a barrier. She drained the soapy water, used running water to rinse a washcloth to clean Resident #7's legs, and reused it, only changing cloths when cleaning the other leg. Before doing the treatment, she removed her gloves, rinsed her hands under running water, turned off the water with a wet hand, dried her hands, and put on clean gloves. After doing the treatment, she removed her gloves, washed her hands with soap, turned off the water with a wet hand, dried her hands, and applied clean gloves. At the end of the procedure, she removed her gloves and sprayed the sink with a disinfectant that didn't list C. diff as an organism it killed. On 5/14/26 at 1:09 PM, Staff F explained when caring for a resident with C. diff, staff must wash their hands. She acknowledged handwashing included turning off the faucet with a paper towel. She explained a resident with C. diff required isolation to their room and signage belonged on the door. She explained the dressing change included her usual practice, and it's normal for her to use the sink as a basin. She didn't know if the disinfectant needed to sit on a surface for a specific amount of time before being wiped off. On 5/14/26 at 2:56 PM, watched Staff H, RN, place a contact precaution sign on Resident #7's door. On 5/14/26 at 2:58 PM, Staff G, Licensed Practical Nurse (LPN), explained staff should've placed Resident #7 on isolation at the time they suspected they had C. diff. She added hand washing required soap and water. On 5/14/26 at 5:17 PM, Staff I, housekeeper, explained she didn't use a specific cleaner for infectious rooms. She explained she hasn't encountered a room bad enough to wear a gown. She added if she knew a resident was infectious, she'd wear a gown. On 5/14/26 at 5:35 PM, the Administrator explained she didn't know if the facility had a product in house that would appropriately disinfect against C. diff. She explained the disinfectant used by Staff F didn't work against C. diff. On 5/14/26, the Administrator explained they did have a product in house that would kill C. diff, and it sat on the housekeeping carts. On 5/21/26 at 4:22 PM, the Director of Nursing (DON) explained she expected staff to wash their hands with soap and water in a room with a resident with C. diff. She explained she expected the staff to turn off the water with a paper towel during handwashing. She explained if a washcloth becomes soiled while cleaning wounds, the staff should use a new washcloth instead of rinsing and reusing it. She explained during wound care the staff should use a basin, not the sink, to hold water.

Based on observation, resident interview, staff interview and policy review, the facility failed to ensure call lights were in reach and accessible for 2 of 5 residents (Resident #9 and a confidential source) reviewed for call light use. The facility reported a census of 131 residents.Findings include: On 5/14/26 at 10:04 AM, an observation showed Resident #9's call light lay on the floor at the foot of his bed. He had a reacher (adaptive grabbing tool) on his bed. He sat in his wheelchair and moved about in his room. On 5/12/26 at 12:27 PM, a confidential interview with a resident revealed staff told them there's a call light in the bathroom, but they didn't know where to find it. An observation of the bathroom during the interview showed a call light sat about shoulder height behind the armrest on the toilet. The string on the call light measured approximately 5 inches long, making it inaccessible to the resident when they sat on the toilet. On 5/21/26 at 4:22 PM, an interview with the Director of Nursing (DON) revealed she expected call lights to be in reach and remain accessible to all residents. The Answering the Call Light policy revised March 2021 instructed staff to ensure the call light remained within easy reach of the resident.

Based on clinical record review, policy review, staff, family, and resident interviews, the facility failed to notify the provider when a resident on an antiplatelet medication developed a nosebleed for 1 of 3 residents reviewed (Resident #5) for medications. The facility reported a census of 131 residents.Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 2/14/26. The MDS documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included a documentation that Resident #5 took an antiplatelet medication (blood thinner). Resident #5's February 2026 Medication Administration Record (MAR) included an order for clopidogrel 75 mg (blood thinner) to give one time a day to prevent blood clots. Staff signed off the medication as given daily from 2/15/26 through and including 2/27/26. The Progress Note written on 2/27/26 at 7:30 AM documented Resident #5 had blood from the nasal area. When the nurse arrived, Resident #5 laid in bed with the head up for an assessment. Once the bleeding stopped, Resident #5 moved into a wheelchair and went about her morning activities. The nurse asked Resident #5 if she wanted to call the doctor or go to the Emergency Department (ED). Resident #5 declined, and said she would have her son take her if she did. She ate her lunch and packed to discharge home. The note lacked documentation of notification to Resident #5's family or provider.The Progress Note written on 2/27/26 at 2:30 PM documented Resident #5 had a swollen nose, with a hairline scratch across the septum (nostril divider) between the nostrils. Resident #5 also had edema (swelling) on both cheekbones below her eyes. Resident #5 reported a nosebleed earlier in the day. The progress note lacked provider notification. The Progress Note written on 2/27/26 at 3:26 PM documented Resident #5's family requested a medical evaluation prior to discharge for the swelling under Resident #5's eyes. The family requested Emergency Medical Services (EMS) transportation to the hospital. The Progress Note written on 2/28/26 at 1:06 AM documented Resident #5 admitted to the hospital with a brain bleed. On 5/18/26 at 1:24 PM, Resident #5's family member reported Resident #5 had a stroke prior to her stay at the facility. She did rehabilitation for a month or so at a local hospital and then discharged home. Once at home, the family decided she needed more rehabilitation, so she admitted to the facility. On 5/19/26 at 3:15 PM, Resident #5 explained she had a bloody nose the morning of discharge, and staff applied an ice pack to stop it. When she stood ready to leave, the nurse prepared her, and she went to the hospital in the ambulance. She explained she went to a different hospital the next morning. She reported she didn't have a brain bleed, she had a stroke previously, nothing new. On 5/14/26 at 3:36 PM, Staff A, Registered Nurse (RN), reported that in a nurse-to-nurse report, the previous nurse reported Resident #5 had a nosebleed prior to his arrival. The family arrived to take Resident #5 home and noticed the swelling under her eyes. When he went in to do his discharge assessment, he agreed with the family that something didn't seem right. He contacted the provider and sent Resident #5 to the emergency department by ambulance. He reported that since Resident #5 took an antiplatelet medication, the provider needed notification when the bleeding occurred to see if they wanted to hold the medication. On 5/21/26 at 4:22 PM, the Director of Nursing (DON) explained Resident #5 shouldn't have a bloody nose, especially while taking the antiplatelet medication. The provider needed notification. The Change in a Resident's Condition or Status policy revised February 2021 instructed staff to notify Resident #5's attending physician or physician on call when there had been an adverse reaction to a medication.

Based on clinical record review, policy review, resident and staff interviews, the facility failed to ensure staff followed physician orders for dressing changes, failed to provide appropriate assistance to a resident that fell, failed to notify all staff when a resident should be on contact precautions and failed to ensure staff washed their hands properly for 2 of 5 nurses reviewed. The facility reported a census of 131 residents.Findings include:1. Resident #9's May 2026 Treatment Administration Record (TAR) directed staff to apply Povidone-Iodine solution 10% to the right foot daily on the day shift (6:00 AM to 2:00 PM) for place gauze per podiatry. The documentation reflected staff completed the treatment daily except 5/1/26, 5/5/26, and 5/11/26. The documentation included to see the progress notes on 5/12/26 and 5/17/26. On 5/18/26 at 2:37 PM and 5/21/26 at 11:12 AM, Staff B, Licensed Practical Nurse (LPN), explained she performed a dressing change to Resident #9's right foot on 5/16/26. She confirmed during both interviews that she completed the dressing change at bedtime and both dressing changes involved the iodine gauze treatment. The Wound Care policy revised October 2010 instructed staff to verify the physician's order for the procedure. On 5/21/26 at 4:22 PM, the Director of Nursing (DON) explained that staff should not perform dressing changes that lack an order. 2. The Progress Note written on 5/3/26 at 11:45 AM documented Resident #1 fell in his room. The progress note documented a 10/10 pain rating in his left hip. He had some redness and mild swelling in his left hip. Resident #1 refused to bend his left leg due to pain. The Progress Note written on 5/3/26 at 6:09 PM documented the hospital admitted Resident #1 for a hip fracture (broken bone) and possible surgery. On 5/12/26 at 8:51 AM, Resident #1 explained on the day he fell, staff assisted him up off the floor with the mechanical lift. He explained the nurse skipped range of motion prior to getting him off the floor. On 5/18/26 at 2:37 PM, Staff B explained Resident #1 complained of pain in his left hip after he fell, while he lay on the floor. She explained they used the mechanical lift to get him up off the floor and into bed. She further explained it was normal protocol to get someone up off the floor when they fall, even if they complain of pain. The Falls - Clinical Protocol policy revised March 2018 lacked direction to staff for what to do in the event of a fall with complaints of pain and swelling of a joint. On 5/21/26 at 4:22 PM, the DON explained if a resident complained of pain and refused to move an extremity, she expected staff to make the resident as comfortable as possible, leave them on the floor, and wait for Emergency Medical Technicians (EMTs) to arrive.

Based on observation, resident and staff interviews, record review and policy review the facility failed to ensure resident's rooms were clean for 4 of 4 residents who complained about the cleanliness of their rooms (Resident #40, #41, #118 and #122). In addition, the facility failed to keep dirty laundry off of the floor in the laundry room. The facility reported a census of 129 residents. Findings include: 1. In an interview on 9/30/25 at 9:05 AM Resident #40 stated they seldom have housekeeping and thinks it has been about 3 weeks since the last cleaning of his room. Stated the bathroom is terrible to the point he doesn't like to use it and most of the time he goes to the up-front bathroom. During an observation of Resident #40's bathroom on 9/30/25 at 9:08 AM noted an unpleasant odor. The observation revealed a very dirty floor and toilet bowl. A dirty seat riser sat on the floor without a barrier. During an observation of Resident #40's bathroom on 9/30/25 at 2:19 PM noted an unpleasant odor and a very dirty toilet bowl. During an observation of Resident #40's bathroom on 10/1/25 at 9:27 AM noted an unpleasant odor. The floor and toilet bowl appeared very dirty with a dirty seat riser on the floor without a barrier. 2. During an observation on 9/29/25 at 11:00 AM noted Resident #41's bathroom floor, toilet, and toilet seat riser dirty. The seat riser sat on the floor without a barrier. During an observation on 10/1/25 at 10:01 AM noted Resident #41's bathroom floor, toilet, and toilet seat riser dirty. The seat riser sat on the floor without a barrier. In an interview on 9/29/25 at 10:58 AM Resident #41 described the toilet and floor as dirty. He explained the facility didn't have a housekeeper for about 2 1/2 weeks. Resident #41 stated the seat riser always sat on the floor. 3. In an interview on 9/30/25 at 9:23 AM Resident #118 reported the facility is really short in housekeeping. In the past couple months, her room has gone weeks without cleaning. Someone swept on Sunday because she called and complained. She added the staff person said he would mop on Monday 9/29/25 but never came back. Resident #118 stated that before that, he said they last cleaned about 3 weeks ago. In an interview on 10/1/25 at 9:25 AM Resident #118 stated that she didn't see any housekeeping in her room during the week. 4. During an observation on 9/29/25 at 11:01 AM noted Resident #122's bathroom smelled. Observed the floor, toilet, and toilet seat riser dirty. The seat riser sat on the floor without a barrier. During an observation on 10/1/25 at 9:25 AM Resident #122's bathroom smelled. The floor, toilet, and toilet seat riser looked dirty. The seat riser sat on the floor without a barrier. In an interview on 9/29/25 at 11:13 AM Resident #122 stated her bathroom smelled and had a booster seat on the floor, she didn't feel it is sanitary. During an observation on 10/2/25 at 8:20 AM of Resident #40, #41 and #121's bathrooms noted all 3 rooms hadn't change since 9/29/25. The seat risers remained dirty and on the floor. In an interview on 10/2/25 at 8:30 AM Staff D, Housekeeping Supervisor, stated over the previous 3-4 months she only had 3 housekeepers and she should have one for each hall at least. Recently, she hired 3 new housekeepers but so far only 2 can be on the floor. She currently had 4 housekeepers, so she is still short staffed. Staff D stated that each room should be cleaned daily but they don't have enough staff. They sweep the rooms they looks like it needs it, but the bathrooms should be cleaned and mopped daily with the trash taken out. Staff D denied having check lists at the time for tasks but they normally do when they are fully staff. When questioned about the seat risers, Staff D replied they should be cleaned but not if on the floor. When shown Resident #40, #41 and #122's bathrooms, , Staff D described them as terrible and admitted they didn't get cleaned. In an interview on 10/2/25 at 9:45 AM the Director of Nursing (DON) stated that if a room has a toilet seat riser on the floor it should be in a plastic bag. She expected the staff would clean it prior to putting in the bag if they removed it between residents. The DON added she would remove them from Residents #40, #41, and #122's rooms if they didn't use the toilet set riser. The Cleaning and Disinfecting Residents' Rooms procedure revised August 2013 lacked information on how often the staff should clean the rooms. The undated Daily Check List directed to sweep the resident's room, mop the resident's room, clean the toilet, sweep and mop the restroom floor daily. 5. During an observation on 10/2/25 at 9:00 AM of the laundry room revealed a pile of approximately 2 feet high by 4 feet wide of resident's dirty personal clothing. The clothing sat on the floor of the dirty side of laundry room, without a barrier between the clothing and floor, in the corner next to dirty laundry bins. During an interview on 10/2/25 at 9:00 AM Staff F, Laundry Aide, reported she didn't work for 2 days and the room shouldn't look that way, as dirty laundry shouldn't be on the floor. She described herself as the full-time laundry person. Staff F reported she had instructions written but the other staff didn't always follow her instructions. Review of the facility Environmental Guidelines and Protocols dated March 2013. Floors shall be kept clean and dry at all times. Facility staff will handle, store, process, and transport linens so as to prevent the spread of infection. Keep soiled linens in carts or bins, not on floor. During an interview on 10/2/25 at 11:17 AM with the Infection Preventionist reported they should use dirty linen bins to put dirty clothes in and not put them on the floor.

Based on observations, policy review, resident and staff interviews, the facility failed to provide sufficient staffing to ensure resident safety and meet their needs. The facility reported a census of 129 residents. Findings include: 1. Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure, and diabetes. On 9/29/25 at 11:28 AM Resident #31 reported the food as cold and added at times she didn't get a tray. Resident #31 on 10/1/25 at 12:55 PM reported she didn't have concerns with the food for the past three days. Resident #31 reported the facility had staff helping the aides, who don't normally help on the floor. 2. Resident #131's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS documented Resident #131 has a limb prosthesis (fake body part). The MDS included diagnoses of hypertension (high blood pressure), anxiety, and diabetes. The Care Plan Focus revised 9/26/25 regarding Activities of Daily Living documented Resident #131 needed assistance of one staff member with bathing, transfers, and personal hygiene. In addition, the Care Plan described Resident #131 as noncompliant with waiting for assistance to transfer and he would self-transfer. During a continuous observation on 9/30/25 at 7:12AM to 7:32 AM outside of the shower room on hall C. As the staff walked the halls at 7:21 AM Staff K, Certified Nurse's Aide (CNA), went into the shower room, as they opened the door noted Resident #131 in the shower room unattended. Resident #131 on 9/30/25 at 9:00 AM reported from time to time the staff leave him unattended in the shower room, usually only for 2-5 minutes at the most. Resident #131 reported when in the shower room he sat in the shower chair and had a stump to his left leg. On 10/1/25 at 1:26 Staff K reported on a normal day, the facility had only one aide on hall C. Staff K reported she had extra staff that day and the day before due to state being in the building. Staff K verbalized the Restorative Aide would help in the morning with transfers but they helped all the halls so they didn't stay long. Staff K reported staff left Resident #13 in the shower on Tuesday and in the past as well, due to him being safe and he would put on his light on when he got done. Staff K reported otherwise the residents wouldn't get showers because it is a lot of work for one person but the management knew and didn't change the staffing. 3. Resident #44's MDS assessment dated [DATE] identified a BIMS score of 5, indicating severe cognitive impairment. The MDS listed her as dependent (helper did all of the effort and the resident did none of the effort to complete the activity.) for all activities of daily living. The MDS included diagnoses of hypertension (high blood pressure), dementia, and malnutrition (inadequate intake of nutrients). On 9/30/25 during a continuous observation from 1:13 PM to 2:08 PM noted Resident #44 at the nurses' station in her wheelchair. She had her pants and shirt are wet. In addition, she had liquid brown matter (similar to fecal matter), around the outer ring of the area appeared to be drying. At 1:44 PM the Assistant Director of Nursing (ADON) asked Resident #44 if she would like to go outside for the activity and she replied yes. When the ADON went to push her, she noted the wet pants. The ADON approached Staff K as they went into the shower room to get supplies for another resident and whispered to her about Resident #44. Staff K reported she would get to her as soon as she could because as she was working with another resident at that time and she would have to give her a shower. The ADON then went and sat at the desk watching down the hallways. At 2:08 PM Staff K went up to Resident #44 and explained she would get her cleaned up. Staff K took Resident #44 to the shower room, put on a gait belt, did hand hygiene, and applied gloves. As Staff K assisted Resident #44 to the toilet, she removed her pants that revealed a mix of wet and dried liquid stool all up her lower half of the stomach, upper thighs, buttocks and peri area. Staff K got Resident #44 to the toilet and reported she would give Resident #44 a shower due to it being so bad. Throughout the time Resident #44 sat at the nurses' station, observed other staff at the nurses' station either charting and/or watching hallways but no one got up to assist her. On 10/2/25 at 8:32 AM the ADON reported all nurses are to help staff when needed with resident care. She verbalized no residents are to be left in the shower room unattended. She reported she told staff even if they are independent, they cannot be left alone in the shower room. On 10/2/25 10:13 AM the Director of Nursing (DON) reported the nurses should assist with the care of residents when they could. Staff should answer calls-lights when they could to help the staff on the floor. She reported the facility had some residents who wanted to be left in the shower room by themselves. She reported the staff could give them privacy but be there either by the door or in the room with the privacy curtain closed. 4. Resident #35's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. In an interview on 9/29/25 at 1:23 PM Resident #35 stated the staff took 30 to 45 minutes at times to answer their call light. 5. Resident #41's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. In an interview on 9/29/25 at 10:58 AM Resident #41 reported sometimes getting help is not easy. Resident #41 added it didn't take long for the call light but sometimes they answer it and turn it off stating they will be back in a minute but they don't always come back. Resident #41 reported the facility only one CNA on her hall usually and she didn't feel it is enough. 6. Resident #118's MDS assessment dated [DATE] a BIMS score of 15, indicating no cognitive impairment. In an interview on 9/29/25 at 11:19 AM Resident #118 stated she thought the facility needed two aides for each hall and most of the time they only had one. Resident #118 added sometime the aides covered E and G halls, and described that as too much. F hall usually had two staff. Resident #118 explained they worried about call lights. Resident #118 stated she waited several times for 45 minutes plus and one time even an hour. They need extra help. Resident #118 added the Administrator told her they are trying to hire people. She didn't blame the staff as they don't have enough help. Also, the nurses didn't help when they didn't have a second aide available. The Administrator told her it was corporate at times. She stated she told him to ask corporate how they would feel if their family sat on the bedpan for 45 minutes. The last time they had two aides on her hall was 9/21/25 and she wrote it down as it was the first time in months having two aides and none since. She yelled out the door sometimes as she needed help and didn't want to wet the bed. 7. Resident #120's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. In an interview on 9/29/25 at 1:22 PM Resident #120 described the facility as short of help, so they couldn't answer as fast as they could. Resident #120 added it sometimes took 30 to 45 minutes for the staff to answer the call light as they only had one CNA usually. 8. Resident #122's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. In an interview on 9/29/25 at 11:13 AM Resident #122 stated call lights sometimes could take a while, once it took about 30 minutes. In an interview on 9/30/25 at 12:15 PM Staff A, CNA, stated the facility normally only had one CNA in G hall. Staff A explained it use to be the independent wing but most of them are no longer independent. She used to be able to do showers right away in the morning but now she couldn't. Staff A described it as tough with one. Staff A explained the work as too much for one CNA anymore as the hall had 3 who used standing mechanical lifts. Unless they are care planned for 1 person, she needed to find help from another hall unless the nurse had time. Staff A reported it as tough when they have 4-5 showers to get done as she can't be on the floor for the call lights. Staff A explained she need to take residents to the toilet after meals and lay people down. Staff A stated she thought the facility should have 2 CNAs down the hall so one could do baths while the other answered the call lights. Staff A, added it would be easier to help residents use the toilet after meals and have help with transfers. In an interview on 9/30/25 at 2:15 PM Staff E, Certified Medication Aide (CMA) described herself as an agency nurse and always worked by herself on Hall G. Staff E explained she also always worked by herself on Hall F which is worse as there are 3 residents that needed help with eating, residents who need mechanical lifts, and one very heavy resident. When she found out the facility had State there, she told her agency she wouldn't work the F Hall as she didn't want to lose her license. She added that on Hall G she prioritizes what needs to be done and she worries about the showers the most. Stated that there is nobody to answer the call lights when giving showers. The nurses don't help and even say that answering call lights is not their job. That's why they went to nursing school. Finally, she stated that there should be 2 CNAs on Hall G and definitely on Hall F, as they might need more.

Based on observations, record review, staff interview and policy review, the facility failed to complete an accurate skin assessment for 1 of 2 residents reviewed (Resident #31). The facility reported a census of 129 residents. Findings include: Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), heart failure, and diabetes. Observation on 9/29/25 at 11:42 AM noted bruises to both of Resident #31's hands. The right hand had a band-aid on part of the bruised area. On 9/29/25 at 11:42 AM Resident #31 and his wife reported he had the bruises and the covered area for a few days. Observation on 10/1/25 at 10:45 AM noted the bruises remain on both hands. The right hand has a new band- aid on it. On 10/1/25 at 11:59 AM Staff I, Registered Nurse (RN), reported she did the weekly skin assessments and documented them in the Electronic Health Record (EHR). Staff I reported the Certified Nurses' Aides (CNA) also let the nurses know about new skin areas. Staff I verbalized she didn't know about Resident #31's areas on his hands. The staff should have documented the areas. Resident #31's September 2025's Treatment Administration Record reflected he had weekly skin assessment completed 9/30/25. Resident #31's EHR lacked documentation of any bruises to the hands or the band-aide to the right hand. In addition, his EHR lacked documentation of a Report of Incident/Accident for the areas. On 10/1/25 at 12:03 PM the Director of Nursing (DON) reported the nurses did the skin assessments weekly and they should document any new areas. The EHR should have an evaluation of the skin assessment. The facility policy titled Skin Tear-Abrasions and Minor Breaks, Care of revised September 2013 directed to complete a Report of Incident/Accident after the discovery of an abrasion, skin tear, or bruise.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure safe and accurate delivery of oxygen therapy for one of one resident reviewed for respiratory care (Resident #95). The facility reported a census of 129 residents.Findings include:Resident #95's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of Coronary Artery Disease (CAD or impaired blood flow from the heart), pneumonia (an infection of the lungs), Chronic Obstructive Pulmonary Disease (COPD or long-term damage to the lungs affecting breathing), pulmonary hypertension (damaged blood vessels from the heart to the lungs, increasing the pressure in the lungs), and hypoxemia (low blood oxygen). The Care Plan Focus revised 8/23/24 indicated Resident #95 had altered respiratory status/difficulty breathing related to COPD. The Intervention directed Resident #95 had oxygen at 2 liters (L) continuous via (/) Nasal Cannula (NC) to keep saturations greater than 90%. The Order Details dated 7/8/25 listed an order for oxygen continuously at 2L/NC. The Order Details dated 10/1/25 ordered oxygen continuously via NC at 2L per minute, as Resident #95 allowed. Chart refusal of oxygen or removal of the NC. The Progress Notes lacked documentation of Resident #95 asking for or refusing her oxygen. In addition, the progress notes lacked documentation of her taking off her oxygen. Resident #95's September and October 2025 Electronic Treatment Administration Record (ETAR) indicated Resident #95 continuously wore her oxygen for at least the last 60 days with no refusals. During an observation on 10/1/25 at 9:15 AM Resident #95 did not wear her oxygen. The observation revealed she had a concentrator and an oxygen container on the back of her wheel chair in her room with neither running. During an observation on 10/1/25 at 9:20 AM Staff B, Certified Nurse Assistant (CNA) took Resident #95 to the bathroom next to the nurse's station. During an observation on 10/1/25 at 10:23 AM noted Resident #95 wore a NC supplying oxygen from an oxygen cannister on her wheelchair at 2L. In an interview on 10/1/25 at 9:15 AM Resident #95 stated she got up that morning at 7:00 AM and the staff never put on her oxygen. She went to breakfast and back without her oxygen. Resident #95 guided to put on her call light. In an interview on 10/1/25 at 9:55 AM Resident #95 reported she still didn't have on her oxygen. Resident #95 reported she told the staff, who said she told the nurse who has to do it but she was busy. In an interview on 10/1/25 at 10:23 AM Resident #95 stated the nurse didn't turn on her oxygen and she felt a little short of breath. She added her granddaughter, Resident #83, turned it on to 2 L and she put the NC on by herself. In an interview on 10/1/25 at 10:24 AM Resident #83 stated she turned on Resident #95's oxygen cannister on the back of her wheel chair. In an interview on 10/1/25 at 10:25 AM Staff B stated Resident #95 told her she wanted her oxygen turned on. Staff B explained she can't turn on the oxygen to the oxygen cannister but she did tell the nurse she wanted her oxygen. In an interview on 10/1/25 at 10:40 AM Staff C, Registered Nurse (RN), stated Resident #95 should receive oxygen at 2 L/NC continuously. Staff C reported a CNA couldn't turn on the oxygen to an oxygen cannister but they could turn on the room concentrator. Staff C explained Resident #95, per her own discretion, could ask the staff to turn on or off her oxygen. Resident #95 didn't ask her to turn on her oxygen that morning and went to breakfast that morning so she must not want the oxygen. In an interview on 10/1/25 at 2:45 PM the Director of Nursing (DON) stated residents that have an order for continuous oxygen have the right to take their oxygen off if they want. The DON verbalized they didn't have to ask to have their oxygen put on. When asked about Resident #95, the DON responded she took off and put on her oxygen by herself. The DON added Resident #95 had an extensive Care Plan that indicated noncompliance, refusal of cares, and false accusations. The DON stated Resident #95's Care Plan oxygen orders should match her current order for oxygen. When the DON asked if the nurse got questioned, the surveyor replied Staff C stated Resident #95 must not wanted to have her oxygen on as she didn't ask for the oxygen. The Oxygen Administration policy revised October 2010 directed to review the physician's orders or facility protocol for oxygen administration. In addition, review the resident's Care Plan to assess for any special needs. The policy lacked direction of documentation of refusals or residents removing their oxygen.

Based on observation, policy review and staff interviews the facility failed to ensure all medications were dated when opened. The facility reported a census of 129. Findings include:During an observation of medication administration on 10/2/25 at 7:00 AM, Staff G, Licensed Practical Nurse (LPN), opened the D wing cart and pulled out a vial of Lantus for a resident. Staff G described the vial as opened but it didn't have an open date on the vial. The pharmacy label identified the vial as Lantus INJ 100 milliliter (ML) with a dispensed date of 9/24/25. The label had a refrigerate sticker attached to it. Staff G stated the vial should have a date when they opened the vial and removed the vial from the medication cart. During an observation of medication administration on 10/1/25 at 9:01 AM Staff H, Registered Nurse (RN), pulled out a box of Artificial Tears for a different resident with the top of the packaging removed. The packaging and Artificial Tears bottle didn't have an opened date. Staff H removed the Artificial Tears from the medication cart. Staff H acknowledged the packaging/bottle should have an opened date. Inspection of the C wing medication cart on 10/1/25 at 1:28 PM revealed the following opened medications without a date opened on the packaging:a. Stock Fiber Powder- Psyllium Husk 19-ounce bottle (fiber supplement)b. Stock Reguloid - Dietary Fiber Supplementc. Stock Calcium Acetate 667 mg (calcium supplement)d. Stock Basic Standardized Cranberry tablets 250 mge. Stock [NAME] & Thrive Calcium 600 mg + Vitamin D3 Plus Mineralsf. Resident #12's Carboxymethyl cellulose Sodium 0.5% eye dropsStaff I, RN, acknowledged the items identified lacked open dates. Staff I verbalized they should date everything when opened. Inspection of the D wing medication cart on 10/1/25 at 1:50 PM revealed the following opened stock medications without an opened date on the packaging:a. Stock Acetaminophen 325 mgStaff G acknowledged the bottle didn't have a date opened and it should have one. Inspection of the E wing medication cart on 10/1/25 at 1:53 PM revealed the following opened medications without a date opened on the packaging:a. Stock [NAME] & Thrive Anti-Diarrheal Loperamide Hydrochloride tablets 2 mgb. Stock [NAME] & Thrive Acid Reducer Famotidine Tablets 20 mgc. Stock Geri Care Vitamin D 25 mcg tabletsd. Stock Geri Care Thiamin Vitamin b-1 100 mg tabletse. Stock Geri Care Vitamin B-12 500 mcg tabletsf. Stock Geri Care Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative 14-ounce bottleg. Stock Geri Care Vitamin C 250 mg tabletsh. Stock [NAME] & Thrive Extra Strength Pain Reliever - Acetaminophen 500 mgi. Stock Geri Care Aspirin 81 mgj. Stock [NAME] & Thrive Ibuprofen 200 mg tabletsStaff H acknowledge the identified items did not have date open on the packaging and had been unsure if date opened was needed. Inspection of the F wing medication cart on 10/1/25 at 2:01 PM revealed the following opened medications without a date opened on the packaging:a. Stock [NAME] & Thrive Acid Reducer Famotidine Tablets 20 mgb. Stock [NAME] & Thrive Anti-Diarrheal Loperamide Hydrochloride tablets 2 mgc. Stock Geri Care Extra Strength Pain- Reliever Acetaminophen 250 mgd. Stock Geri Care Geri-Dryl Allergy Relief Diphenhydramine HCL 25 mge. Stock Marlex Vitamin B-1 (Thiamine HCL) 100 mgf. Stock [NAME] & Thrive Melatonin 3 mcgStaff J, LPN, acknowledged the identified items should have a date when opened. Inspection of the skilled medication storage room on 10/1/25 at 2:01 PM revealed an unlabeled Basaglar Kwik pen (insulin glargine injection) laying in loose a plastic basket. Staff J, verbalized the pen should be in a bag with a resident's name on the pharmacy label. In an interview on 10/1/25 at 2:15 PM the Director of Nursing (DON) verbalized she saw the Basaglar Kwik pen (insulin glargine injection) laying in the plastic basket earlier that morning but didn't dispose of it at that time. The DON acknowledged she meant to come back to take care of the insulin pen but forgot. The DON verbalized they expected medications to have a date when they open the medication. The facility provided Administering Medications police revised April 2019, directed the following:a. The expiration/beyond use date on the medication label is check prior to administering. When opening a multi-dose container, the date opened is recorded on the container. b. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verified that the correct pen is used for that resident.

Based on clinical record review, resident, family and staff interview the facility failed to complete oral cares as required for 1 of 4 residents reviewed (Resident #1). The facility census was 120 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #1 as dependent on staff for oral care and eating. The MDS included diagnoses of hypertension (high blood pressure), cerebrovascular accident (stroke), hemiplegia or hemiparesis, (muscle weakness or partial paralysis on one side of the body that affect the arms, legs and facial muscles), anxiety and depression. The MDS documented Resident #1 denied pain. The Care Plan Focus of activities of daily living (ADLs) initiated 9/29/23 included an intervention that Resident #1 required maximum assistance of 1 person with oral hygiene. Resident #1's February 2025 Documentation Survey Report lacked documentation on 2/2/25, 2/6/25, 2/14/25 and 2/23/25, indicating he didn't receive oral care those days. Resident #1's March 2025 Documentation Survey Report lacked documentation on 3/2/25, 3/17/25, 3/18/25, 3/19/25, 3/22/25, and 3/24/25 indicating he didn't receive oral care those days. Interview on 4/8/25 at 4:45 PM, Resident #1, stated sometimes his teeth get brushed and sometimes they don't. He added it depended on who worked. He denied mouth pain. Interview on 4/9/25 at 2:00 PM, Resident #1's family reported they expected staff to brush Resident #1's teeth after every meal. Interview on 4/9/25 at 3:00 PM, the Director Of Nursing (DON) verified they expected the staff to do oral cares twice daily. After reviewing the Documentation Survey Report for February and March 2025, the DON acknowledged Resident #1 didn't receive oral cares twice daily. On 4/10/25 at 8:30 AM, observed Resident #1 had missing top and bottom teeth. As he received oral cares, his upper gums started to bleed. Resident #1 denied having pain during oral cares. The Activities of Daily Living Supporting Policy/Procedure dated March 2018, directed the residents would receive care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who can't carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will receive appropriate care and services who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate supports and assistance with hygiene (bathing, grooming and oral care). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

Based on observation, policy review and staff interviews, the facility failed to date, date, cover, or label items after opening. In addition, the facility failed to have clean dishes when serving the meal. The facility reported a census of 114 residents. Findings include: 1. On 12/30/24 at 9:45 AM observed in the drink area refrigerator with the Certified Dietary Manager (CDM) present revealed the following: a. An open, undated, and uncovered piece of cherry pie. b. An undated and unlabeled, covered plate covered with a prior day's meal. c. Unlabeled and undated items in a clear plastic small container. D. Two unlabeled and undated juice pitchers. During an interview 12/30/24 at 10:00 AM the CDM reported the staff should have covered, dated, and labeled the items. 2. During the 12/30/24 lunch meal, observed the staff serve the following: a. 11:25 AM: Staff A, Cook, served fish, hashbrown casserole, and mixed vegetables on a dirty plate containing dried food particles. Staff A got another dirty plate and served the same meal on the new dirty plate contained dried food particles for the A wing. b. 11:37 AM: Staff B, Cook, dished tomato soup into a dirty bowl containing dried food particles and served it in the main dining room. Staff B removed an dirty bowl with dried food particles and served another tomato soup in the dining room. Staff B then served a third dirty bowl with tomato soup into the dining room. c. 11:45 AM: Staff B serve fish, hashbrown casserole, and mixed vegetables on a dirty plate with dried food particles on the plate to the dining room. On 12/30/24 at 11:52 AM during an observation in the dining room Resident #1 reported she had a bowl of soup for lunch and didn't notice the rim of the bowl was dirty on the side with dried food until finished the bowl. She reported they frequently received dirty dishes. On 12/30/24 at 12:37 PM observed the clean dish caddy to hold the clean dishes, dirty with dirt and dirty dishes containing food particles on them. During an interview on 12/30/24 at 12:45 PM the CDM reported the staff need to send the dishes back through the dishwasher if the dishes didn't get cleaned. Facility Policy titled Food Receiving and Storage revised October 2017, directed food services or other designated staff to maintain clean food storage areas at all times, and have all foods stored in the refrigerator or freezer covered, labeled and dated with a use by date. Facility Policy titled Sanitization revised October 2008, instructed to keep all utensils, counters, shelves and equipment clean and washed to remove or completely loosen soil by using the manual or mechanical means necessary.

Based on clinical record review, policy review, and staff interviews, the facility failed to have a consistent code status between the physician orders, the electronic health record (EHR), and the Care Plan for 1 of 1 resident reviewed for Advanced Directives (Resident #101). The facility reported a census of 116 residents. Findings include: Resident #101's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. Resident #101's Clinical Physician Orders included an order dated [DATE] for cardiopulmonary resuscitation (CPR). Review of the facility form titled, Cardiopulmonary Resuscitation and DNR order Declaration Form, signed by Resident #101 on [DATE], indicated he desired to have CPR initiated to prolong his life when biological death (final death) is not imminent. The Care Plan Focus initiated [DATE] reflected Resident #101 had an Advanced Directives code status of do not resuscitate (DNR). The Care Plan documented the goal was for Advanced Directives to be followed per resident/family request. The Care Plan further directed staff to perform CPR, honor the resident's wishes and review the resident's wishes quarterly and as needed. Review of facility policy titled, Advanced Directives, revised [DATE] directed to have consistent Plans of Care for each resident with their documented treatment preferences and/or Advanced Directive. The staff will inform the Care Plan Team of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and Care Plan. During an interview on [DATE] at 8:12 AM, the Director of Nursing (DON) reported they expected consistent Advanced Directives between the resident's physician orders, the EHR, and the Care Plan. During an interview on [DATE] at 8:37 AM, Staff A, Registered Nurse (RN), explained the facility kept the Advanced Directives on the resident's Medication Administration Record (MAR), in the EHR, in a book at the nurse's station, and on the Care Plan. During an interview on [DATE] at 1:15 PM, the DON acknowledged Resident #101's Care Plan Focus had DNR documented and the rest of his clinical record listed he desired CPR.

Based on clinical record review and staff interviews the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non coverage form CMS 10055 (SNF ABN) for 1 of 3 residents (Resident #372) reviewed. The facility reported a census of 116. Findings include: Resident #372 Minimum Data set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 11, indicating moderately impaired cognition. The MDS indicated Resident #372 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand, chair/bed to chair transfer, toileting, and walking. Resident #372's MDS included diagnoses of cancer, coronary artery disease (impaired blood vessels), heart failure, diabetes mellitus, cerebrovascular accident (stroke), wound infection, non traumatic ischemic (dead tissue) infarction (inadequate blood supply) of the muscle (right lower leg), and non Alzheimer's dementia. The Notice of Non Coverage form CMS 10123 (NOMNC) dated 9/10/24 at 3:27 PM indicated the Social Worker contacted Resident #372's Power of Attorney (POA) and explained the NOMNC. The POC indicated they would sign it on 9/11/24. An addendum added on 9/11/24 at 10:42 AM indicated the Social Worker spoke with the POA and notified him Resident #372 knew about his discharge from skilled services and he understood, he didn't wish to appeal. The POA signed the form on 9/11/24. The Social Service Progress Note dated 9/11/24 at 4:20 PM indicated Resident #372 would remain in the facility at an intermediate care facility (ICF) level of care after his Medicare A skilled stay ended. Resident #372 Clinical Census listed an admitted [DATE] as Medicare Part A skilled stay. The Clinical Census documented on 9/13/24, Resident #372 continued to reside in the facility after his Medicare Part A skilled services ended. Resident #372's clinical record lacked a SNF ABN. On 10/22/24 at 1:42 PM Staff B, Social Worker, declared themselves as the person responsible for reviewing the SNF ABN and the NOMNC with the resident/responsible family. Staff B verified they didn't provide Resident #372 with the SNF ABN. On 10/22/24 at 2:16 PM the Administrator said they expected all required notifications be completed as required. The facility failed to provide a policy for providing Medicare required notices.

Based on clinical record review and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #63). The facility reported a census of 116 residents. Findings include: Resident #63's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of anxiety, depression, psychotic disorder, post-traumatic stress disorder (PTSD). In addition, Resident #63 received antipsychotic and depression medications during the lookback period. The Care Plan Focus initiated 1/18/23 reflected Resident #63 had the potential for psychosocial well-being problems related to anxiety, depression, PTSD, psychosis, delusions, and hallucinations, due to his loss of independence and being away from family following his recent admission to the facility. The Psychological Service Progress Note dated 3/6/23 listed a diagnosis of PTSD. Resident #63's Level 1 PASRR dated 11/20/23 lacked a diagnosis of PTSD. Resident #63's clinical record lacked a PASRR after 11/20/23. During an interview on 10/23/24 at 11:24 AM, the Social Services Coordinator reported they missed PTSD on the PASRR and they should have completed a new one. In an interview on 10/23/24 at 11:32 AM, the Director of Nursing (DON) reported the facility didn't have a policy for PASRR, as the facility followed the regulations.

Based on clinical record review, staff and resident interviews and observations, the facility failed to provide adequate supervision to ensure the environment was as free of hazards as possible. Observation on 9/19/2022 at 9:55 am revealed 7 male residents on the B wing CCDI (Chronic Confusion or Dementing Illness) unit. Resident #18 had his breakfast tray in front of him with several bites gone. Tour of the entire unit at 9:55 am failed to reveal any staff member present on the unit. This failure resulted in Immediate Jeopardy to the health, safety and security of the 7 residents. The facility reported a total census of 122 with 7 male residents on the B Wing (CCDI) unit. Findings include; According to the significant change Minimum Data Set (MDS) dated [DATE], Resident #18 had diagnoses which included Alzheimer's, Dementia, Diabetes, history of falls, need for continuous supervision and abnormalities of gait and mobility. The resident could not participate in the Brief Interview for Mental Status (BIMS) exam which indicated severe cognitive ability. The resident required extensive assistance of 1 staff for transfers, ambulation, dressing and supervision and assistance of 1 person for eating. The resident experienced 2 or more falls since admission and utilized a walker to ambulate with staff. Review of Resident #18's Care Plan dated 7/13/2022 directed staff to remind resident to eat meals due to low body weight. Identified the resident at a risk of wandering and he resides on the CCDI unit for safety as he has had several attempts to leave the building in the past. The Care Plan revealed the resident does not like to wait for assistance and will ambulate independently. The resident has a history of wandering into peers rooms. Observation on 9/19/2022 at 9:50 am revealed Resident #18 sitting alone at a dining room table with his breakfast tray in front of him, his head was down and appeared to be asleep, his walker at his side. The resident appeared to have eaten several bites of food. The dining room had 4 other male residents in the room watching television at this time. No staff observed in the dining room. At 9:52 am on 9/1/9/2022 the Surveyor walked up Hall B, checking each resident room from the dining room to the nurses station, no staff present in any resident rooms, dining room or nurses station. Observation at 9:55 am revealed a male resident sitting by the nurses station, stated he is waiting for a staff member to help him get some money from his account. Asked the resident where staff were, he stated he did not have any idea but he's waiting for them. Observation of B Wing at 10:00 am, no staff are present on the unit or the nurses station. At 10:03 am, Staff C-Assistant Director of Nurses (ADON) entered CCDI nurses station, Surveyor made her aware that no staff were currently on the B Wing. The ADON acknowledged the lack of staff on the unit, stating it was a problem, turned and left the CCDI nurses station. Observation on 9/19/2022 at 10:06 am of the A Wing CCDI unit revealed Staff B-RN standing at the medication cart next to Room 4. The RN grabbed a medication from the top of the cart and entered Room 4, leaving the medication cart unlocked and unsecured. Observation of the cart revealed on the top sat multiple plastic cups. At the same time the RN entered Room 4 a female resident walked up to the cart and grabbed something from the trash receptacle that hung from the side of the medication cart, level with the top of the medication cart. The female resident looked at the article she grabbed from the cart which appeared to be a disposable medication bubble pack. The resident looked at the piece of plastic and threw it on the floor and walked away. The Staff B-RN returned to the medication cart about 1 minute later and Surveyor informed her she left her medication cart unlocked a a female resident grabbed a piece of trash from the trash receptacle hanging from the medication cart. Staff B became tearful and stated she is doing the best she can, she is alone on both units, is still passing her morning medications and her 1 aide she had for both units is on break. The RN stated she must supervise the residents and pass medications at the same time, she stated it is a dangerous situation. Observation on 9/19/2022 at 7:45 am revealed 2 staff assigned and working on Hall A and Hall B CCDI unit, Staff B-RN and Staff J-Certified Nurses Aide. Staff B-RN stated they started their shift today with 2 aides and 1 nurse but the second aide got pulled right away at beginning of shift due to staff call ins. Staff B stated she has been told the CCDI units should be staffed with 2 aides and a nurse but this does not happen. Review of the 9/19/2022 assignment sheets revealed a total of 2 staff assigned to work both the A and B Wing of the CCDI unit, Staff B-RN and Staff J-C.N.A. Observation on 9/19/2022 at 10:12 am revealed Staff F-SW enter the B Wing and walk down the hall to the day room. During an interview with Staff D-Administrator on 9/19/2022 at 1:40 pm, Staff D stated it is okay to have 1 person, either an aide or nurse alone on a Wing of the CCDI unit but it is not okay to leave a CCDI wing unattended. The Administrator acknowledged they are required to have a least 1 staff on the CCDI unit at all times. During an interview with Staff K-C.N.A. on 9/26/2022 at 4:46 am, the staff stated prior to 9/19/22 staffing was inconsistent, many nights the staffing would be 2 staff total for both A and B wings. It would be a nurse or certified medication aide and 1 certified nurse aide. Staff K stated when the aide or nurse would take a break, the remaining staff would have to watch both A and B wing. This was especially true when the assigned staff called in sick at the last minute. During an interview with Staff J-C.N.A. on 9/26/22 at 7:00 am, the staff stated the staffing on last Monday, 9/19/22 was a normal day staff. They would frequently assign 2 staff total for both A and B wings. Staff J stated when the person she is working with takes breaks or has to leave the unit for any reason, this leaves on 1 staff to work both units. If she is attending to a resident on the A wing, the B wing will not have any staff present on the wing during that time. During an interview with Staff L-C.N.A. on 9/26/22 at 5:00 am, the staff stated prior to 9/19/22 the staffing was not good. At times there would only be 2 staff assigned to the night shift, usually a nurse/medication aide and 1 CNA. If the other person would take a break the remaining staff would be expected to work both units. If a nurse worked alone and a resident needed a medication or treatment, the nurse would take care of the resident leaving the other unit unattended and without staff. During an interview with Staff E-Social Worker on 9/19/2022 at 2:45 pm, Staff E stated Resident #18 has a tendency to be exit seeking and has gone out the doors of the facility, with the last incident on 7/7/2022 when he walked out of the Skilled Unit door. The staff transferred the resident to the locked CCDI unit for closer supervision. During an interview with Staff F-Social Worker/Program Director for CCDI unit on 9/19/2022 at 3:15 pm revealed the facility does not have a policy for staffing requirements for the CCDI unit that she is aware of. Observations from 9:50 am-10:12 am, a total of 22 minutes, the B Wing of the CCDI unit was left unattended and without staff to supervise and provide care for the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/19/2022 at 1:40 pm and was given the IJ template. The facility removed the Immediate Jeopardy on 9/20/2022 through the following actions: a. A facility wide staff re-education directed the staff per CCDI guidelines a unit must always be supervised. If an employee should leave the unit for any reason they must find a replacement to cover their hall and a Certified Medication Aide or Nurse are not to leave medication and/or treatment carts unlocked at any time. Even if stepping into resident's rooms, the medication carts must be locked. b. If the facility staff received their re-education via telephone or text message, the staff must read and sign the re-education prior to working their assigned shfit. c. The staff coming to work from a staffing agency must read and sign the re-education prior to working their assigned shift. At the time of exit, the scope and severity was lowered to a D after verification staff education completed and staff observed in the CCDI units.

Based on record review, staff and physician interviews the facility failed to provide assessment or implement interventions for skin ulcerations in a timely manner for one of six residents reviewed (Resident #1). The facility reported a census of 107 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #1 scored a 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderately impaired cognitive status. The MDS indicated the resident needed extensive assist of 2 staff with transfers, bed mobility, dressing, toileting and the resident at risk for developing pressure ulcers. The resident identified with no pressure ulcers or venous and arterial ulcers. The resident had a pressure reducing device for the chair and device for the bed. The resident did not have a turning and repositioning program. The Care Plan dated 11/24/21 revealed Resident #1 had impairment to skin but failed to address type or location of the skin impairment. Interventions directed staff to educate causative factors and measures to prevent skin injury. Staff were to monitor for and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan failed to direct staff on any interventions to prevent further skin breakdown. The Admission/Readmission Evaluation dated 11/24/21 in the skin integrity section revealed no pressure injury but did have a non-pressure wound. The assessment failed to reveal site, type or size of wounds. The additional information provided was bruising to both upper extremity. Right foot all toes purple/black with multiple small open areas to right foot. Dressing on and unable to remove as resident reports pain. The Transfer Order from the Hospital on admission 11/24/21 directed to keep wound clean and dry. No tub soak. Daily showers. Begin painting with [MEDICATION(S)] should the right toe wounds begin to demarcate. The Skilled Progress Note dated 11/25/21, documented all toes on right foot discolored. The Skilled Progress Note on 12/2/21 documented the toes on right foot remain black in color, no odor noted. The Skilled Progress Note dated 12/7/21 documented the toes on right foot remain black in color, no odor noted, and dressing intact. A 12/11/21 Nurse Progress Note revealed the resident went to the Emergency Department. The Emergency Department Physician Note dated 12/11/21 identified significant eschar and necrosis was appreciated of digits 1, 2, 3 and 5 of the right foot. Skin sloughing was also appreciated on the plantar aspect. There is also a 2 x 2 centimeter (cm) heel ulcer on the posterior aspect of the right foot. The Emergency Department Assessment/Plan Notes identified the following: a. Ischemic necrosis of toe. b. Pressure ulcer of right foot. The Electronic Health Record failed to reveal any assessment or intervention of any open wounds on or after the emergency room visit on 12/11/21. The Admission Braden Scale (Scale used to predict pressure sore risk) dated 12/15/21 Score was 16 indicating Resident #1 at risk for pressure sore. The Progress Note from a Physician Visit on 12/14/21, notes debrided ulcers. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Operative Procedure documentation dated 12/16/21 reveals procedure #6: Extensive debridement of wound, right foot. Attention was directed to the posterolateral aspect of the right foot where the ulceration resides. Ulceration underwent sharp subcutaneous debridement with a #15 blade down to good, bleeding, tissues. All visible, non-viable, necrotic tissue was removed. The patient tolerated the procedure well with no complications. The ulceration was then dressed with a 3 x 3 [MEDICATION(S)] border. During an interview on 3/9/22 at 10:10 A.M., the Director of Nursing (DON) states she would expect staff to complete a skin check on admission and every week after. If a resident has skin issues there should have been an evaluation picture and obtain a treatment. During an interview on 3/9/22 at 11:37 A.M., the DON states she can not find wound measurements for Resident #1 and staff should have done wound measurements. The staff should have completed a skin evaluation on admission and upon return from the emergency room . The facility provided a policy titled Pressure Ulcer Skin Assessments from the Nursing Guidelines and Procedure Manual January 2015 edition. The policy directed staff to assess any new pressure ulcer as soon as discovered. Include all pertinent information on Nurse's notes: location of ulcer, stage, measurement in centimeters of length, width and depth surrounding skin conditions and any drainage should be described. On 3/14/22 at 4:26 PM, the Podiatrist (foot Doctor), reported necrotic tissue can develop almost immediately or happen within 24 hours. The Podiatrist, stated most times in the nursing home when they have a bed bound resident with vascular problems they will implement interventions like; bunny boots or pressure relieving devices.

Based on record review, staff and Physician interviews the facility failed to remove a narcotic medication patch from a resident's skin before administering another one per the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 107 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had intact cognitive status. The MDS documented the resident needed limited to extensive assist of 1 staff with transfers, dressing and toileting. The MDS indicated the resident received scheduled pain medication and revealed a pain assessment should be completed but the Pain Assessment Interview was not assessed. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply one patch transdermally every 72 hours for pain and remove per schedule. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse Progress Notes failed to reveal any documentation of the patch not being removed on 2/8/22 or 2/11/22. The undated Care Plan indicated Resident #14 has chronic pain related to a rod in the right arm and left leg, it causes constant pain. Resident #14 uses a pain patch, scheduled opiods, as needed pain medications and topical pain medication. The interventions directed staff to administer pain medications as ordered by the physician. The Nurse Progress Note dated 2/13/22 state the resident experiencing involuntary muscle spasms/movements, she states she is tired. Physician notified and order received to send to the emergency room (ER). The ER documentation dated 2/13/22 revealed resident was noted to have 2 [MEDICATION(S)] patches on her when she was examined today. The Hospital History and Physical dated 2/13/22 reveal Resident #14 was sent to hospital from a skilled nursing facility, on admission to hospital Resident #14 was lethargic and found to have [MEDICATION(S)] 50 mcg patches dating from 2/8/22 and 2/11/2022. 1 of those patches was removed. Patient admitted with Aspiration Pneumonia. Review of the MAR for February 2022 provided by the facility revealed an audit after medication was found at hospital and Staff E, Registered Nurse (RN) documented [MEDICATION(S)] patch was on left shoulder 2/8/22 and the left scapula on 2/11/22. The location of the [MEDICATION(S)] Patch in the Administration Record the facility provided documented on 2/8/22 and 2/11/22 the transdermal patch was on the left chest and right chest. During an interview on 3/8/22 at 8:58 A.M., Staff B, RN stated they now have 2 staff to verify medication patch is removed and new one applied to the resident. This is new since there was a medication error with another resident. During an interview on 3/9/22 at 1:30 P.M., the Physician felt the increased [MEDICATION(S)] caused the hospitalization . They ruled it as Aspiration Pneumonia and the narcotic caused sedation which in turn caused the aspiration pneumonia. Doubling the patches is a significant medication error. During an interview with the Director of Nursing (DON) on 3/9/22 at 2:30 P.M., she states the nurse who made the medication error did not see the patch and applied another one. She states she would expect them to have two staff to confirm there is only one patch on the resident. During an interview on 3/9/22 at 4:05 P.M., the DON states she would expect staff if they did not find a patch to remove they should have another nurse check for it or a Certified Nursing Assistant (CNA) assist them to find it. If still unable to find the patch they need to notify the DON so they can determine what happened to the patch. During an interview on 3/10/22 at 7:30 A.M., the DON presented a log of Administration Records which revealed location of transdermal patches on the body. She stated it is difficult to find and print but is documented in the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/10/22 at 7:35 A.M. Staff C, RN demonstrated in the EMAR with difficulty how to find the location of the transdermal patches. She stated it is in there but difficult to find. During an interview on 3/10/228:23 A.M., Staff D, Licensed Practical Nurse (LPN) stated if couldn't find a patch on a resident she would check notes to see if came off for some reason or if a note on the report sheet. She would also do a head to toe skin check. She would notify her manager and apply the patch after full body checked for previous patches. On 3/10/22 at 4:20 PM,, Staff E, RN/Agency Nurse, reported she looked at Resident #14 and failed to find the [MEDICATION(S)] patch on 2/11/22. Staff E, revealed if she can't find a patch, she doesn't do anything special, Staff E said she signed off the patch but she didn't remember if she documented the location of the patch. Staff E stated she doesn't remember where she applied the patch on 2/8/22 or 2/11/22. Staff E, explained she didn't really get any training at the facility because she's from Agency and doesn't remember doing any training with the Agency either. Staff E, indicated she failed to let anyone know the patch was not there at the end of the shift. Staff E, reported at the time, she would give all the medications, and then sign off at the end of the shift when doing my documentation, and that is why she just signed it off as removed even though she failed to remove it. Staff E commented she just found out she should document medications as they are administered. The facility provided a policy titled medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The purpose was to assure each resident receives the proper medications at the correct time as ordered by their physician. Place a circle in square to show it has not been given and chart reason on the as needed sheet. The facility provided a policy titled Medication: Administration Guidelines dated January 2015, directed staff how to administer oral tablets and capsules, liquid medications, cough medicines and eye drops. The policy failed to address how to administer transdermal medications (patches).

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents reviewed for risk of elopement (Resident #3). Resident #3 eloped from the facility without the staff's knowledge. The facility reported a census of 123. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] documented [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented the resident was frequently incontinent of both bowel and bladder. Review of the Care Plan identified the resident as at risk for falls, potential for skin breakdown due to urinary incontinence and at risk for elopement. The focus area for elopement risk included interventions of a wander guard placed on August 23, 2018 and 15 minute checks initiated on June 10, 2019. The care plan had an intervention dated August 23, 2018 to distract from wandering by offering pleasant diversions, structured activities, food, conversation, TV shows and books the resident prefers. Care plan interventions with initiation dates of 7/6/20 and revision date of 7/7/20 identified the resident was in quarantine (as a COVID-19 precautionary measure) and had alarms placed on the room door and bathroom door to alert staff if he began to wander due to his quarantine and to help with his elopement risk. The window cranks had been removed from the window in his room as he was known to mess with the window screens-initiation date 7/6/20. The care plan has a focus area identified of: I am feeling restless and anxious. My doctor has ordered that I am able to have alcohol twice a day for a calming aid with an initiation date of 7/30/2018. A virtual visit completed on 7/6/20 at 8:30 a.m. by the ARNP (Advanced Registered Nurse Practitioner) for the facility documented an order for [REDACTED]. Review of the resident's Treatment Administration Record for July documented the wander guard had been checked every shift, with the last check occurring during the evening shift on July 6, 2020. Review of the Fifteen Minute Checklist for the past 30 days documented the resident as being visualized every 15 minutes, day and night, except for the time period when the resident was out of the facility (OOF) for an appointment on July 6, 2020. Review of the progress notes documented the following: Progress Note dated January 8, 2020 at 4:07 a.m. documented the resident was in bed at that time and 15 minute checks continued. Progress note dated January 10, 2020 at 1:22 p.m. documented Resident #3 had been actively seeking exits for 8 hours and had removed the window screen in the day room and opened the windows. The nurse documented she put in a maintenance request to remove the cranks from the windows. Progress Note dated January 21, 2020 at 12:51 p.m. stated family and friends visit often and take him out into the community often. January 24, 2020 at 12:13 p.m., the MDS coordinator documented Resident #3 had returned from a leave of absence to Florida. Progress Note dated February 6, 2020 at 9:17 p.m. stated 15 minute checks continued and no exit seeking behavior. Progress note dated March 2, 2020 at 4:37 a.m. documented Resident #3 was resting in bed with his eyes closed, no attempts to get up. Progress note dated March 18, 2020 at 9:35 p.m., nurse documented Resident #3 has attempted to escape all evening. He tried opening a window but was caught by aide and had been climbing on the toilet as well. Progress noted dated(NAME)23, 2020 at 12:30 a.m. documented Resident #3 was given prn (as needed) Captain(NAME)(alcohol) at 10:42 p.m. due to restlessness, continue to monitor for safety and exit seeking. Progress Note dated March 24, 2020 at 7:19 a.m. stated no anxiety noted, continued on 15 minute checks. Progress Note dated April 2, 2020 at 1:32 a.m. stated wander guard in place and working, no anxiety. Progress note dated April 9, 2020 at 11:44 a.m. stated Resident #3 disassembled a wheelchair back up brake and was redirected multiple times during the shift. Progress note dated April 15, 2020 at 10:04 a.m. stated the resident required increased supervision, was found in room [ROOM NUMBER] attempting to go out the windows, redirection given. Progress note dated April 17, 2020 at 1:48 p.m. documented the resident had to be redirected 20 times from going into the day room. The resident had taken the screen off the window and maintenance had completed a repair. Staff was aware of his attempts to leave the facility and 15 minute checks were ongoing. Progress Note dated April 20, 2020 at 3:15 a.m. documented the resident was resting in bed with his eyes closed at that time. He had an alcoholic drink at 10:30 p.m. due to restlessness. Progress note dated April 29, 2020 at 1:06 p.m. stated Resident #3 was anxious and attempted to get out of the window in room [ROOM NUMBER]. The resident had the screen off and and was attempting to climb on the heater to get outside. The crank was removed from that window for safety. Progress Note dated April 30, 2020 at 4:30 a.m. documented wander guard was checked and working. Progress Note dated May 1, 2020 at 1:08 a.m. documented the wander guard was checked and working. Progress notes dated May 6, 2020 at 2:17 a.m. stated the wander guard was in place, checked and working. Progress Note dated May 12, 2020 at 1:21 p.m. documented the resident was not following instruction, not wearing face mask, and running out of his room. He was observed taking the screen off of the window in room [ROOM NUMBER]. The screen was replaced and the door to the room was closed. Progress note dated May 19, 2020 at 9:06 p.m. documented Resident #3 was seen walking out of the D-wing back door, heading outside after supper. The alarm sounded. Staff saw the resident and remained in the staff member's visual field the entire time until he was back in the facility. The resident was taken to his room and given some rum. 15 minutes safety checks continued. Resident #3 was in his bed in his room at the time the note was written. Progress note dated May 26, 2020 at 6:01 a.m. stated the resident was out of his room from 5:00 a.m. to 6:00 a.m. He was redirected and assisted back to his room. Interventions of being taken to the restroom, water, and turning on the TV were ineffective. Oncoming charge nurse advised of restlessness. Progress Note dated June 4, 2020 at 8:48 a.m. documented the resident was attempting to climb out the window in room [ROOM NUMBER]. The resident in that room had a hold of Resident #3's pant leg to keep him in the room and screamed for help. Resident #3 was given alcohol and soda. He calmed down and was able to fall asleep. Progress Note dated June 5, 2020 at 4:19 a.m. documented the resident was resting in bed with his eyes closed. His wander guard was checked and working. He had no attempts to leave the facility by door or window. Progress Note dated June 12, 2020 at 3:03 p.m. documented the resident was wandering, exit seeking and leaving his room. He was redirected easily and given a snack. Progress Note dated June 12, 2020 at 3:45 p.m. documented a CMA (certified medication aide) discovered the resident had removed the screen from the room across the hall and was attempting to crawl out the window. He was still in the building and redirected to his room. There was a movie playing and he finished his alcohol that had been given previously. Progress Note dated June 18, 2020 at 1:07 a.m. documented the resident was still up pacing in his room and then out in the hallway. He was assisted back to his room and given a drink which was effective. The resident was resting in bed at the time this note was written. Progress Note dated June 18, 2020 at 3:47 p.m. documented a conversation between facility staff and Resident #3's wife. The wife stated she was going to take Resident out of the facility for a graduation and keep him home overnight. Facility staff and Advanced Registered Nurse Practitioner (ARNP) explained that Resident #3 would not understand social distancing, keeping a mask on or self-isolation and attending the ceremony would put the facility population at risk. Wife stated she was taking him anyway. Facility staff advised that would be against medical advice. Progress Note dated June 18, 2020 at 4:11 p.m. documented facility staff had a conversation with Resident #3's wife stating if she were to take the resident out for graduation it would be an emergency discharge. The wife verbalized understanding as stated she would call the governor and state senator's office. Facility reminded her they were following Iowa Department of Public Health (IDPH), Center for Disease Control (CDC) and Department of Inspections and Appeals (DIA) guidelines. Facility Medical director and ARNP were aware of situation and supportive. Progress Note dated June 18, 2020 at 4:28 p.m. documented conversation with the wife on speaker phone with Resident #3 explaining there is [MEDICAL CONDITION] spreading through the community and explained to the resident why he was unable to leave the facility to go to the graduation. He was offered to have a computer set up to watch it virtually and he said that sounded good. Wife stated she would be picking him up for the graduation and was bringing the police with her. The wife stated she was looking for another place for Resident #3 to live. Facility offered assistance with alternative placement. The resident's wife stated she would be contacting everyone she can about this. After the call, the resident was assisted to his room to watch a movie. Progress Note dated June 19, 2020 at 1:57 p.m. stated a chart review was completed for hospice eligibility per the wife's request. The resident was not appropriate for hospice care at this time. Progress Note dated June 19, 2020 at 2:29 p.m. documented wife notified of hospice ineligibility. Wife states she had not made up her mind about taking him out to graduation. She was reminded of emergency discharge. Progress Note dated June 20, 2020 stated the resident's wife had decided not to take Resident #3 out of facility and declined offered virtual viewing. Progress Note dated June 25, 2020 at 4:13 p.m. stated the wife set up an appointment with [MEDICAL CONDITION] treatment center in Cedar Rapids for July 6, 2020 and she was going to take him. Facility staff called the doctor's office asking got a telehealth session. The doctor's office deferred a decision to the wife but did state they were able to do telehealth sessions. Progress Note dated June 26, 2020 at 2:07 p.m. documented wife was contacted about telehealth. Facility staff explained labs could be drawn at facility and sent to Mercy One. The resident's wife stated she would look into it and let the facility know. Progress Note dated June 28, 2020 at 4:37 a.m. documented the resident had not displayed any anxiety. His wander guard checked and working. Progress Note dated June 30, 2020 at 2:08 p.m. documented the doctor's office called the facility and stated the visit on July 6, 2020 could be telehealth. The facility attempted to call the resident's wife. Progress note dated July 4, 2020 at 3:34 a.m. documented the resident's wander guard was checked and working. Resident #3 did not have any anxiety or attempts to leave facility. Progress note dated July 6, 2020 at 10:54 a.m. documented the resident's wife was notified of the need for him to go to a different room upon return to the facility from the doctor's appointment (for COVID-19 precautionary isolation). Progress note dated July 6, 2020 at 1:14 p.m. documented the doctor's office called the facility and stated the visit needed to be done in person and was medically necessary. The facility set up transportation and a Certified Nurse Aide (CNA) escort for the resident. Progress Note dated July 6, 2020 at 1:16 p.m. documented the resident's wife and daughters were waiting outside the facility for the resident to get into the arranged transportation vehicle. The resident's wife refused to social distance and hugged Resident #3. The resident's wife assisted him into the transportation van and then followed the van to the doctor's office in her car. Progress note dated July 6, 2020 at 10:45 p.m. documented the CNA yelled out from resident's room that he was not in the room. The window was open and the screen was on the floor. The nurse jumped out the window and searched immediate area outside while staff searched inside. The nurse got in his vehicle and continued the search. Progress note dated July 7, 2020 at 6:24 a.m. IMPACT team (facility's medical team, ARNP's office) was notified of resident's situation. Progress note dated July 8, 2020 at 10:20 a.m. stated that the resident's wife was notified that the resident left the facility through a window on July 6, 2020 at 11:20 p.m. Review of the surveillance video from the front door of the facility, on July 6 at 6:00 p.m., showed the resident entering the facility with the assistance of Staff C. The video revealed a staff person at the door when the resident entered the building keying in the code to quiet the wander guard alarm. Review of the 15 minute check list documented Resident #3 was out of the facility from 1 p.m. on 7/6/20 until visualized again at 6:00 p.m. on 7/6/20 when he returned from the doctor's appointment. Review of the facility's missing resident procedure and Code Yellow (missing resident) policy outlined the steps to be taken in the event of a missing resident. The facility followed the policy, searching the facility and grounds as outlined. The facility followed the procedure, notified all appropriate staff, law enforcement, emergency services and local hospitals. All agencies were in frequent contact with the facility over the days the resident was missing. Statements were collected by the facility from staff on duty the night of July 6. The statements documented a code yellow was activated and the areas outside the facility and the city had been searched immediately. Multiple additional staff were called to assist in the search as well. July 7, 2020 the facility assigned staff to search specific areas of the city. The resident's wife was notified at 11:15 p.m. and the local police department was notified at 11:19 p.m. on July 6, 2020. The facility also collected a statement from an alert and oriented resident 2 doors down from Resident #3. In a statement collected by the facility, Staff E stated she had checked on Resident #3 at 10:15 p.m. and he was sleeping. She stated she checked on the resident again at 10:31 p.m. and he was still asleep. In a statement collected by the facility on July 7, 2020, Staff F stated she was checking on the resident on his 15 minute check around 10:45 p.m. or so. She noticed the screen was off the window and the resident was not in the room. She alerted the nurse and ran out the back door and began searching for the resident. During an interview with the Administrator, Assistant Administrator and Director of Nursing (DON), the Assistant Administrator outlined the timeline of events for the last few weeks. All events were documented in the progress notes. During an interview on July 8, 2020 at 6:15 p.m., Staff C confirmed she assisted the resident to the transportation van on July 6, 2020 a little before 1:00 p.m. She stated the taxi driver was acting weird and was really trying to get Resident #3 to like him. When arriving at the doctor's office, Staff C had to wait in the first floor waiting room as the receptionist would not allow too many people up to the second floor office. Resident #3, his wife, 3 daughters and a male with a guitar all went upstairs to the second floor office. Staff C confirmed she was able to see the wife's car the whole time she was in the waiting room and it did not move. At 3:30 p.m., Staff C texted Resident #3's daughter to ask how much longer they would be so Staff C, CNA, could let the transportation service know. The daughter responded it would be another hour or so. Staff C stated she went outside to tell the driver it would be a while longer. The driver stated to his dispatch that the CNA is right here and listening, she told me it will be a while longer. Resident #3's daughter sent a text to Staff C at 4:34 p.m. stating they were just finishing up. Resident #3 and Staff C were in the transportation van at 4:58 p.m. to leave the office. Staff C stated Resident #3 seemed his usual self. Resident #3 and Staff C were both wearing masks, but she stated she did not smell alcohol on his breath. Staff C assisted Resident #3 to his new (isolation) room and let staff on that hall know he had been incontinent and then went to her assigned hall to work. During an interview on July 8, 2020 at 6:36 p.m., Staff D stated he visualized Resident #3 in his room at 10:00 p.m. on July 6, 2020. He stated the resident was wearing gray sweatpants and a plaid shirt. Staff D stated he visualized the resident again at 10:15 p.m. At that time Resident #3 was in his bed, under the covers. Staff D stated staff F yelled down the hall at 10:41 p.m. that Resident #3 was not in his room and the window was open. Staff D ran down to the resident's room and jumped out the window to search the immediate area outside and went around the facility to the parking lot. Staff D called into the facility to let the other nurse on duty he didn't see the resident and was going to continue the search in his car. Staff D called the resident's wife from his car about 11:15 p.m. He said the resident's wife was very calm and not upset. Staff D then drove around Target, Home Depot, Yes Way (gas station) and Walgreens. Staff D returned to the facility between 1:30-2:00 a.m. Staff D stated there was nothing bent or broken on the window. During an interview on July 16, 2020 at 12:58 p.m., Staff D stated the resident wandered out of his room just before 8:00 p.m. on July 6, 2020. He stated the resident needed his brief changed. The aide saw him within seconds and took him to the shower room to be changed. Resident #3 was directed to his room on C hall. Staff D stated there was not a crank in the room or on the window the resident went out. During an interview on July 16, 2020 at 12:55 p.m., Staff E stated there was not a crank on the window in the room the resident went out. She stated her shift on July 6 started at 10:00 p.m. and she did not see the resident out of his room. During an interview on July 15, 2020 Staff G stated he removed all the window cranks from all windows on the C wing (where Resident #3 would be temporarily isolated after his doctor's appointment) and on the A wing where the resident's regular room was. He stated all the cranks were kept together while being removed and immediately taken to the maintenance shed. Staff G stated there is absolutely no chance he could have missed the resident's room or placed the crank in a drawer or on a shelf in the resident's room intending to return for it later. Review of hospital emergency room records revealed Resident #3 was taken to the emergency roiagnom on [DATE], no time documented. Resident #3 was seen by the emergency room physician at 11:25 a.m. His temperature was 35.8 degrees Celsius (96.44 degrees Fahrenheit) per EMS. No additional temperatures were documented. Emergency Documentation documented the resident was found in about 2 feet of water, submerged up to his chest. Integumentary review stated no rashes or [MEDICAL CONDITION]. Extremity physical exam documented [DIAGNOSES REDACTED] (redness) on his forearm and hands bilaterally as well as macerated feet appeared to be soaking in water. The resident was alert and oriented to person, place and time with no sensory deficit and no motor deficit. The resident was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION], hypothermia, elevated troponin (lab test measuring skeletal or heart muscle damage) and altered mental status. Observation of Resident #3's C-wing room on July 7, 2020, where he had been moved to the night he went missing showed the room window to be open 9 inches. There was no crank on the window. There were hand prints and smudges on both the inside and the outside of the window. During a room walk through on July 8, 2020, two surveyors, the facility administrator and the facility maintenance supervisor all attempted to open the window by hand without a crank with no success. During an interview with the Administrator on July 8, 2020 regarding how the resident could have gotten out of the window in 11 minutes (from 10:30 p.m. to 10:41 p.m.) and not be able to be located, the Administrator stated she was unsure as to how the resident was able to elope.

Based on clinical record review, staff interviews and observation, the facility failed to provide adequate supervision to prevent hazards from self and elements in the environment (elopement) for one of five sampled (Resident #1). Resident #1 had a history of [REDACTED]. The failure to provide supervision resulted in an immediate jeopardy to Resident #'s health and safety. The facility reported a census of 138 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had moderately impaired cognitive skills for daily decision making, transferred and ambulated with oversight, required extensive assistance for dressing and personal hygiene. The MDS reported no wandering behaviors, no mobility devices, and [DIAGNOSES REDACTED]. The Wandering Evaluation dated 1/22/18 and 4/22/18 revealed Resident #1 had a High Risk and included the resident had attempts to leave the facility since admission. The Care Plan dated 8/23/18 identified Resident #1 had an elopement risk related to disorientated to place, and staff witnessed an attempt to exit the A wing doors. The Care Plan directed the staff to alert others of wandering behaviors, distract from wandering, approach in a calm manner, apply a wander guard, transfer and ambulate independently with no assistive device, notice exits resident favors, place in an area where frequent observation is possible and place monitoring device on resident that sounds alarm when leaving the building. The Care Plan updated on 6/9/19 revealed Resident #1 exited the building and did not experience any injuries from the incident and directed the staff to provide 15 minute checks. The Care Plan updated 6/10/19 revealed staff education provided and door alarms modified after 6/9/19 incident. The Physician order [REDACTED]. The Progress Note dated 5/12/2019 at 6:50 p.m. revealed the staff informed the nurse Resident #1 exited the back door on A wing. The staff escorted Resident #1 back indoors without any problems. At 7:30 p.m., the staff planned to continue 15 minute checks on Resident #1 and staff educated on answering alarms even if not on their assigned hall. Resident #1 rested in bed. The Progress Noted dated 6/10/19 at 9:55 a.m. revealed the staff planned to continue 15 minute checks and the secondary alarm modified. The Incident Report dated 6/9/19 at 6:30 p.m. by Staff A (Registered Nurse) revealed Resident #1 eloped from the facility. Staff A observed Staff B (Registered Nurse) assisting Resident #1 back indoors. Staff A last observed Resident #1 at 6:00 p.m. in the dining room. Staff B observed Resident #1 at 6:18 p.m. close to Ridgeway and 9th Street and assisted Resident #1 back to the facility by 6:20 p.m. Staff A completed a head to toe assessment and Resident #1 denied pain or discomfort, had intact range of motion to the upper and lower extremities and had no signs of trauma. Resident #1 had no signs of shortness of breath, bowel sounds present in all four quadrants, no visible injuries or skin breakdown and vital signs were within normal limits. The resident was alert, oriented to person, place and situation and ambulated without assistance. The facility investigation included the following: a. Resident #1 resided at the facility since (MONTH) 25, (YEAR), ambulated without an assistive device and had [DIAGNOSES REDACTED]. Resident #1 had a wander guard device. b. On 6/9/2019, the door alarm on the skilled unit went off a couple of times. Each time the staff checked the alarm and found the paramedics set off the alarm. Staff C (Nurse Aide) cleared the alarm both times at the nurse's station after determining the cause. c. Around 6 o'clock p.m., the G wing alarm sounded and Staff C went to her hallway and a resident stated they saw a man just go out the door. Staff C immediately went to the end of the hallway and noticed the secondary alarm was undone. Staff C re-attached the alarm and informed the charge nurse of the resident going out the door. d. Staff immediately started a head count in the dining room, looking out the windows to see if they could see someone. The charge nurse then went to the hallway, opened the door and did not see anyone. e. As the charge nurse went to the nurse's station to clear the alarm, the front door wander guard system started going off. The nurse who clocked out at 6:09 p.m. brought Resident #1 back into the building. The nurse stated the resident was walking down the sidewalk. f. At 6:00 p.m., Resident #1 ate in the dining room and when finished ambulated out of the dining room to go back to his/her room. Instead of taking a right out of the dining room towards his/her room, the resident turned left and ambulated down the incorrect hallway. The resident then removed the secondary alarm by reaching up high on the door and taking the string off the door hook and walked out of the building, looking to go home. g. Staff easily returned the resident to the facility. The facility estimated the resident remained outside less than ten minutes. h. Administration came to the facility to review the situation and determined staff did hear the alarm sounding in the hallway. Staff cleared the alarm at the nurse's station as the CNA went to check the hallway. At that time, the resident at one of the front rooms said someone just went outside, resulting in an investigation to see who went outside. The CNA appropriately notified the charge nurse who joined in the search to determine if indeed a resident went outside. i. Staff checked outside, started a head count on the skilled unit and by the time staff could alert the LTC (Long Term Care) side of the building, staff brought the resident back into the facility. The CNA received education to go outside immediately when a door alarm sounded to determine if someone is outside and to leave the alarm sounding until staff identified a cause. j. Conclusion: Resident #1 looked to go home after supper. The facility followed their protocol when a resident was potentially missing. A charge nurse who had just left, brought the resident back into the facility. The resident had the appropriate clothing and footwear. The resident re-enacted taking the secondary alarm string off the door hook. The facility modified all secondary alarms so nobody can move the string that attaches to the door. The facility completes monthly drills and as needed to prepare for this type of occurrence. The resident is on 15 minute checks. Observation on 6/25/2019 at 9:00 a.m. revealed Resident #1 seated on the side of the bed eating breakfast independently. The resident had a wander guard bracelet on his/her right wrist. On 6/9/2019, Staff C (Nurse Aide) received a verbal warning for failure to fulfill job responsibilities. The G warning revealed the wing exit door does not have a camera on it. Any time an alarm goes off, you must verify the exact cause as to why it activated. After identifying the G wing door opened, go outside to visually check for a resident. Initial education given on Sunday, 6/9/2019 by the Assistant Administrator. On 6/12/2019, Staff D (Licensed Practical Nurse) received an employee coaching regarding the identified concern. The coaching revealed when a resident is potentially missing from the facility, call a Code Yellow immediately. The Employee Punch Report dated 6/9/2019 revealed Staff B (Registered Nurse) punched out of the facility at 6:09 p.m. The facility map revealed Exit G faced east towards St Francis Avenue with Covenant Hospital located across the street. The resident ambulated out G wing exit, used the sidewalk and turned right on 9th street towards Ridgeway Avenue. Resident #1 traveled approximately 0.5 miles before Staff B noticed Resident #1 and assisted him/her in returning to the facility. The state climatologist reported on 6/9/19 at 6:00 p.m. a temperature of 66 degrees Fahrenheit in Waterloo. The facility Missing Resident policy included the following procedure when a resident is missing: 1. If after normal business hours, notify the Administrator. 2. Assemble all available Department Heads. 3. Organize and institute a thorough search of the facility and surrounding grounds and buildings. 4. If a search of the facility and grounds is not successful, notify the next of kin. 5. Notify the Law Enforcement. 6. Recall off-duty personnel as needed. 7. Notify local Civil Defense Agency and request search assistance. 8. Contact volunteer assistance. 9. Organize and institute an expanding search of the neighborhood surrounding the facility. 10. Notify known relatives, friends, and favorite stopping places that the resident is missing. 11. When resident is located, notify all agencies and individuals involved in the search that the resident has been found. The facility Door Alarms policy given to all staff at orientation included: It is everyone's responsibility to respond to door alarms when you hear them sounding. If you are a non-nursing staff member, you can stay with the resident until a nursing staff member comes and assists the resident. Doors in the facility are equipped with two types of alarms. The first is a main door alarm that alerts when the alarm has not been disengaged (shut off), the second is a wander guard alarm intended to alert staff if a resident who is at risk for wandering exits the building. If a door or wander guard alarm is sounding, you need to go to the door where the sounding alarm is coming from and visually assess the area to figure out what caused the alarm to sound. This may include looking out a window or going outside in order to determine if any resident is outside unattended. You need to be able to explain or determine what caused the alarm to sound. If you are unable to, you need to let the charge nurse, supervisor or department manager know that the alarm was going off and you did not see anyone so that they can determine if a head count needs to be done. During an interview on 6/26/2019 at 10:17 a.m. the Administrator revealed Staff F (Assistant Administrator) responded to the incident related to Resident #1 exiting the facility, and came to the facility on Sunday, 6/9/2019. Resident #1 exited the G wing door after he/she unhooked the string attached to the TAB alarm. The door alarm sounded at the nurse's station while Staff B (Registered Nurse) gave report to the oncoming nurse. Staff C (Nurse Aide) thought all the exit doors had cameras and silenced the door after she thought Staff C checked the cameras. The facility had a busy evening with paramedics going in and out of the facility. Staff B clocked out of the facility at 6:09 p.m. and observed the resident at 9th Street and Ridgeway Ave. Staff A (Registered Nurse) reported seeing the resident in the dining room at 5:45 - 6:00 p.m. Another resident reported to Staff C that someone went out the door. Staff C checked the door and saw the TAB alarm was not hooked, hooked it, looked out the window and failed to see anyone, checked on another resident who also had exit seeking behaviors and then went to inform Staff D (Licensed Practical Nurse). Staff D checked the G wing exit door and came up towards the front entrance when Staff B returned to the facility with Resident #1. Staff D had intended to call a Code Yellow at that time. Staff D received coaching related to the need to call a Code Yellow immediately. Staff C received a verbal warning for not determining the cause of the door alarm sounding prior to turning it off. Resident #1 made prior attempts to exit the facility though not successful until 6/9/2019. Staff F immediately began staff education regarding Code Yellow and alarm response and placed duct tape over the TAB alarm hooks. The facility maintenance staff crimped the TAB alarm hooks. The facility also practiced Missing Resident drills. Staff receive the Missing Resident policy in orientation and they review the policy along with drills routinely. During an interview on 6/26/2019 at 10:40 a.m., Staff B (Registered Nurse) reported she worked on 6/9/2019 until 6 o'clock p.m. on [NAME] wing. Staff B gave report and clocked out at 6:09 p.m. Staff B failed to recall hearing any door alarm between 5:45 and 5:55 p.m. Staff C assisted residents out of the dining room after supper. Staff B thought she saw Staff C near the F wing nurse's station computer at that time. If the G wing door opens, an alarm sounds at the door and also at the nurse's station. A panel located at [NAME] and G wing nurse's station reveals which door opened. A monitor located at the nurse's station has a four way split screen that monitors [NAME] wing and Therapy exits. Staff B clocked out and 4 minutes later she spotted Resident #2 at 9th Street prior to reaching Ridgeway Ave. Resident #1 informed Staff B she was going home. Resident #1 recognized Staff B and agreed to get in Staff B's vehicle. Staff B called the front desk and told the receptionist that she had Resident #1 in her car. When Resident #1 walked through the front entrance the door alarm sounded and the staff immediately responded. During an interview on 6/26/2019 at 3:00 p.m., Staff D (Licensed Practical Nurse) reported working on 6/9/2019 when Staff C (Nurse Aide) informed Staff D that another resident observed a person walk out G wing door. Staff D assisted in the dining room at approximately 6:10 - 5:15 p.m. when Staff C notified him/her. Staff D began counting residents in the dining room, walked up to the G wing exit and checked it. Staff C had re-attached the string and the TAB alarm functioned. Staff D looked outside and failed to see anyone went to the nurse's station and silenced the alarm and as he/she walked towards the front entrance, Staff B and Resident #2 walked through the door. Resident #1's wander guard set off the front door alarm. Staff B reported finding Resident #1. Staff D never saw the resident in the area and never heard the alarm sound but Staff C may have been in that area. Staff cannot hear the G wing door alarm in the skilled dining room but can hear Therapy, [NAME] and F alarms. Staff remain in the halls during meal times. Resident #2 had no prior incidents of exiting the facility. Nurses typically complete the 15 minute checks. During an interview on 6/26/2019 at 12:10 p.m. and 1:45 p.m. Staff A (Registered Nurse) reported she worked from 2:00 p.m. until 10:00 p.m. on 6/9/2019. Staff A assisted in the dining room from 5:30 - 6:30 p.m. Staff A never knew the resident had exited the facility until he/she returned with Staff B. Staff A did a head to toe assessment and found no injury. Staff A learned Resident #1 exited through the G wing exit door. The nurse completes the 15 minute checks. Staff A revealed he/she saw the resident around 6:00 p.m. sitting at a table. Staff A assisted another resident and never saw Resident #1 leave the dining room. Staff A had the 15 minute checklist in the dining room. Staff F (Assistant Administrator) arrived at the facility and made a copy of it the checklist. The 15 minute checklist completed by Staff A on 6/9/2019 revealed Staff A initialed the 6:00 p.m. slot, but failed to initial the 6:15 p.m. slot. During an interview on 6/26/2019 at 1:50 p.m., Staff C (Nurse Aide) reported working on 6/9/2019 on G wing. Around supper time, Staff C took residents to and from the dining room. Between 5:30 and 6:00 p.m., the door alarm went off and Staff C turned off the alarm thinking Staff B checked the monitor. Staff C also checked the monitor. Staff C assumed all exits had a camera since the monitor had four screens. Staff C reported she received training to check the door, go outside and check for residents, and report it. Staff C failed to ask Staff B if she checked the monitor. Approximately 10 minutes later a resident reported seeing someone walk out the door. Staff C checked the door and saw the TAB alarm string had been removed from the hook, looked out the window and then went to check on another resident who had wandering behaviors, counted her residents and reported it to Staff D in the skilled dining room. Staff D came walking up the hall when Staff B came through the front entrance with the resident. Staff C reported the resident had wandering behaviors and sets off door alarms. Staff provide 15 minute checks. Staff C received a verbal warning for failing to check the door before silencing the alarm. During an interview on 6/26/2019 at 12:15 p.m., Staff G (Receptionist) reported working on 6/9/2019 from 10 a.m. until 6 p.m., Staff G observed Resident #1 leave the dining room and walk towards the front entrance door. Staff G informed Resident #1 she could not go out outside. Resident #1 repeated, no outside, turned, and walked towards G wing. Resident #1 typically eats in the dining room at 5:30 p.m. and left with a coffee cup in her hand. Staff B called Staff G and said she had Resident #1, who had been down the street. The camera monitor at the receptionist's desk shows the front door and parking lot. The facility abated the immediate jeopardy on 6/9/19 by providing staff education on the door alarm policy and the elopement policy.

Based on record review and staff interviews, the facility did not always provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Concerns were noted for one resident (Resident #7) in which facility staff failed to complete on going physical assessments and intervention. The facility reported a census of 156 residents. Findings include: According to documentation in the Minimum Data Set (MDS) assessment form dated 04-05-16 Resident #7 scored 10 (of 15) on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive decline. The assessment form also described Resident #7 as requiring staff assistance with completing activities of daily living such as transfers, ambulation, dressing, bathing and toilet assistance. Review of the clinical record revealed that Resident #7 had [DIAGNOSES REDACTED]. The care plan dated 12/28/15 documented Resident #7 staff would monitor the resident ' s health status including but not limited to oxygen saturation, blood pressure, pulse, lung sounds, signs/symptoms of shortness of breath and notify the physician of significant changes in any of the prior. According to documentation the clinical record, Resident #7 was hospitalized for [REDACTED]. Resident #7 returned to the facility on skilled care on 04-11-16. Review of the nurse's notes revealed staff completed skilled assessment documentation via flow sheet on 04-12-16, 04-13-16, 04-14-16, 04-15-16 and 04-16-16. Review of the clinical record revealed staff did not complete the skilled assessment documentation for 04-17-16 or 04-18-16. Documentation in the nurse's notes dated 04-17-16 at 1:50 a.m. indicated Resident #7 had no complaints of pain and had an oxygen saturation level of 92 % and refused oxygen. Documentation in the nurse's notes dated 04-17-16 at 8:00 a.m. indicated Resident #7 refused morning cares, the morning meal, weight, vitals and meals after numerous attempts. The notation indicated Resident #7 swung at staff and told staff to get out of the room. The next documentation in the nurse's notes at 10: 30 p.m. indicated Resident #7 refused a pain medication at 8:30 p.m. but requested a pain medication at 10:10 p.m. Documentation in the nurse's notes dated 04-18-16 at 6:05 a.m. included vital signs and an oxygen saturation level of 88 % on room air. The notation addressed Resident #7's behaviors and refusal to take medications. Staff indicated a facsimile was sent to Resident #7's physician addressing vital signs, refusal of oxygen, nebulizer treatments and medications. The notation also indicated Resident #7 had no [MEDICAL CONDITION] to lower legs, lung sounds posterior decreased, lobes with crackles to lower right bases, combative and rude to staff. Documentation on 04-18-16 at 1:45 p.m. indicated staff received a return order from Resident #7 physician with direction to hold [MEDICATION NAME] for today (04-18-16). The next documentation on 04-18-16 at 8:30 p.m. indicated staff received a physician's orders [REDACTED].#7 to the emergency room for evaluation due to an elevated temperature. Review of the clinical record for Resident #7 indicated staff completed a SBAR (Situation Background Assessment Recommendation) form on 04-18-16 at 7:50 p.m. At this time the summary of observations and evaluation documented, Resident appears to be acutely ill with respiratory illness. Resident #7 ' s condition, symptom had worsened since it started. The description identified Resident #7 a primary [DIAGNOSES REDACTED]. Documentation in the emergency room chart dated 04-18-2016 at 8:52 p.m. indicated Resident #7 was dropped off at the ER (emergency room ) registration desk by Dolly's Taxi, patient was unaware of why he/she was brought to ER. Triage nurse was told by the facility registered nurse, patient is septic. Review of the emergency room chart dated 04-18-16 at 8:52 p.m. triage is documented as urgent. Additional assessment indicated Resident #7 arrived by taxi. Resident #7's family stated the resident has a decreased amount of fluid intake and fever today. Resident has audible wheezing and oxygen saturation initially at 89%. Nurse states patient was sent by taxi with instruction by unit manager. Resident was at 85% (oxygen saturation) at the facility on 2 liters of oxygen per nasal cannula. Upon arrival Resident #7 was at 88% (oxygen saturation) on 2 liters of oxygen. Resident states he/she hurts all over. During an interview on 04-26-16 at 3:45 p.m. Nurse Manager Staff D indicated the nursing staff were to complete daily flow sheet skilled charting. Staff D also indicated he completed an assessment of Resident #7 the evening of 04-18-16 and stated he did had tried to keep Resident #7 at the facility. Staff D stated he saw Resident #7 as sick, non-emergent, but not acutely ill. Staff D stated Resident #7's lungs sounded nasty but added not a lot different, and not remarkably different from day to day. Staff D did state he was concerned with Resident #7's (elevated) temperature. Staff D stated the change in Resident #7's mental status seemed to alarm the resident ' s family member most, and perhaps Resident #7 had a little dehydration due to no urine output. Staff D went on to add one can get pneumonia just like that. Staff D stated he set up a ride through Dolly's Taxi as a non-emergent transfer. Staff D stated there was about a 20 minute wait, but the taxi service was encouraged verses an ambulance transfer due to the cost involved. During an interview on 06-21-16 the emergency room physician stated Resident #7 had been dropped off at the emergency room by a taxi. No phone call to the emergency room preceded the resident ' s appearance and Resident #7 was not competent enough to be dropped off and left alone in the emergency room . The emergency room physician also stated the emergency room nurses were horrified that Resident #7 had been transferred by a taxi. The physician stated Resident #7 had a low oxygen saturation level, a fever and a cough. He stated that Resident #7 was quite ill/sick and a transfer by taxi rather than by ambulance was not appropriate. According to documentation in the hospital history and physical, dated 04-19-16, Resident #7 was admitted to the hospital with [REDACTED]. The general observation described Resident #7 as very frail looking, and currently in respiratory distress. The laboratory results showed a urinalysis which showed greater than 900 WBC's (white blood cells), positive for bacteria and RBC's (red blood cells). The CBC (complete blood count) showed a WBC (white blood count) of 19.7 X10**3/ul (Normal = 4.3 - 11.3) On 04-26-16 at 11:47 a.m. the facility assistant Director of Nursing indicated skilled nursing flow sheet records for Resident # 7 for 04-17-16 and 04-18-16 could not be located. At 11:57 a.m. the facility director of nursing indicated that if no skilled flow sheets could be located, then the only assessments completed for Resident #7 was the documentation in the nurse's notes.

Based on record review, staff and resident interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure Resident #1 remained free of hazards when staff placed a hot pack on the resident's back which resulted in a third degree burn. The sample consisted of 4 residents and the facility reported a census of 154 residents. Findings include: 1. Resident #1 had a (Minimum Data Set) assessment with a reference date of 7/6/15 which reflected the resident had no cognitive impairments. The MDS identified the resident had [DIAGNOSES REDACTED]. The Care Plan identified on 8/1/14, the Resident #1 had a problem with the potential for skin breakdown due to quadriplegia with impaired mobility and incontinence of bowel. The Care Plan reflected the resident had an open burn wound to the left scapula area due to a hot pack. The resident had a history of [REDACTED]. The approaches directed staff to avoid the use of heating pads/hot packs at the level of the upper chest. The physician's orders [REDACTED]. On 6/5/15 at 3:35 p.m. a note from the ARNP (Advanced Registered Nurse Practitioner). The note reflected the resident as seen for a new Stage II open area on the left posterior scapula measuring 2 cm (centimeters) with open stage II, 5 cm area in the center. The ARNP questioned the area caused from rubbing or pressure from the wheelchair back. The ARNP ordered a transparent dressing or Mepilex and change every bath day. On 6/12/15 at 8:55 a.m., a note from the ARNP reflected the wound on the left scapula now has slough, measuring 3.8 by 3.2 cm. The resident stated he/she had a hot pack on the sore shoulder and fell asleep on the pack. The ARNP documented the burn as full thickness. The ARNP ordered the left shoulder scapular wound to be cleansed twice a day with normal saline or wound spray, dress with Silvadene (antibacterial) cream, apply gauze and secure with paper tape On 6/22/2015 at 11:35 a.m. the ARNP discontinued the Silvadene cream to the left scapula and ordered to cleanse the left scapula every day with normal saline or wound spray, cover with gauze and impregnated with hydrogel. Cover the wound with a transparent dressing and change as needed if loose or leaking. The wound measured 3 by 4 cm, with eschar present and without signs of infection. The ARNP performed a sharp debrided. On 7/7/2015 at 1:05 p.m. reflected the left scapula burn still had fibrous slough, debrided and without signs of infection. The ARNP provided treatment orders. On 7/20/2015 at 5:10 p.m. the ARNP identified the burn as starting to heal. Treatment orders were given. On 8/19/2015 at 11:40 p.m. the ARNP noted the measurements to be 2 by 1.5 by .1 cm deep. The area showed no signs of infection and had a scant amount of serous (watery- normal) drainage noted. The treatment consisted of 2 times a week dressing changes with Mepilex as ordered. The Treatment Record directed staff on 7/20/15 to not use hot packs as the resident has decreased sensation due to quad status. The Nurse's Notes dated 6/5/2015 at 4:00 p.m. reflected the nurse observed an open area on Resident #1's left shoulder blade measuring 5.5 by 7 cm (centimeter), red, open area with blisters noted. The resident had no complaints of pain and has sensory lost on left shoulder blade prior to open area. Observation on 8/24/2015 at 2:20 p.m. revealed Resident #1 seated in the wheel chair. The Nurse Practitioner pealed back the posterior scapula wound dressing and revealed a round, pink, open area about the size of a nickel, and intact surrounding skin. On 8/24/2015 at 1:15 pm, Resident #1 reported having shoulder pain one night and asked the CNA (Certified Nurse's Aide) for a hot pack. The Aide wrapped the pack and applied the pack to his/her shoulder. The resident stated he/she fell asleep. The resident failed to feel the pack burning and the next afternoon, felt something run down back. The blister had opened. On 8/24/2015 at approximately 1:30 p.m., the Nurse Practitioner stated she originally thought Resident #1 had rubbed his/her shoulder on the wheelchair and caused the blister. The resident informed the Nurse Practitioner that a hot pack had been applied. The Nurse Practitioner stated the resident received a full thickness, third degree burn since it had developed eschar. The Nurse Practitioner said the resident's wound appeared to be healing. On 8/26/2015 at 6:40 a.m., the Administrator was interviewed and stated Staff A, CNA made an honest mistake, received education and coaching and all staff received education as well. The DON (Director of Nursing) updated the facility policy regarding hot packs. Staff B noticed the blister on Resident #1's back when he/she returned from an outing and thought the wheelchair caused it. Staff A never saw the hot pack when getting the resident up that morning. On 8/24/2015 at 2:00 p.m. the DON was interviewed and stated she updated the facility policies that are specific to the type of hot and cold packs the facility used. Certified Nurse's Aides can apply cold packs, but cannot apply hot packs. Staff A, CNA applied the hot pack when Resident #1 asked for it. The DON stated the staff received education regarding the facility hot and cold compress policy and procedure. The hot packs were kept in the supply closet and were moved to the locked medication room, where only nurses could have access. During a phone interview on 8/24/2015 at 12:30 p.m., Staff C, LPN (Licensed Practical Nurse) reported working second shift when a CNA observed Resident #1's blister on the resident's shoulder. The resident said he/she felt something running down his/her back after receiving a shower. The area resembled a burn. Initially the resident had no idea what could have caused it, then later said a CNA put a hot pack on his/her back the night before. When Staff A, CNA arrived for night shift duty, Staff C questioned him/her about placing a hot pack on the resident's shoulder. Staff A verified he/she placed the hot pack on the resident's shoulder and forgot to take it off. During a phone interview on 8/24/2015 at 1:50 p.m., Staff A, CNA reported working on the night shift. One night, Resident #1 asked for a hot pack due to shoulder pain at approximately 4:45 a.m. Staff A got the hot pack from the supply closet, wrapped it in a pillow case and put it behind the resident's shoulder. Staff A completed rounds and went home. Staff A indicated he/she forgot about the hot pack and felt terrible about it. He/she indicated applying a hot pack to one other resident in the recent months when the resident asked for it. Staff A received education and a discipline. The facility policy/procedure titled Compresses, Warm (not dated) identified the purpose of the compress is to relieve inflammation and swelling and control pain. The policy identified the responsibility for the warm compresses are the Licensed RN or LPN. The guidelines directed the staff to check the physician's order [REDACTED].

Based on clinical record review, staff, resident and family interviews, the facility failed to provide adequate supervision to protect 1 of 6 residents reviewed (Resident #5) from hazards in the environment. On 1/25/15 Resident #5 eloped from the facility without the facility staff aware of his/her whereabouts as the resident crossed into the street and asked an oncoming passerby to take him/her to an appointment. The passerby loaded the resident ' s wheeled walker and staff intervened to remove the resident from the passerby ' s car. Record review established the facility increased supervision of Resident #5 by placing him/her on 15 minute checks after the elopement and the resident continued to attempt to exit thus the facility transferred him/her to an emergency room without a staff/escort. Record review and interviews determined Resident #5 lacked the ability for make decisions about his/her safety and had made attempts to exit the facility. The findings constitute an immediate jeopardy to the resident's health and safety. The facility reported a census of 181 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #5 had [DIAGNOSES REDACTED]. The resident had a cognitive score of 15 which indicated their cognitive ability intact and gave accurate information. Resident #5 ambulated about the facility independently with the use of their wheeled walker. Review of the Nurses Notes indicated the resident eloped from the facility on 10/25/13, being found at an apartment complex across town by the resident's family member and a police officer 9 hours later. Review of the Elopement Risk assessment dated [DATE] indicated the resident had a score of 0 which indicated they were not at a risk to elope. The elopement assessment dated [DATE] the staff gave the resident a score of 6. The elopement risk assessment form indicated if the resident scored 10 or above, it necessitated a Wanderguard bracelet would be used. The resident ' s care plan dated 6/12/14 indicated Resident #5 had a potential for falls due to their use of psychotropic medications. The resident used a Wanderguard bracelet due to his/her elopement potential and staff would monitor the functioning daily. Review of the care plan identified the resident required psychological counseling or services from a mental health specialist to address his/her thoughts of harming him/her(self) or to address thoughts of suicide. On 1/26/15 the care plan indicated the staff placed the resident on 15 minute checks, around the clock, to know the resident's location due to his/her exit seeking behavior. The staff placed a Wanderguard alarm on the resident's walker in addition to the Wandergaurd bracelet on the resident's wrist. Review of the Nurses Notes revealed Resident #5 attempted to leave the building on the following dates: 5/16/14, 5/28/14 (2 times), 9/25/14, 11/29/14, 12/19/14, 1/13/15, 1/21/15 and on 1/25/15 when the resident eloped from the facility and got into a strangers car on the street across from the facility. During an interview with Resident #5 on 1/28/15 at 10:30 a.m. the resident said on 1/25/15, he/she put their coat on and walked up to the front exit door, and put in the exit door alarm code and left the building. The resident stated their Wanderguard bracelet did not set off the alarm system and he/she just kept on walking. The resident walked across the parking lot out onto the street. The resident stated a car came by, and he/she stopped the car and asked them for a ride to see his/her doctor. The passerby asked the resident if he/she lived at Ravenwood, the resident replied no. The driver put the resident's walker in the vehicle and the resident got into the back seat of the vehicle. The resident stated he/she had been somewhat afraid to get into a strangers car but wanted to see the doctor and then go see his/her friends where he/she used to live. Review of the Nurses Notes dated 1/25/15 at 7:30 p.m. indicated off duty Staff A, certified nurse aide (C.N.A.) noted Resident #5 walking on the street when she arrived to work and alerted the staff in the building. Staff B, licensed practical nurse (LPN) ran outside to return the resident to the building. Staff B found the resident in the backseat of a passerby's vehicle. Resident #5 told Staff B he/she was on their way to see their psychiatrist at a local hospital. The individual in the vehicle stated they stopped when they saw the resident approach their vehicle. The passerby transported Resident #5 to the front door of the facility, the resident re-entered the facility activating the Wanderguard alarm system. Staff B documented they placed the resident on 15 minute checks at this time. Review of the Nurses Notes dated 1/26/15 at 4:50 p.m. indicated the Director of Nurses (D.O.N.) the D.O.N. contacted the resident's physician informing the physician the resident continues to want to exit the facility and the facility is not a locked facility. The D.O.N. informed the physician that even though the staff placed the resident on 15 minutes checks and feel they are unable to meet the resident's supervision needs. The D.O.N. requested an evaluation at a local emergency room and requested admittance to the hospital. The D.O.N. stated Resident #5 went to a local emergency room via a transport service without a staff escort. The DON stated the transport service picked up the resident, took him/her into the emergency room (ER) signed him/her in at the ER and then left the resident alone at the hospital. During an interview with the local transport company on 2/3/15 at 2:30 p.m., their company transported Resident #5 to a local emergency roiagnom on [DATE]. They received the call to transport the resident to the emergency roiagnom on that day and no staff escorted the resident to the hospital. The driver took the resident into the emergency room , checked the resident in and then left. The hospital staff had to call the company to have transportation for the resident back to the facility. Review of the Nurses Notes dated 1/26/15 at 6:30 p.m. the staff notified the resident's family member/ P.O.A. (power of attorney) that the physician ordered an evaluation at a local hospital. The Nurses Notes failed to indicate what time the resident left for the emergency room and the mode of transportation. The Notes indicated the resident returned from the emergency roiagnom on [DATE] at 1:00 a.m. The ER chart documented on 1/26/15 at 7:02 p.m. the resident had been sent from Ravenwood for trying to leave multiple times and it ' s not a locked unit. The resident stated he/she had been on the street when a worker came after him/her and told him/her to return. The resident reported he/she was going to stay with family and when he/she woke up the next morning, he/she would go to church. The resident reported he/she hears voices, nothing new and not worse than usual. The resident had been transported back Ravenwood by the local transport company. During an interview with Resident #5's sister on 2/4/15 at 11:30 a.m., the resident's family member stated he/she did not escort or accompany Resident #5 to the emergency roiagnom on [DATE]. The family member did indicate they received a phone call from the emergency room to inquire why the resident came to the emergency room that night. Review of the Fifteen Minute Checklist dated 1/26/15, the checklist indicated from 6:30 p.m. until 11:45 p.m. the staff indicated Resident #5 either in their room or by the nurse ' s station in the lounge. The checklist noted that the resident remained in the facility when in fact Resident #5 went to a local emergency room for an evaluation and not in the building during that time. Review of the Incident/Accident/Unusual Occurrence Form dated 1/25/15 revealed at 7:30 p.m. Resident #5 had displayed behaviors indicating he/she were planning to go outside, such as standing by the door and putting on their coat. The staff told the resident to stay by the nurse ' s station after he/she refused to go to their room. A staff member then found the resident outside by the front of the building and then the resident had been returned to the facility. Review of the Doctors Order Sheet dated 1/26/15 at 10:00 p.m. revealed the physician discharged Resident #5 back to Ravenwood with orders to continue all medications and to follow up as soon as possible with their psychiatrist or primary care physician for recommendations for transfer to a locked unit. During an interview with Staff C, C.N.A. on 2/3/15 at 3:00 p.m., Staff C stated she noted Resident #5 sitting alone in the dining room on 1/25/15 at about 5:30 p.m. with their coat on watching the front exit door. Staff C informed the nurse in the dining room at that time. Staff C attempted to redirect the resident to watch a movie by the nurse ' s station. Staff C stated she observed the resident for about 10 minutes and then left the area to attend to other residents. Staff C stated she did not hear the Wandergaurd alarm sound prior to the elopement but had been down A wing. During an interview with the Administrator on 2/3/15 at 2:15 p.m., she stated she watched the security film for 1/25/15 resident elopement; the film revealed Resident #5 put in the posted security code to bypass the exit alarm but cannot enter a code to silence the Wandergard alarm. She stated the Wandergard alarms failed to alarm to alert the staff Resident #5 left the building. She stated the code for the exit door alarm is no longer posted by the door. During an interview with Staff E, LPN on 2/3/15 at 12:43 p.m., Staff E stated Resident #5 had exit seeing behaviors on 1/25/15 prior to their elopement on that day. Staff E stated the resident put on their coat and walked slowly. Staff E directed the staff to keep an eye on the resident and directed the resident to stay by the staff so she could watch him/her. Staff E stated she did not know Resident #5 left the building until alerted by another staff. Staff E stated she saw Resident #5 in the street and by the time they reached the resident, he/she was in a passerby's vehicle. Staff E stated she did not hear the Wandergard alarm sound prior to the elopement. During an interview with Staff F, LPN on 2/2/15 at 4:30 p.m., Staff F stated a staff member who came to work early on 1/25/15, saw Resident #5 out on the street getting into a vehicle. Staff F stated when the resident returned to the facility through the front doors the resident's Wanderguard bracelet activated the alarm system. Staff F stated when she performed the shift Wandergard check for Resident #5 on 1/25/15 at midnight, after their elopement, their wandergard bracelet did not function and she replaced the bracelet. Staff F stated the resident was known to have exit seeking behaviors, attempting to leave the building through various exit doors. During an interview with Staff G, C.N.A. on 2/2/15 at 10:00 p.m., Staff G stated on 1/25/15 at about 7:30 p.m. she had to come to work early due to a car issue, she was scheduled to arrive at 10:00 p.m. for the night shift. Staff G stated they drove up the street by the facility when they observed Resident #5 walking on the street with their wheeled walker. Staff G stated she knew the resident and realized he/she was not to be outside. Staff G got out of their car and approached the resident to inquire what he/she was doing outside. The resident indicated he/she was going to speak with their psychiatrist that night. Staff G attempted to phone the facility but they failed to answer the phone. Staff G had her spouse drive her up to the facility and ran into the building to alert the staff. Staff G stated their spouse then watched as a silver vehicle stopped by the resident on the street, they loaded the resident's walker and then the resident got into the back seat of the vehicle. Staff G's spouse approached the vehicle and alerted the passerby that this person in their car is a resident at the nursing home. At this time additional staff arrived on the scene and the vehicle drove to the front of the building and the resident got out of the vehicle and returned to the facility. During an interview with Resident #5's Psychiatrist on 2/5/15 at 10:15 a.m. the Psychiatrist indicated he/she had known Resident #5 for [AGE] years. The doctor indicated the resident is impulsive, attention seeking and makes poor judgments. Resident #5 does not want to be in a nursing home but does not have the ability to care for him/her(self). The psychiatrist stated the resident would have been safe to go to the emergency roiagnom on [DATE] if someone went with him/her. According to an Elopement Prevention policy dated March 2007, the policy directed the staff to evaluate and identify potential elopements from the facility by identifying aimless wandering behaviors, verbally expressing desire to leave, perimeter wandering and sudden changes in behaviors. The policy stated the resident's care plan will contain interventions and actions to monitor and prevent elopements. The facility abated the IJ on 2/4/15, when they completed the following: On 1/27/15, the facility trained all staff on the elopement policy and included specific training on what to do when a resident puts their coat on. In addition staff were trained that all exit seeing behaviors require close monitoring of residents during 15 minute safety checks and if this is not sufficient staff need to stay with them until you call the physician and have them sent out to the hospital. On 1/28/15, the facility removed the code posted at the door and poste a note for family/friends/visitors to ask the receptions for the number to the keypad to exit the building everytime they leave. On 2/4/15, the facility abated the IJ when they educate staff that residents with Wandergaurds, going to an appointment or out the facility will have an attendant with them. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of residents at risk for elopement and to ensure the necessary provisions to maintain residents safety are inplace.

Based on record review and staff and resident interviews, the facility failed to provide adequate supervision to protect against hazards from self or elements in the environment and failed to direct the nursing care and services to insure the resident ' s needs are met and have written policy and procedures for the implementation of checking residents. Resident #1 attempted to ambulate to the bathroom alone and fell during the night shift. A nurse saw the resident at 4 a.m.in bed and asleep. The staff then saw the resident at 7 a.m. on the floor. The resident had been yelling out for help from a dark room and door closed. The resident laid on the floor with a fractured wrist and pelvis. The nursing assistant did not check on the resident during the 5 a.m. rounds or with the next shift personnel at 6 a.m. The sample consisted of 6 residents and the facility reported a census of 154 residents. Findings include: 1. According to the Minimum Data Set (MDS) with reference date of 6/18/14 revealed Resident #1 had [DIAGNOSES REDACTED]. The MDS identified Resident #1 had a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 reflected the resident did not have cognitive problems. The resident required extensive assistance of 1 staff for bed mobility, transfers, toilet use and personal hygiene. The resident could only stabilize themselves with staff help when walking and moving about. Review of Resident #1's Care Plan dated 6/23/14 reflected the resident required assistance for all Activities of Daily Living. The approaches directed the staff to assist the resident with toileting. An approach reflected the resident had a visual deficit related to macular degeneration and the resident could see better out of the right eye than the left eye. A Fall Risk Evaluation form dated 6/11/14 revealed Resident #1 had a score of 20. A score of 10 and above identified the resident at a high risk for falls. Review of the Nurse's Notes dated 6/25/14 at 7:00 a.m. revealed the staff found Resident #1 on the floor of their bedroom. The resident complained of pain to the left wrist, back and left hip. The resident stated he/she tried to go to the bathroom and didn't ask for help. The call light had been tied to the resident ' s side rail. The note reflected the resident was trying to go to the bathroom and did not ask for assistance. The resident had stated she/he did know was to ask for help. The note reflected the resident did not know what had caused the fall and did not remember the actual fall. At 7:30 a.m., the resident was sent to the hospital by ambulance. The incident/accident report dated 6/29/14 at 7:00 a.m. identified the resident called out and was found on the floor. The resident stated she/he got up to go to the bathroom, but did not remember falling. The call light had been tied to the bed side rail. Review of the emergency room Report revealed the resident arrived at the hospital at 7:21 a.m. and was given Fentanyl (narcotic analgesic) 25 mcg (micrograms) intravenously at 8:07 a.m. Review of a Radiology Report dated 6/25/14 revealed the resident fell at the nursing home and suffered pain with deformity of the wrist and left hip. The x-ray revealed Resident #1 had a nondisplaced left superior and inferior pubic ramus (pelvis) fractures, and a left wrist fracture. The Nurse ' s Notes dated 7/3/14 at 3:30 p.m. identified the resident returned to the facility after the hospitalization . The Resident Assessment-Data Collection/Initial Care Plan document dated 7/3/14 identified the resident had a cast on the left wrist and multiple bruises on both upper and lower extremities, including left hip. The resident expressed pain. On 7/15/14 at 9:15 a.m. the Director of Nursing was interviewed and stated Staff B failed to do rounds on Resident #1 the morning of 6/25/14. The Director of Nursing stated the standard of care at the facility is the nurses ' aides do round on their residents every 2 hours. On 7/16/14 at 8:23 a.m. revealed Staff B (certified nursing assistant) stated she last checked on Resident #1 at 3:00 a.m. and failed to complete her expected rounds at 5:00 a.m. Staff B stated she completed walking rounds at about 6:30 a.m. with the oncoming shift and the resident had her/his room door shut. Staff B and the oncoming aide failed to open the door and view the resident that morning. Staff B signed a facility typed document which identified she had last checked the resident at 3:00 a.m. Staff B opened the resident ' s bedroom door and observed the resident in bed and then shut the door again. Staff B did not toilet the resident at that time. Staff B reported off to the day shift at 6:00 a.m. and walked the hallway but did not visually open and check on the resident. The day shift (first shift) aide went into the resident ' s room and found the resident on the floor. Staff B stated staff cannot always get to the resident before the resident would get up on own. Staff B stated the resident had a history of [REDACTED]. A Corrective Action Form, signed by the Director of Nursing on 6/25/14 and Staff B on 6/30/14, identified Staff B had documented Resident #1 had been continent, toileted and repositioned at 3:23 a.m. on 6/25/14, however, this had not been completed and Staff B assumed the resident had did this independently. The corrective action directed that Staff are expected to complete resident rounds at least every 2 hours and documentation to be factual and accurate. On 7/21/14 at 2:25 p.m. Staff C (certified nursing assistant) was interviewed and stated she did not look at Resident #1 but instead walked by the room. The resident ' s room door was shut and she did not open the door. Staff C stated she assumed the resident to be okay (alright). Staff B had informed Staff C she had seen the resident about 3 a.m. and she was alright. On 7/23/14 at 10:45 a.m., Staff D (registered nurse) was interviewed and stated she made rounds at 4:00 a.m. and saw Resident #1. Staff D stated she opened the closed door and peeked in. The resident was asleep in the bed. On 7/21/14 at 8:30 a.m. Resident #1 was interviewed and stated she/he could recall the fall the morning of 6/25/14. The resident stated she/he reached for the call light and fell out of bed. The resident stated she/he laid on the floor for quite a while and yelled for help. The resident stated the room door was shut and the room was dark. The resident stated he/she yelled for help but no one heard. A staff member finally heard the resident yelling and found her/him on the floor. The resident stated she/he had a fractured hip and wrist from the fall. On 7/15/14 at 11:05 a.m., the Nurse Consultant was interviewed and stated the facility does not have a policy for rounds but the aides are expected to make rounds on every resident every 2-3 hours during the night.

Based on record review and staff interviews, the facility did not always ensure that each resident received adequate supervision and protected against hazards in order to prevent accidents Concerns were noted for one (Resident #1) of four residents reviewed. Interviews revealed the clip alarm had been placed on the handle of the wheelchair and staff had been aware the resident would unclip or could turn off the pressure seat alarm. The facility staff failed to implement ongoing and additional interventions aimed at the safety of the resident for prevention of accidents and/or injuries. The facility reported a census of 156 residents. Findings include: 1. The resident clinical record had a face sheet dated 7/2/2012 which identified Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of 01/11/13 described Resident #1 with a BIMS (Brief Interview for Mental Status) score of 8/15. A score of 8 reflected the resident had moderate impaired cognition. The MDS described Resident #1 as requiring extensive staff assistance with bed mobility, transferring and the resident did not ambulate. The individual plan of care dated 1/15/2013, identified a potential problem for falls with injury related to impaired balance, decreased vision, impaired judgment and recall with a fall occurring on 12/25/12 which resulted in a fractured acetabulum (which was not surgically repaired). Planned interventions on the individual plan of care at that time directed staff to: a. Use a wheelchair for independent mobility; monitor for need of assist/direction. b. Pressure alarm to bed and pull alarm when in the chair. c. Attempt to anticipate needs to avoid self- transfer attempts. d. Assist to be in a supervised area when up in the wheelchair. e. On 03/14/13 the intervention to ambulate with one assist and gait belt and wheeled walker was added to the plan of care. The Nurse's Notes dated 3/4/2013 at 6:30 p.m. reflected Resident #1 sustained a fall. Staff responded to the alarm sounding and Resident #1 stated he/she attempted to move back in the wheelchair and the chair moved (causing the resident to slip/slide down to the floor). (Staff implemented auto- lock brakes as an intervention). The Nurse ' s Notes dated 3/16/2013 at 8:40 p.m. indicated staff responded to Resident #1's alarm sounding and observed Resident #1 to stand and loose his/her balance. Staff could not reach Resident #1 in time to prevent the fall. On 03/04/13 at 9:59 a.m. Staff A (Registered Nurse) was interviewed and stated no new or additional interventions were added after this fall, as interventions already in place were effective; staff just didn't reach the resident in time. The Nurse's Notes on 03/18/13 at 7:40 p.m. reflected the staff found Resident #1 sitting on the floor in front of the wheelchair, with no alarms sounding. Staff completed assessments, notified the physician and received orders to send Resident #1 to the emergency room (ER) where he/she was diagnosed with [REDACTED]. On 04/01/13 at 4:07 pm, Staff G (Licensed Practical Nurse) was interviewed and stated she received a phone call from Resident #1's daughter indicating Resident #1 had fallen. The daughter stated she had been on the telephone with her parent when the resident voiced he/she was on the floor. Staff G stated she went to Resident #1's room and he/she was on the floor, and neither the pull/clip alarm nor the pressure alarm was sounding. Staff G stated the two alarms were pretty much all the interventions planned for Resident #1, however, she stated on the evening shift she didn't like to have Resident #1's door closed (with him/her in the room) as she didn't know what he/she might be doing. Staff G also stated that some "interventions" got passed along in the nurse's report such as placing the alarm box under the wheel chair. On 04/01/13 at 8:11 pm Staff E (Certified Nursing Assistant) was interviewed and stated she was aware of Resident #1 being able to removed his/her clip alarm and she stated that is likely what happened when he/she fell . Staff E stated staff usually placed the alarm box on the handle of the wheelchair, but now the alarm box is placed under the seat of the wheelchair. Staff E stated she had not observed Resident #1 to turn his seat alarm off, but she had overheard nurses saying maybe he/she could turn the alarm off. Staff F (Certified Nursing Assistant) was interviewed on 04/01/13 at 3:51 and stated she was aware that Resident #1 had a seat alarm and a clip alarm. Staff F stated she was aware that at times Resident #1 removed his/her cardigan so staff would make sure to attach the clip alarm to his/her shirt. Staff F also stated at the time of the fall, she understood that staff were to place the alarm box under the seat of the wheelchair so Resident #1 could not reach it. Staff F stated she tried to keep the door of his/her room open and checked his/her whereabouts each time she passed his/her room. On 04/02/13 at 10:41 Staff C (Certified Nursing Assistant) was interviewed and described Resident #1 as being fidgety and he/she could remove the clip alarm. Staff C also stated that not very often, but every once in a while Resident #1 also turned off the pressure alarm. Staff C also kept the door to his/her room open to monitor the resident ' s whereabouts. On 04/02/13 at 10:49, Staff D (Licensed Practical Nurse) was interviewed and stated she had "caught" Resident # 1 removing the clip alarm, and "playing"/fidgeting with the alarm box as well as pulling at the mattress pad alarm. Staff D stated she kept the door to Resident #1's room closed during the day and attempted to keep him close to her as she completed her duties. Staff D stated she didn't think Resident #1 could cognitively process turning off the alarm intentionally, but she did think if he/she "fiddled" with the alarm box, he/she could accidentally turn the alarm off.

Based on observation, clinical record review, staff and resident interviews, the facility failed to adequately supervise a resident to ensure against hazards from self and failed to ensure staff followed the planned interventions to keep residents safe by using a gait belt when transferring a resident. (Resident #1 & #3) The facility census was 153 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment dated [DATE]. The MDS reflected the resident had intact cognitive abilities for daily decision making, transferred and toileted with extensive assistance of two staff, and used a wheel chair for locomotion. The MDS identified [DIAGNOSES REDACTED]. The Care Plan identified the resident had potential for falls related to a history of a fall prior to admission and brain cancer with a craniotomy for tumor removal. The intervention directed staff to apply an alarm to the bed and wheel chair. On 04/03/2012 the Care Plan directed staff to transfer with the assistance of one and a gait belt, but discontinued on 10/29/2012. On 10/25/2012 the Care Plan directed staff to assist Resident #1 with two staff and a gait belt for toileting transfers. On 10/29/2012 the Care Plan directed staff to use the assistance of two staff and a gait belt or mechanical lift for all transfers. The Care Plan indicated the resident participated in restorative therapies. Nurse Notes dated 11/24/2012 at 6:30 p.m., documented the resident slid out of the wheel chair and onto the floor after staff transferred the resident from the bed to the wheel chair with no injuries noted. Nurse Notes dated 11/24/2012 at 9:45 p.m., documented staff transferred the resident to bed and the resident sat on the floor, and no injuries noted. Facsimile's to the physician dated 11/24/2012, reported the resident had two falls that evening, one when the resident slid from the wheel chair to the floor and another when staff transferred the resident from the wheel chair to the bed; the resident denied pain. On 11/25/2012 staff notified the physician the resident complained of left shoulder pain after two falls on 11/24/2012, and staff sent the resident to the emergency room . The Incident/Accident Report dated 11/24/2012 at 3:00 p.m., indicated a Certified Nurse Aide, CNA was with the resident when the resident slid out of the wheel chair after the resident transferred from the bed. Staff circled they did use a gait belt. The Incident/Accident Report dated 11/24/2012 at 5:30 p.m., reported staff lowered the resident to the floor during a transfer from the wheel chair to bed. Staff indicated not using a gait belt because the belt did not fit the resident. Radiological exams dated 11/25/2012 included the resident had partial dislocation or subluxation of the glenohumeral joint, and a minimally displaced fracture through the greater tuberosity. The Emergency Department Report documented the resident had a soft tissue injury to the left shoulder, had a history of [REDACTED]. The resident returned to the facility with a sling and orders for pain medication and follow up care with an orthopedic physician. The Ortho Office Visit Summary dated 11/28/2012 documented the resident complained of left shoulder pain, evaluated as a personal injury when he/she fell on [DATE], described as sharp and continuous and an eight on a scale of 1-10. The patient had paralysis on that side from a [DIAGNOSES REDACTED]. The current resident ADL (Activities of Daily Living) sheet revealed the resident transferred with the assistance of two staff, and a mechanical lift; wheel chair dependent. On 12/06/2012 at 1:00 p.m., the resident was interviewed and reported slipping off the wheel chair. When staff went to get him/her up off the floor, that is when it broke, it snapped, and they put the gait belt on. The gait belt was under the arms, and it put pressure on the shoulder causing it to break. Staff used a machine, and E-Z lift to adjust him/her. On 12/06/2012 at 12:00 noon, the interim Director of Nursing (DON) reported after being made aware of the two incidents on 11/24/2012 involving the resident and staff failing to use gait belts during the transfers, the facility suspended staff involved and then conducted five minute educational meetings. On 11/27/2012 the DON provided staff in-services and education regarding resident transfers. Resident #1 had a Physical Therapy evaluation in August, 2012. After the falls on 11/24/2012, staff received direction to transfer the resident with a mechanical lift. On 12/12/2012 at 10:15 a.m., Staff G, Licensed Practical Nurse, LPN was interviewed and reported assisting Staff D, CNA transfer the resident from the bed to wheel chair on 11/24/2012 at 3:00 p.m. without a gait belt. Staff knew to transfer the resident with two assist or a mechanical lift due to recent falls. Staff held onto the resident's pants and assisted with the pivot transfer. Shortly after Staff G left the resident's room, Staff D summoned Staff G to assist after the resident slipped out of the wheel chair. Staff G reported assessing the resident who had no complaints of pain or signs of injury and then transferred the resident to the wheel chair with no gait belt along with Staff D. After supper, at approximately 5:30 p.m., the resident fell again in his/her room. Staff G observed the resident on the floor near the bed. Staff G along with Staff D and Staff F assisted the resident to transfer from the floor to the bed without a gait belt. Staff G and Staff F held onto the resident's pants and waist and Staff D positioned his/her feet. They stood and assisted the resident to bed. At some point during the transfer, while the resident lay on the floor, the resident reported hearing a "pop", but had no complaints of pain with passive range of motion. When Staff G asked the aides later, they reported the gait belt didn't fit the resident. Staff knows how to transfer a resident by reading the care plan, care sheet posted in the resident room or by accu-nurse via their headset. Staff G heard the resident complained of pain the next morning and x-rays results revealed a shoulder dislocation and a hair line fracture. The facility suspended Staff G for failure to use a gait belt. On 12/12/2012 at 1 p.m., Staff D was interviewed and reported working on 11/24/2012 when the resident requested for staff to transfer him/her from the bed to wheel chair. Staff D had a gait belt, but failed to use it since it didn't fit the residents' waist. Staff G assisted Staff D to transfer the resident from the bed to wheel chair without a gait belt. Shortly after, the resident slid out of the wheel chair to the floor. After Staff G assessed the resident they assisted him/her from the floor to the wheel chair with the resident holding onto the bed rail without a gait belt. The resident fell after supper while Staff D remained in the dining room, but assisted Staff F and G to transfer him/her from the floor to the bed with no gait belt. Staff D held the resident's feet to keep them from sliding, and Staff F and G held the resident's pants to stand and pivot to bed. Staff D never heard a "pop" and never heard the resident complain of pain. Staff D knew the facility policy required them to have a gait belt on at all times and use it with any transfer. Staff D had no knowledge of the facility having an extra-large gait belt on hand. On 12/12/2012 at 12:30 p.m., Staff F, CNA was interviewed and reported working on 11/24/2012 and knew the gait belt did not fit the resident's waist and had no knowledge of an extra-large gait belt on hand. After supper the resident returned to his/her room and had incontinent bowel. Staff F asked Staff C to assist with transferring the resident to bed so he/she could provide incontinence cares. During the transfer without a gait belt, the resident began sitting and they lowered the resident to the floor. The resident asked to lie on the floor and never reported hearing a "pop". Staff G assessed the resident and assisted Staff F and D transfer him/her from the floor to the bed without a gait belt by grabbing the pants and waist. The resident never complained of pain the remainder of the evening shift. Staff F knew the resident had a history of [REDACTED]. On 12/12/2012 at 12:15 p.m., Staff C, CNA was interviewed and reported working 11/24/2012 on C wing. After supper Staff F asked for assistance with transferring Resident #1 from the wheel chair to the bed. Staff C had a gait belt on, but Staff F reported the standard gait belts failed to fit the resident's waist. They both held onto the resident's pants, but he/she began to sit and they lowered the resident to the floor and sat up fine, but decided to lie down on the left side. Staff returned to the C wing and Staff F remained with the resident. After the facility suspended Staff C, he/she heard they had an extra-large gait belt available, and if he/she had known, they would have used it. On 12/12/2012 at 11:40 a.m., Staff P, LPN was interviewed and reported working the day shift on 11/25/2012 on D wing. Staff P stated she heard in report the resident had two falls the previous evening shift, staff lowered the resident to the floor both times and had no complaints of pain. When Staff P assessed the resident at 7:00 a.m., he/she complained of severe pain in the left shoulder with palpation. Staff H assisted the resident out of bed that morning, and had no reports of pain. No staff ever reported the gait belt failed to fit the resident. The resident gained weight and Staff P put the gait belt up under the resident's arms. On 12/12/2012 at 2:30 p.m. Staff H, CNA was interviewed and reported assisting the resident up out of bed and transfer to the wheel chair with the Hoyer lift on 11/25/2012. They decided to use the lift due to the two falls the previous evening. The resident had no complaints of pain. Staff H's gait belt fit the resident, but they had to place it higher up on the chest area. On 12/12/2012 at 11:30 a.m. Staff O, LPN was interviewed and reported working the night shift on 11/24/2012 until 6:00 a.m. on 11/25/2012. During the night the resident had numerous requests for food, drink and repositioning but no complaints of pain. Staff O never turned the resident, just pulled on the draw pad to adjust the shoulders and hips. 2. According to the MDS assessment dated [DATE], Resident #3 transferred with extensive assistance of staff and had [DIAGNOSES REDACTED]. The Care Plan directed staff to keep call light within reach, provide alarms to bed and chairs, use a wheel chair for mobility, transfer with one assist and a gait belt, no not leave unattended in wheel chair in room, and stay with resident in the bathroom to prevent falls. The Incident/Accident forms included two falls. On 11/21/2012, the resident fell from the bed, the alarm in the on position, but not sounding. Staff checked the alarms and sent the resident to the emergency room for evaluation and treatment which required four sutures to the left ear. On 11/24/2012 at 6:55 a.m., the resident fell in the shower room without injury noted. Staff I, LPN completed the Incident Form and assisted Staff Q transfer the resident to the wheel chair from the floor. Staff I educated Staff Q and instructed him/her to use a gait belt with all transfers. On 12/12/2012 at 12:45 p.m. Staff Q was interviewed and reported the resident fell after the shower when the resident decided to get up from the shower chair, prior to the transfer to the wheel chair. Staff Q reported leaving the gait belt in the resident's room that morning after transferring him/her from the bed to the shower chair with the help of Staff J. On 12/12/2012 at 4:00 p.m., Staff J, CNA was interviewed and reported assisting Staff Q transfer the resident the morning of 11/24/2012. Staff J and Staff Q transferred the resident from the bed to the wheel chair and used Staff J's gait belt since Staff Q had no gait belt. Staff Q told Staff J his/her gait belt remained in the shower room. Staff Q took the resident to the shower room via wheel chair. Later, Staff Q reported the resident fell in the shower room and needed a gait belt to get the resident up. Staff Q asked to borrow Staff J's gait belt, and could not find his/hers. During an interview by telephone on 12/13/2012 at 9:45 a.m., Staff I, LPN reported on the morning of 1/24/2012, a CNA stepped out of the shower room and asked for assistance; the resident fell . Staff I observed the resident fully dressed with shoes, but no gait belt, on the floor and holding onto the shower chair. Staff I assessed the resident and found no injury. Staff I asked Staff Q about the missing gait belt, and Staff Q reported he/she failed to have one and left the room to get one. The resident's wheel chair sat in the shower room as well as the shower chair. The facility Transfer Activities policy including one person transfer, two person transfer for resident's who can pivot, paralyzed resident all required the use of a gait belt with the purpose of assisting dependent residents in transferring safely.

Based on observation, clinical record review, nurse practitioner and staff interview, the facility failed to monitor for the identification, assess and treat pressure sores for one of five residents reviewed with skin breakdown (Resident #1). The facility census was 181 residents. The care plan for Resident #1 directed staff to toilet the resident every 2 hours. The resident did not always receive toileting as planned and the resident sat in a soiled incontinent brief. The resident developed facility acquired and avoidable pressure ulcers. Findings include: 1. Resident #1 had an Minimum Data Set (MDS) assessment with a reference date of 3/20/12 which identified [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of two for bed mobility and transfer. The MDS assessment indicated the resident had no pressure ulcers on prior assessments and as at risk for pressure sore development. The Care Plan dated 1/3/12, identified a problem of potential for impaired skin integrity related to incontinence, immobility and decreased sensation. An addition of an open area to buttock noted 3/18/12 was added on 3/19/12. A goal was established for the resident would be free of areas of pressure. Approaches included: a. Float heels off of mattress. b. Monitor skin with daily cares. Report redness, rash, open areas, etc. as occur. c. Treatments per order. d. Pressure relieving mattress and wheel chair cushion. e. Assist to reposition. The problem included no intervention to assist the resident to lie down at any times during the day. The Care Plan identified a problem of frequent incontinence of bowel and bladder of long standing, 30 plus years. The resident did not voice or indicate the need consistently, unable to toilet self, usually incontinent prior to toileting assistance, recurrent urinary tract infections. The problem included a goal of will have no skin irritation due to incontinence. The approaches identified the following: a. Wear adult incontinence protection. b. Need assistance for perineal cares. c. Encourage fluid intake. d. Monitor perineal skin for redness, rash, open areas, etc. and report as it occurs. e. Monitor for sign/symptoms of urinary tract infection and report. f. Assist to toilet every two hours and as needed as tolerates. Check and change on routine rounds at night. During a facility tour on 6/12/12 at 10:00 a.m., Staff K, Registered Nurse, RN reported the resident had no pressure sores or skin abrasions. On 6/13/12 at 8:05 a.m., the resident laid in bed as Staff A, Certified Nurse Aide, CNA and Staff B, CNA completed incontinence cares. Observation revealed the resident had a superficial open area on the right inner buttock. At 8:19 a.m., Staff A and Staff B transferred the resident into a wheel chair. 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. At 9:37 a.m., the resident remained in a wheel chair in his/her room with a breakfast tray. At 10:45 a.m., the resident remained in the wheel chair with beverages from the breakfast tray in front of him\her on a tray table. At 11:15 a.m., or one hour and fifty six minutes later the resident remained in the wheel chair. At that time, Staff B wheeled the resident from his/her position in front of the tray table, to a bathroom in the hallway across from the nurse ' s station. Staff C, CNA and Staff D, Licensed Practical Nurse, LPN entered the bathroom. After assisting the resident to transfer to the toilet, Staff B un-taped the resident ' s incontinent brief and stated it was dry and did not need to be changed. At that time, the resident stated the brief was wet. Staff B told the resident the brief was dry but if he/she wanted it changed they would. Staff B removed the brief and placed a new one on the resident. The resident voided on the toilet and Staff B used disposable wipes to cleanse the resident ' s posterior perineal area. The resident cried out several times as Staff B cleansed the resident ' s perineal area and stated the area was sore. At 11:25 a.m., staff transferred the resident to a wheel chair. After the observation the surveyor requested to see the old brief, at which time Staff B stated "Oh I guess it was wet." At 12:20 p.m., the resident sat in a wheel chair in the dining room. At 12:30 p.m., the resident sat in a wheel chair in the dining room. At 1:25 p.m., the resident sat in the wheel chair in the hall across from the nurse ' s station. At 1:37 p.m., Staff B and Staff C transferred the resident from the wheel chair to a shower chair. On 6/14/12 at 8:17 a.m., the resident sat in a wheel chair in the hall way. At 9:00 a.m., the resident sat in a wheel chair in the dining room. At 9:50 a.m., Staff B transported the resident out of a shower room in a wheel chair to his/her room. At 10:24 a.m., the resident remained in the wheel chair in his/her room. At 11:00 a.m., the resident sat in a wheel chair in his/her room. At 11:30 a.m., the resident sat in a wheel chair in his/her room and appeared to sleep. At 11:50 a.m., Staff B pushed the resident from his/her room to the dining room. At 12:12 p.m., the resident sat in a wheel chair in the dining room, appeared to sleep. At 12:50 p.m., the resident remained in the wheel chair in the dining room. At 12:53 p.m., the resident sat in the wheel chair in the A-wing hallway. At 12:55 p.m., Staff B wheeled the resident to his/her room. At that time, Staff B and Staff F, Restorative Aide transferred the resident from the wheel chair to a bed, to which the resident agreed to with no objection. No cares were completed at that time. Staff B stated he/she would check the resident ' s incontinent brief later and would notify the surveyor at that time. During an interview at 1:05 p.m., Staff B retrieved a piece of paper from his/her pocket and stated these were the things they had done with the resident for the day: a. assisted the resident from bed to the wheel chair at 7:45 a.m.. b. toileted in the bathroom at 9:50 a.m., and was wet as well as voided. c. incontinent brief was checked at 11:45 a.m. ,in the resident ' s room and the resident was repositioned in the wheel chair at that time. Staff B verified the only time the resident was toileted during the shift was at 9:50 a.m. At 1:57 p.m., the resident laid supine in bed (on his/her back). Staff B stated he/she knew the resident was dry. Staff K, Registered Nurse, RN in the room as an observer stated the resident would normally be checked for incontinence at that time. At 1:59 p.m., Staff L, CNA entered the room and assisted Staff B to check the resident ' s incontinent brief. Staff L stated the brief was wet and proceeded to complete incontinence cares. The resident had visible superficial open areas on both the right and left buttock. At that time the surveyor pointed the areas out and asked Staff K if he/she was aware of the open areas. Staff K replied " no " , and Staff B at that time stated he/she had informed Staff D the resident had an open area that morning. At 2:09 p.m., Staff D stated he/she did not know anything about open areas on the resident ' s bottom. At that time the surveyor requested to be present when Staff D measured the areas. At 2:15 p.m., Staff D measured a superficial open area on the resident ' s inner right buttock near the coccyx to be 0.6 centimeters (cm) by 0.5 cm. and measured a superficial open area on the resident ' s left inner buttock as 0.6 cm by 0.4 cm.. Staff D stated maybe Staff B had reported an open area that morning but he/she did not know because it was a busy day. At 2:32 p.m., Staff K stated Staff B was filling out a nurse aide skin sheet. At that time, observation revealed Staff B sat at the nurse ' s station and documented on the form. Staff K provided a copy of the nurse ' s notes that had no documentation of any open areas. At 2:45 p.m., Staff K provided the surveyor with a copy of the nurse aide skin form dated 6/14/12 at 7:45 a.m. The form documented staff found an open area on the resident ' s buttocks and the nurse was notified. The form documented the contributing factors to be scar tissue, nutrition and positioning. The form included the intervention done to prevent the injury from happening again to be positioning. At 3:00 p.m., Staff K provided the surveyor with a copy of a nurse ' s note dated 6/14/12 at 2:00 p.m., which documented it was reported the resident had some skin issues on the buttocks. The note included an assessment of two areas, one on the right inner buttock that measured 0.6 cm by 0.5 cm and one on the left inner buttock which measured 0.6 cm by 0.4 cm. The note documented the resident had broken down on the area before and the resident was frequently wet. At 3:12 p.m., Staff K provided the surveyor with a copy of a non-pressure skin condition report with a date first observed as 6/14/12. The form documented the resident had two areas and documented an assessment date of 6/9/12. Staff K verified Staff D had just filled the form out. The form documented physician and family notification on 6/14/12. Staff M, Director of Nursing, DON stated on 6/15/12 at 7:03 a.m., the open areas were related to pressure. Staff M stated he/she had argued with Staff D about how the areas were documented on a non-pressure form. At 7:05 a.m., Staff D stated he/she had documented the wrong assessment date on the skin assessment the previous day, and provided the surveyor with two different assessment sheets, one for each open area with both assessment dates documented 6/14/12. At 7:31 a.m., Staff M provided the surveyor with a Physician order [REDACTED]. The note documented the resident was seen due to skin breakdown on bilateral inner buttocks, with the area scarred from previous breakdown. The note documented the resident was incontinent of urine and stool, with very superficial open areas noted 6/14/12. The assessment documented the areas appeared to be improving and measured the left inner buttock to be 0.8 cm by 0.3 cm with no depth. The assessment documented the area on the right inner buttock to be 0.5 cm by 0.3 cm with a depth of 0.1 cm and a yellow base. The note documented the areas were likely related to incontinence associated [MEDICAL CONDITION] and skin on skin friction. The same order sheet included a physician order [REDACTED]. During an interview on 6/15/12 at 10:00 a.m., Staff N, ARNP stated it would benefit the resident to lie down rather than sit in a wheel chair for extended periods. At 11:10 a.m., Staff M stated checking and changing a resident ' s brief would not be considered the same thing as toileting.