**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #51 A. Resident status Resident #51, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included difficulty walking, muscle weakness, abnormal posture, dementia, and depression. The 10/21/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident was not able to walk and required extensive assistance for transfers and was dependent for all mobility tasks. He was dependent in all self care areas except for eating, which he was independent of. He was incontinent of urine at all times and frequently incontinent of bowels. The resident was at risk for pressure ulcers (he had none at time of admission) and required pressure reducing devices for his chair and bed. B. Record review The resident had a baseline care plan initiated 2/10/2020 and revised 11/10/21 that read in pertinent part: Resident #51 had potential for pressure ulcer development related to immobility and incontinence. He was to have a full body skin assessment weekly and frequent repositioning. On 11/9/21 the care plan was updated to include that the resident had actual impairment to his skin integrity to both buttocks along the gluteal cleft. Interventions of frequent repositioning, frequent incontinence care, and wound care were added to the care plan. A CPO dated 9/10/21 read: Apply Z guard (barrier cream) to excoriation as needed Resident #51 had a braden scale (skin risk assessment tool) performed on 10/20/21 which assessed the resident to have a score of eight out of 23, indicating that he was at a very high risk for skin breakdown. A weekly skin assessment progress note dated 11/2/21 read: Skin is intact. No new skin concerns identified. A CPO dated 11/7/21 documented that Z guard should be applied to the reddened area on buttocks three times a day. A change in condition evaluation dated 11/7/21 documented that the resident had a change in skin color or condition with blanchable redness to the right buttock. The recommendation was to apply barrier cream, place the resident in bed, and offload pressure to the affected area. -However, there was no root-cause analysis to determine the cause of the change of condition. A CPO dated 11/8/21 documented that the resident should be laid down after meals to reduce pressure on buttocks. A SBAR (situation, background, assessment, and recommendation) dated 11/8/21 read in pertinent part: New redness and blistering to right and left inner buttocks. Repositioning every one to two hours and as needed, pericare to be performed every two hours, apply Z guard, and increase water intake. Provider, on call nurse, and the resident's son were notified. -There was no investigation into the root-cause anaylsis relating to the redness and blistering to the right and left inner buttocks. A weekly skin assessment progress note dated 11/9/21 documented: Redness and blisters to right and left buttocks. Z guard applied and provider, on call nurse, and the resident's son were notified. A SBAR nursing note dated 11/10/21 documented in pertinent part: The blister to the residents buttock is now open with minimal drainage. New wound care orders received, wound care clinic to be notified, and wound team to follow Resident #51 until the wound was healed. A CPO dated 11/11/21 read in pertinent part: Cleanse open blister area to buttocks with wound cleanser and to cover with a foam bandage. C. Observations Resident #51 refused surveyor observation of pressure ulcers and/or activities of daily living (ADL) and transfers throughout the survey. On 11/10/21 at 12:17 p.m. Resident #51 was observed in his wheelchair for lunch. It was noted that he had a Hoyer lift sling placed beneath him. On 11/10/21 at 2:05 p.m. the resident was noted in his wheelchair with a Hoyer lift sling underneath his bottom. D. Staff interviews The director of nursing (DON) was interviewed on 11/10/21 at 4:00 PM. She stated that the facility did try to keep slings out from underneath residents in their wheelchairs, unless it would cause more harm to the resident to remove the sling. She said that she did not think the sling would cause additional pressure and contribute to a pressure injury for Resident #51. Licensed practical nurse (LPN) #2 was interviewed on 11/11/21 at 11:35 a.m. She said that she performed Resident #51's wound care on his buttocks and she did notice that there were blisters, however the resident did not have any open areas. She said the staff was laying the resident down in between meals to reduce pressure off of his bottom. Certified nurse aide (CNA) #1 was interviewed on 11/11/21 at 2:00 p.m. She said that Resident #51 did have wounds on his bilateral buttocks and that the blisters had popped and were now open sores. She said the resident denied pain, but grimaced and tightened up with incontinence care. She could not recall what day the wound appeared, but said it had been a couple days. She said that to prevent more pressure on his bottom staff were getting him up last for breakfast and then laying him down in between meals. She said that when staff laid him down they put him on his side, took the resident's brief off, performed peri care, and left the wound open to air. She said that the staff repositioned him and provided incontinence care every two hours and as needed. She said the resident had a pressure reducing cushion on his wheelchair, however she said he did not tolerate a pillow in the wheelchair to offshift his weight. The DON was interviewed again on 11/11/21 at 3:45 p.m. She said that if a new wound developed the nurse was responsible for documenting an incident report and notifying whoever was on call. She said if she was not on call she would be notified of the change in condition in the 24 hour report, which was done each morning. She said the wound team would start to follow Resident #51 on a weekly basis every Wednesday to evaluate the wounds and treatment. She said that the resident was to be repositioned frequently to keep pressure off of the buttock area to prevent the wound from worsening. Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#52 and #51) of five residents reviewed for pressure ulcers out of 34 sample residents. Resident #52 was admitted to the facility with intact skin, and no pressure ulcers, and developed multiple areas of skin breakdown to her buttocks, perineal area, heels and ankles. The facility failed to consistently and accurately assess and monitor the resident's skin and provide adequate pressure-relieving interventions. As a result, Resident #52 developed multiple pressure areas, some of which had healed. Her skin breakdown as of 11/11/21 included two unstageable pressure ulcers to her heel, irritated and reddened areas to her thigh from the strap that held her catheter tubing in place, irritation to her nose and ears from her oxygen nasal cannula and tubing. Resident #52 said she experienced discomfort, soreness and burning as a result of pressure areas acquired at the facility. Resident #51 was admitted with intact skin and developed skin breakdown described as blisters and open areas to his coccyx. The facility failed to ensure Resident #51 received the standard level of care necessary to prevent development of pressure ulcers. Findings include: I. Professional references According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from http://www.npuap.org (11/16/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. According to Key Points for Pressure Ulcer Staging and Documentation, 11/23/13, MedLeague.com (11/16/21), in pertinent part: Pressure ulcer staging and correct documentation are critical in acute care settings as well as long-term care settings. Pressure ulcers are caused by unrelieved pressure. Any bony prominence is at the highest risk. After a pressure ulcer has been assessed it is essential that the correct stage of pressure ulcer is assigned and documented. Here are a few essential do's and don ' ts of pressure ulcer staging. Pressure ulcers are assessed as Stage 1, 2, 3, 4, Unstageable and Deep Tissue Injury. Documentation must accurately reflect each stage. The higher the stage the more underlying tissue damage there is. Once a pressure ulcer is 'staged' it can progress to a higher stage but can NEVER be 'BACK-STAGED, REVERSE STAGED or DOWN STAGED.' Example: A Stage 3 pressure ulcer can worsen and become a Stage 4 but it NEVER becomes a Stage 2 as it heals. II. Facility policy The Pressure Injury Prevention and Management policy, dated 1/1/2020, provided by the corporate vice president of operations (VPO) on 11/11/21, in pertinent part: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Assessments of pressure injuries will be performed by a licensed nurse and documented in wound rounds or in skin/wound portal in the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (minimum data set assessment). Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed. III. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), pertinent diagnoses included abnormalities of gait and mobility, need for assistance with personal care, acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction (paralysis following stroke) affecting left non-dominant side, sepsis, and bladder-neck obstruction. According to the 10/21/21 minimum data set (MDS) significant change assessment, Resident #52 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15, with no behavioral symptoms and no rejection of care. She required extensive two-person assistance for activities of daily living (ADLs) including bed mobility, transfers, toilet use, dressing and bathing. Ambulation did not occur. She had an indwelling catheter and was always incontinent of bowel. She had occasional mild pain and weight loss without a physician-prescribed weight loss regimen. She had two stage 2 pressure ulcers, none present upon admission, and moisture associated skin damage. She was not on a turning/repositioning schedule. She had pressure-relieving devices to her bed and chair, pressure ulcer care, nutritional/hydration interventions, and applications of dressings/ointments/medications other than to her feet. According to the 5/19/21 admission MDS assessment, Resident #52 was at risk but had no pressure ulcers upon admission. B. Resident interview/observations Resident #52 was interviewed on 11/9/21 at 9:10 a.m. She was lying on her back in bed, her heels were not floated and one of her padded booties was on the floor. She said her booties did not stay on, and that nursing staff had to come in periodically and make sure her left leg was on the bed. She said her legs and feet jerked uncontrollably at times, and her booties fell off. She said the staff tried to float her heels, reposition her, and remind her to wear booties, but they had to check frequently because of her involuntary movements to her legs and feet. She said she had wounds on both feet because her feet jerked and twitched. She said physical therapy had her doing exercises while she was in bed and she did that so her feet did not get stiff and jerk and twitch. She said she did not take medications to address the jerking and twitching, just pain medications like Tylenol, but she used to have a Fentanyl patch. She said she had an open wound on her bottom but it was healed now. Resident #52 said, and observation revealed, she did not have an alternating air mattress, and said, That would be nice. She said she just had a regular hospital bed mattress now. She said the wounds on her feet hurt, especially when her legs moved back and forth and it rubbed her skin. That's why they need to have my boot on and the moisturizer to keep my feet from drying out. She was wearing her right bootie (heel protector) but not her left. She said she had skin breakdown/irritation to her nose and ears from her oxygen nasal cannula and tubing. She said they would not give her any ointment to relieve the discomfort to her nose or padding to protect the sensitive skin around her ears. Her nostrils just above her lip were red and irritated. She said she had just pulled a scab off her thigh that was caused by the Velcro strap that held her catheter tubing in place (cross-reference F690 catheter care). She said she also had skin issues related to moisture, and that nursing staff used moisture barrier and powder to treat those areas. Observations during the survey conducted 11/8 to 11/11/21 revealed the resident was always in her bed lying on her back. She was able to shift her weight and slightly reposition herself using a trapeze bar above her bed and repositioning rails on the upper bilateral sides of her bed. On 11/8/21 from 2:00 to 6:00 p.m. and 11/9/21 from 8:15 a.m. to 5:00 p.m., the resident's heels were not consistently floated with pillows, her soft padded booties were not on her feet, and her heels and/or the sides of her feet frequently rested directly on the mattress. Observations on 11/10/21 and 11/11/21 from 8:15 a.m. to 6:00 p.m. revealed the resident's heels were more consistently floated and her booties were on during frequent observations. During wound care observations on 11/10/21 at 10:33 a.m., licensed practical nurse (LPN) #2 washed her hands and donned gloves. The resident had two scabbed areas to her left heel, which LPN #2 cleaned with wound cleanser and painted with betadine. She used a new swab for each wound and replaced the resident's heel protectors afterwards. The resident's left heel had a wound on the medial posterior the size of a dime that was difficult to visualize due to the resident's discomfort when her leg was moved or lifted, but the area was partially covered with a dark red scab. The resident's second heel wound, on the lateral side of her heel, was approximately the size of a pencil eraser and was completely covered with a dark red scab. Her buttocks were intact, and her skin was clear from any excoriation. The site where her strap held her catheter tubing in place appeared excoriated with dryness and a superficial wound with a pink wound bed about the size of a nickel. The strap had been moved to a different part of the resident's leg. C. Record review The resident's pressure ulcer care plan, revised on 10/29/21, identified the potential for and actual pressure ulcer development related to immobility. I have 2 pressure ulcers to the medial and outer aspect of my left heel. The goal was, I will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included: -Assist and encourage me to reposition and or turn at frequent intervals to provide pressure relief. -Complete a full body check weekly and document -Encourage and assist me to change positions for prevention of pressure ulcers. -Encourage small frequent position changes. -Encourage and assist me to reposition in chair frequently for comfort and pressure reduction. -Interdisciplinary team (IDT) referrals as indicated to registered dietitian (RD), physical therapy (PT), occupational therapy (OT) or other. -Observe nutritional status. Serve diet as ordered, observe intake and record. -Observe/document/report as needed (PRN) any changes in skin status: appearance, color. -Provide incontinence care after each incontinence episode, or per established toileting plan. -Use pillows to reposition me off of my pressure areas. -Encourage adequate hydration and nutrition to assist in the healing process of my wounds. -Please ensure that I am wearing my heel protectors at all times while in bed. -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate me/family/caregivers of causative factors and measures to prevent skin injury. -Encourage and assist me to reposition frequently. Use pillows to position me off my pressure areas. -Follow facility protocols for treatment of injury. -Identify/document potential causative factors and eliminate/resolve where possible. -Keep skin clean and dry. Use lotion on dry skin and apply moisture barrier cream as needed. -Monitor dressing to ensure it is intact and adhering. -Observe site for redness, swelling, increasing drainage, pain. -Observe/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician. -Use a draw sheet or lifting device to move me. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Current pertinent physician orders included: -Use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily and as needed every day shift, dated 6/12/21. -Observe skin integrity every shift at pressure points from the oxygen delivery device while in use every shift, dated 6/26/21. -Cleanse both wounds to left medial and outer heel with wound cleanser. Paint with betadine ensuring not to get on healthy skin. Please reapply heel protectors at all times. Observe for abnormalities to wound bed, surrounding skin, or pain associated with wound. Document + (plus sign) for no abnormalities noted, - (minus sign) for abnormalities, must document abnormalities in nursing notes, every day and evening shift, dated 10/30/21. (On the treatment administration record from 11/1 to 11/11/21, abnormalities were documented on the evening shift on 11/1, 11/2 and 11/3/21. Day shift documented no abnormalities, and did not document on 11/4/21.) The nursing admission assessment on 5/12/21 documented the resident's skin was intact and she had no pressure ulcer risk. Physician progress notes on 5/18/21 documented the resident's skin was warm and dry. The summary of plans included skin care. The 5/19/21 Braden scale for predicting pressure sore risk, documented a score of 16, at risk, due to occasionally moist skin, chairfast, slightly limited mobility, probably inadequate nutrition and potential for friction and shear. (The scoring scale was at risk 15-18, moderate risk 13-14, high risk 10-12 and very high risk nine or below.) The 5/20/21 skin assessment documented intact skin. The resident was hospitalized from [DATE] through 6/8/21. There were no nurses' notes regarding the resident's skin condition upon her return from the hospital on 6/9/21. The 6/10/21 skin assessment documented an existing pressure ulcer described as two open wounds to sacrum, red and friable; fragile, excoriated perineum, and rash with open sores to her groin and labia. -There were no further nursing notes or evidence of physician notification. The 6/11/21 Braden scale assessed her at risk with a score of 15. The 6/16/21 weekly pressure ulcer record documented a sacrum pressure ulcer, date of onset 6/9/21, documented as a stage 1 and a stage 2 in the same assessment, 3x3 cm, described as a stage 2 to sacrum presents as intact dark purple superficial area with surrounding excoriation. Dark area peeling off on one edge presenting healthy blanchable skin surrounding the purple area. The ulcer was documented as admitted with as the resident had been in the hospital. The IDT team recommended to continue with treatment. Wound team to reassess weekly until healed. The 6/17/21 skin assessment documented excoriation with superficial open areas to buttocks, dark eschar skin to left buttocks. -There was no documentation of a wound assessment of the dark eschar which indicated an unstageable pressure ulcer. The 6/23/21 weekly pressure ulcer record documented a 2x2 cm stage 2 to the sacrum described as very superficial pressure area presenting as dark tissue with surrounding blanchable excoriation, no s/sx (signs/symptoms) of infection noted. The wound bed was described as black. The IDT recommended to continue treatment, wound team to assess weekly, and hospital wound care following as well. -There were no notes in the resident's medical record regarding hospital wound care. The 6/27/21 skin assessment documented no changes to the sacral wound. The 6/30/21 weekly pressure ulcer record documented the sacral wound as a stage 2 measuring 4.0 x 2.6 cm, black/purple tissue to wound bed with surrounding excoriation to skin. Skin sloughing off from surrounding (area), does (complain of) minor discomfort when area is cleansed. The wound had deteriorated, increased in size as well as surrounding skin with excoriation. -There were no changes to treatment, and no documentation of hospital wound care. The 6/17/21 physician progress notes documented the resident's skin was warm and dry and plans included skin care. -The resident's skin breakdown was not documented. The 7/4/21 skin assessment documented new and existing skin issues, (left) upper thigh healing skin tear (2x2 cm), (left) outer ankle blister (2 x 2 cm with 4mm depth), 3 excoriation areas on (left) buttocks, reddened peri area, (left) sacrum necrotic area, (left/right) buttocks reddened. -There was no evidence in the medical record that the physician was notified. On 7/7/21 the weekly pressure ulcer record documented: (1) The existing sacral pressure ulcer measured 4.8 x 3.0 cm, assessed as stage 2, wound improving in size, black eschar has sloughed off revealing healthy pink tissue to wound bed with surrounding excoriation to skin. A new order was received to cleanse the wound and back, apply Aquaphor to healthy tissue and leave wound open to air as it appears foam adhesive may be worsening surrounding excoriation. (2) The new left buttock pressure ulcer measured 2.1 x 1.2 cm, stage 2, new wound to left buttock to the side of previous sacral wound. Area presents with 75% slough with surrounding excoriation/sloughing of skin. The wound bed description was yellow. New orders were received to cleanse wound, apply mixture of A&D ointment and antifungal cream, leaving open to air. The onset date was 7/4/21. (3) The new unstageable pressure ulcer to the left heel measured 2.2 cm length x 2.0 cm width, was described as a new intact blister to left heel with translucent intact skin with darker hard tissue to blister edges, first observed on 7/4/21. New orders were received to paint with betadine twice daily. -There were no corresponding nurses' notes and the physician was not notified until 7/7/21, three days after the new pressure ulcers were identified as acquired. The 7/11/21 skin assessment documented existing pressure ulcers described as left upper thigh healing skin tear, left outer ankle blister and three excoriation areas on left buttocks. -The sacral pressure ulcer was not documented. The 7/14/21 weekly pressure ulcer record documented: (1) Sacrum pressure ulcer, 4.0 x 3.5 cm, stage 2, wound continues with 25% slough to wound bed with surrounding excoriation of lower back. (2) Left buttock, 1.0 x 2.3 cm, stage 2, wound continued with slough to 25% of wound with surrounding excoriation. (3) Left heel, 2x2 cm, unstageable, hard intact non fluid filled blister to left outer aspect of heel. Treatment to all wounds continued as ordered. Physician progress notes on 7/14/21 documented nothing about skin status or pressure ulcers. Summary of plans included skin care. The 7/18/21 skin assessment documented new and existing issues as follows: 3 open wounds on left buttocks with granulation tissue continues, left ankle blister; and existing-left thigh skin tear with scab, abdominal fold with excoriation. Further description of skin issues: gluteal fold reddened, peri area reddened, buttocks reddened on left side. -The sacrum pressure ulcer was not documented. The 7/20/21 Braden scale assessed the resident at high risk with a score of 12, due to very moist skin, bedfast, very limited mobility, probably inadequate intake, and friction and shear problem. The 7/21/21 weekly pressure ulcer record documented: (1) Sacrum 4.1 x 3.5 cm, stage 2, same description as previous assessment. (2) Left buttock 1.2 x 2.5 cm, stage 2, same description. (3) Left heel 2x2 cm, unstageable, hard intact non fluid filled blister to left outer aspect of heel. -The sacrum and left buttock wounds were slightly larger, but the left buttock was the only wound documented as deteriorated. No new orders or treatments were documented. The 7/25/21 skin assessment documented three open wounds on left buttocks with granulation tissue remain, left ankle open area where pustule was, redness under gluteal fold and perineal area. -The sacral wound was not documented. The 7/28/21 weekly pressure ulcer record documented: (1) Sacrum 4.0 x 1.7 cm, stage 2, wound bed with healthy granulation, improved. (2) Left buttock 1x2 cm, stage 1, wound bed beefy red. (3) Left heel 1.8 x 1.6 cm, unstageable, improved in size and appearance, intact, hard, translucent blister continues. -Although the left buttock wound was documented initially as a stage 2, it was downgraded to stage 1 in addition to improved. The 8/1/21 skin assessment documented three open wounds on left buttocks with granulation tissue, and left ankle open area where pustule was. The 8/4/21 weekly pressure ulcer record documented: (1) Sacrum 3.0 x 2.3 cm, 0.9cm depth stage 2, area with beefy red granulation tissue throughout, improved. (2) Left buttock, 1.0 x 1.3 stage 2, with 25% slough, diffuse edges, improved. (3) Left heel 1.0 x 1.3 cm, stage 1,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#38,#72) residents of six residents reviewed for falls and accidents out of 34 sample residents. Resident #38 who had severe cognitive deficits and resided on the facility's memory care unit (MCU), resulting in four falls in four months. One of the falls, which occurred on 8/4/21, resulted in harm to the resident. Due to a deep laceration to her right outer hand, Resident #38 required transport to the local emergency room for stitches. The facility also failed to provide supervision, monitoring and education to staff to prevent Resident #38 from eloping from the MCU's secured patio via a gate on 10/4/21, which led to the resident sustaining another fall in the community while away from the facility. The facility failed to thoroughly investigate and document every fall Resident #38 sustained in IDT meetings, including adding new and effective fall interventions to the resident's care plan following every fall. Additionally the facility failed to provide adequate supervision and safe environment to prevent Resident #72, with multiple incidents of exit seeking and dangerous elopement attempts, from eloping from the facility on 9/9/21. The facility failed to develop an effective performance improvement plan (PIP) for resident falls until the recertification survey began on 11/8/21. I. Facility policy The Elopement and Wandering Resident policy, dated 2021, was provided by the nursing home administrator (NHA) on 11/11/21 at 3:45 p.m. The policy read in pertinent part: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systems approach to monitor and manage residents at risk for elopement or unsafe wandering, including identification and risk assessment and evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary According to the policy the interdisciplinary team (IDT) would evaluate the factors contributing to the resident ' s risk in order to develop a person-centered care plan. Interventions would be included in the care plan and communicated with staff to increase staff awareness of the resident ' s risk. The policy guided staff to provide adequate supervision to help prevent accidents or elopements and evaluate the effectiveness of the interventions, modifying as needed. The policy defined elopement when a resident leaves the premise or a safe area without authorization and/or any necessary supervision to do so. The policy defined wandering occurrence as random or repetitive locomotion that may be goal-directed or non goal-directed or aimless. The policy gave the search for an exit as an example of wandering. The Accidents and Supervision policy, revised November 2017, was provided by the NHA on 11/11/21 at 8:05 a.m. The policy read in pertinent part: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: -Identifying hazards and risks; -Evaluating and analyzing hazards and risks; -Implementing interventions to reduce hazards and risks; and, -Monitoring for effectiveness and modifying interventions when necessary. According to the policy the facility should establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. All staff should be involved in the observation and identification of potential hazards in the environment while considering the unique characteristics and abilities of each resident. The policy read the facility should make reasonable efforts to identify hazard and risk factors for each resident and provide various sources of information about the hazards and risks in the residents ' environment. The policy indicated the sources of information could include but not limited to quality assessment and insurance activities (QAPI), environmental rounds, the minimal data set assessment (MDS), a resident ' s medical history, a physical examination, and the facility assessment. II. Resident #38 A. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included dementia with behaviors, abnormality of gait and mobility and muscle weakness. Resident #38 resided in the facility's secured memory care unit (MCU). The minimum data set (MDS) assessment dated [DATE] documented the resident had severe cognitive deficits with a brief interview for mental status (BIMS) score of four out of 15. It documented the resident required supervision with set up for bed mobility, transfers, ambulating with her walker and eating. She requires extensive assistance from one for dressing, toileting, personal hygiene and bathing. The MDS documented the resident had physical and verbal behavioral symptoms towards others on a daily basis, as well as behavioral symptoms not directed towards others on a daily basis. It documented the resident rejected care and also wandered on a daily basis. B. Resident observations Resident #38 was initially observed on 11/8/21 at 1:30 p.m. She was seated at a table on the MCU, putting together a large-sized puzzle. She was pleasant, smiling and displayed a calm manner. -At 6:00 p.m., she was eating her dinner at a table in the MCU dining room with another resident and they were socializing together. The resident was observed on 11/9/21 at 9:30 a.m. She was seated at a table in the MCU dining room by herself and she was independently looking at a People magazine. -At 12:01 p.m., the resident was, once again, having a meal with her friend and was eating her meal independently. -At 3:45 p.m., the resident was in her room taking a nap. Resident #38 was observed on 11/10/21 at 8:15 a.m. She was seated alone and finishing her breakfast. Her walker was not observed within reach of the resident or anywhere nearby. -At approximately 10:15 a.m., the resident was engaged in an activity with assistant activity (AA) #1 of making eagle pictures by tracing their hands. Resident #38 was observed on 11/11/21 at 10:33 a.m. She was with AA #1 participating in a Veteran's Day trivia activity. She said she could remember back to WWII and that her family was so happy when the war ended. Her walker was observed to be in another common area of the MCU at this time. -At 12:53 p.m., the resident was observed going through her dresser drawers looking for clothes because she wanted to go and see her mother for a few days. Staff redirected her back to the group of residents in the common area and she readily complied with staff. -At 3:00 p.m., Resident #38 was observed to be engaged with three other resident coloring pictures. She was coloring [NAME]. Her walker was left in another room with a glass of water on it. It was not within reach of the resident at this time. C. Record review The care plan dated 10/17/21 related to falls documented Resident #38 was at risk for falls related to gait/balance problems. Unaware of safety needs, wandering. The goal was to have decreased risk of falls with the staff helping the resident as needed. The general intervention was to anticipate and meet the resident's needs. More specific interventions related to falls included needing a safe environment with even floors free from spills and/or clutter, documenting the resident's falls had been happening the majority of the time in the evening, so the resident would need stand-by assistance when walking at that time, offering the resident a seat if she was pacing and to be outside with her when she was outside in the patio area in case she needed redirection or assistance. Another intervention in this care plan was when the resident's anxiety was increasing, staff should attempt to find the source and alleviate it and attempt to redirect the resident. If the resident was not redirectable, staff should allow her to call her son, as talking with him and being assured she was okay, would usually relieve the resident's level of anxiety. The care plan dated 10/17/21 related to elopement documented Resident #38 was an elopement risk/wanderer related to her history of packing, attempting to leave and arguing for staff to let me go. It documented the resident could be disoriented to place and situation, with impairment to safety awareness, which is why I resident on (MCU). It documented the resident would remain safe in the facility and not exit the building without supervision. It documented the staff should distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. It documented staff should identify the resident's pattern of wandering and intervene as appropriate. It documented if the resident was exit seeking, staff should attempt to redirect the resident by offering to walk with her and engage her in conversation during those walks. It documented staff should observe Resident #38 at regular and frequent intervals and document the wandering behavior and attempted diversional interventions. The Morse fall scale assessment dated [DATE] documented Resident #38 score was 80.0 or a high risk for falling. It documented the resident had fallen prior, used a cane or walker for ambulation, had a weak gait and over-estimated her limits. This was the only Morse fall assessment seen in Resident #38's chart. D. Elopement investigation The suspected abuse investigation form dated 10/8/21 documented Resident #38 was found to be missing from the facility on 10/4/21 at 5:10 p.m. A staff member leaving the facility found the resident at 5:15 p.m., approximately one block from home. The resident had fallen outside while she had been missing. Resident #38 resided on the Primrose Hall, the facility's MCU. The form documented the resident resided on this unit due to dementia and exit seeking behaviors. It documented Resident #38 had been agitated and exit seeking prior to the incident. It was discovered a staff member entering through the MCU's back gate failed to ensure the gate closed behind them after they came through the gate. Resident #38 then exited through this gate and walked approximately one block where she was found after she had fallen. This form documented there were no injuries, which was incorrect, as the resident sustained bruising to her right knee (See fall investigations below). Following this elopement, the facility added automatically closing gate hinges and a spring to ensure the gate will always close. Education was provided to all staff to ensure the gate to the secured courtyard of the MCU actually closed behind them. The progress note related to this elopement, dated 10/4/21 at 9:41 p.m. documented Resident #38 eloped from the facility at approximately 5:00 p.m. It documented the back gate in the MCU secured patio area had been left open by a staff member using that entrance. It documented Resident #38 had been actively exit seeking all afternoon. The resident was discovered making her way down the sidewalk outside by a passerby on the street, who then apparently let someone in the facility know where she was. The housekeeping supervisor was the first person to discover the resident alone on the sidewalk. Resident #38 had fallen on the sidewalk (See fall investigation #1 below). When the documenting nurse was alerted and reached the scene, there were several staff members already present who had helped Resident #38 stand up and retrieved a wheelchair to escort her back into the building. Resident #38 appeared a bit shaken, but was consolable. She mentioned that her right knee hurt. There were no visible signs of abrasions at this time. Emergency medical services arrived at approximately 5:45 p.m. and transported the resident to the local hospital for evaluation. She returned from the hospital at 9:45 p.m. and was returned to her room on the MCU, where she was assisted to bed. This progress note documented one hour checks, as well as neurological exams due to the unwitnessed fall the resident sustained while she had eloped from the facility's MCU. E. Fall investigations 1. Fall #1 The SBAR form dated 7/29/21 documented Resident #38 sustained an unwitnessed fall on 7/29/21 at 1:45 p.m. as the resident was found outside, lying on the grass, yelling for help. It documented the resident sustained several new abrasions and the fall was related to the resident's agitation and the uneven ground she was walking on. The progress note dated 7/30/21 documented the IDT met with Resident #38 after her fall. It documented the resident had no memory of falling, but the resident sustained abrasions to her arms. It documented a CNA observed the resident had gone outside and saw the resident trying to pick up and throw her walker. It documented the CNA tried to go out to assist the resident and redirect her, but she had already fallen. The IDT post fall review dated 9/2/21, which was completed over a month since the resident's fall occurred, documented Resident #38 sustained abrasions to her forehead, left wrist and her left 3rd and 4th knuckles. IDT recommended that physical therapy reassess the resident's type of walker being utilized for appropriateness. It documented staff would be educated to be out with this resident when she was outside to supervise her more efficiently and provide assistance to the resident in a timely manner. The facility failed to adequately supervise and monitor Resident #38 while she was ambulating outside, per the MDS assessment dated [DATE]. (See above). 2. Fall #2 The SBAR form dated 8/4/21 documented Resident #38 sustained a witnessed fall on 8/4/21 at 8:54 p.m. with the resident falling on her knees, front and face. She rolled onto her back by the time staff got to her. She sustained a small cut on the bridge of her nose and a bruise to her forehead. She also suffered a deep cut to her right outer hand by the little finger, which needed stitches. She sustained a skin tear to her right lower arm, measuring 3 cm X 3 cm. She was sent to the local hospital's emergency room for stitches for the deep cut. The progress note dated 8/5/21 documented the IDT met with Resident #38 after her fall. It documented the resident had no memory of the fall, but did sustain a few injuries. The resident complained of mild pain. Staff state Resident #38 was agitated at the time of fall as evidenced by making statements of wanting to go home, while she was pulling on the back gate outside the MCU. They said the resident fell forward. The resident's care plan was updated and staff was advised to use prn (as needed) Ativan (an anti-anxiety medication) if the resident became too agitated. The IDT post fall review dated 8/16/21 documented the fall occurred at 5:35 p.m., which was an approximate three hour difference than documented in the SBAR above. It documented the resident required first aid, including stitches. It documented Resident #38 was pulling on a patio gate handle, trying to get it open. She turned to the left and fell on her knees and face. There was a small round pipe by the wall, which probably cut her hand. The resident sustained no loss of consciousness. She was trying to go home. IDT recommended staff notify the MD of possible need for med(ication) review. Anxiety meds were increased as deemed appropriate. PT to evaluate the type of walker for appropriateness. Staff to assist the resident while outside in the courtyard. Neuro(logical checks) done in case she did hit her head. The facility failed to adequately supervise or re-direct Resident #38 while she was actively trying to elope from the facility in order to prevent her falling and sustaining an injury requiring stitches. 3. Fall #3 The SBAR form dated 9/17/21 documented Resident #38 sustained a witnessed fall in the MCU dining room on 9/16/21 at 6:41 p.m. It documented the resident fell after slipping on water, falling to her knees and brushing her forehead against the dining room wall. The progress note dated 10/5/21 documented the IDT met with Resident #38 after her fall. It documented the resident stated she did not remember what occurred, but denied pain or injury. It documented formal education was provided to staff about keeping the residents' environment clear and safe. The IDT post fall review dated 9/21/21 documented the fall occurred at 7:00 p.m. and Resident #38 sustained no injury. It documented another resident pulled a pitcher of water off the counter top and the water spilled on the floor. Resident #38 went over to help catch the pitcher and wipe up the water and ended up slipping on the floor. IDT recommended staff education to keep the MCU environment clean and clear for resident safety and to check the environment frequently. It was documented staff should frequently encourage the resident to use her walker due to her cognitive barriers with dementia. The facility failed to supervise and re-direct Resident #38 away from the spilled water in the MCU dining room, causing Resident #38 to fall. 4. Fall #4 The situation, background, assessment and recommendation (SBAR) communication form and progress note dated 10/4/21 documented Resident #38 sustained an unwitnessed fall on 10/4/21 at 10:25 p.m. It should be noted the fall was documented here as occurring approximately five hour later than was noted in the elopement documentation (See above). It documented Resident #38 had eloped outside the facility and fell on the sidewalk. It documented the resident had been exhibiting new or worsening behavioral symptoms. The assessment was Resident is an active exit seeker. It documented, per the progress note dated 10/5/21 at 9:32 a.m. (See below), the resident had no pain or injury other than bruising of her right knee. The progress note dated 10/5/21 documented the interdisciplinary team (IDT) met with Resident #38 after her fall. She said she fell on the street, but denied having any pain or injury at the time. It documented all staff education was to take place. The IDT post fall review dated 10/6/21 documented the resident hit her right knee on the sidewalk and said it was hurting. She had a history of falls and cognitive deficit. The summary of the interdisciplinary team was the secured back gate was left unlocked and the resident went through the gate. It documented education was to take place related to gate checks, when the gate was to be locked and monitoring of the residents in the area of secured patio gate in the MCU. Maintenance was to inspect the gate and apply a spring for automatic closure and ensure proper latching of the gate. The facility failed to provide adequate supervision and re-direction for Resident #38 to prevent the resident from eloping from the facility and sustaining a fall in the community after she eloped. F. Family interview A family member of Resident #38 was interviewed via telephone on 11/11/21 at 10:40 a.m. He said it had been about two months since he had seen his mother due to COVID-19 restrictions. He said he wished he could see her more often. He said he did not receive a phone call earlier in the day on 10/4/21 prior to his mother eloping from the facility. He said he wished he had received a call and maybe he could have calmed her down so she did not escape and fall, but said he was almost proud of her for trying to get to her family. G. Staff interviews The director of nursing (DON) was interviewed on 11/11/21 at 1:52 p.m. She said Resident #38 was able to escape from the facility because staff had been using the back gate in the secured MCU's patio, the gate did not latch properly and no one noticed this until after the resident eloped. She said Resident #38 had been reported as a missing person on 10/4/21. She said the spring on the gate was replaced and all staff were educated about no longer using that gate to enter and exit the facility. She said normally the doors to the MCU were left open during the summer months and the facility assumed the secured area of the MCU patio was safe for residents. She said it was not until Resident #38 eloped from the facility when they realized there was a safety issue. She acknowledged there was only one staff member working on the MCU at the time of the resident's elopement, but that was usually enough to handle the low census of six residents on the unit. She said MCU staff could ask for help from other halls if needed by means of a walky-talky. She said Resident #38 had been assessed by both physical therapy (PT) and occupational therapy (OT) and that the resident was still receiving OT services. She said staff had been aware the resident had been agitated and exit seeking most of the day on 10/4/21, but staff also felt that cornering the resident agitated her more, so they just allowed Resident #38 to come in and out of the facility, feeling the secured patio was safe for the resident. She said it was not until after Resident #38 eloped, staff realized the resident should not have been left alone outside in the secured courtyard. She said after the elopement, all staff were educated about not leaving this resident outside by herself without supervision. She also said gate checks have been initiated and staff were no longer using that gate to enter or exit the premises. She said all staff training had been completed by 10/6/21. The maintenance manager (MM) was interviewed on 11/11/21 at 2:20 p.m. He said after Resident #38 eloped from the facility, he placed a self-spring on the gate so when someone opened the gate, it would automatically shut itself. He said he made sure the new spring, latch and everything was functioning on the MCU gate, including the magnet. He said no staff should be entering or exiting through that gate and he believed education had been provided to all staff about this. Registered nurse (RN) #2 was interviewed on 11/11/21 at 2:40 p.m. She said when Resident #38 was first admitted to the facility, she was out of her mind and would sit at the front door, threatening and yelling about leaving. She said the resident stabilized with some medication changes, but had begun getting agitated and asking for either her mother or her husband recently. She said Resident #38 was very pleasant, but would also flip on a dime because she needed to leave for some family reason. She said Resident #38 was hard to redirect, especially during the afternoons and early evenings when she was sun-downing. She said when the resident got revved up, staff would try to verbally redirect her. She said, If I was the nurse on duty during the times of her elopements and falls, I would have wanted to have my eyes on her. She said Resident #38 was more of a risk for falling if she was outside by herself. She said she got nervous when any of the MCU residents were outside by themselves. She said she would, at least, stand by the door so she could see the residents outside at all times. She said there was not always enough staff on the MCU when residents were revved up because the resident upset needed one-on-one attention while someone else was monitoring the other residents residing on the unit. She said some falls and the elopement could have been prevented. She said once Resident #38 was observed trying to throw her walker over the fence and if staff had been out there with her at the time, this resident's fall could have been prevented. She also said having the resident speak to her son over the telephone was a good intervention to calm the resident before she really escalated. The nursing home administrator was interviewed on 11/11/21 at 3:50 p.m. She stated Resident #38 was reported to the state portal as a missing person on 10/4/21. She said after the elopement, the facility placed hinges and springs on the gate, causing it to self-latch after the gate had been opened. She said she did not believe staff were outside with the resident when she eloped because they had the doors between the facility and the secured patio open to let fresh air in. She said staff did not feel they needed to be outside with her because of the secured gate. She said the reason staff came through the secured gate earlier that day was because the staff was afraid to enter through the main door to the MCU through the facility because that was the door Resident #38 had been trying to exit seek through most of the day. She said right before Resident #38 eloped, she had calmed down a bit and when staff saw her go outside, they just let her be. She said, Luckily, they went out to check on her about five or six minutes later. The NHA said staff were educated the day following the elopement, on 10/5/21, about any staff using the gate, to ensure the gate was completely shut and the magnet was engaged. She said the facility thought about permanently closing off the gate, but families used that gate to come and visit their loved ones on the MCU. The NHA said, in relation to Resident #38's falls, she did not like to see any of the residents fall. She said there should not have been water on the floor when Resident #38 fell in the water on 9/16/21. She said if Resident #38 needed to use a walker, she should and it should have been within the resident's reach, but most of the time the resident chose not to use the walker. At this time, approximately 4:05 p.m., the vice president of operations (VPO) entered and joined the interview. She said the facility had opportunities for improvement with resident falls and the facility now had a performance improvement plan (PIP) for falls, which they just developed on 11/8/21, the day the recertification survey began. She said education was provided to the IDT earlier that week and the facility's next step was to roll the information in the PIP out to the nursing department. She said, with the facility's recent change in corporate management and confusion related to the reporting process, the facility did not currently have a systemic approach related to falls and they would be working on this. The VPO brought the DON into the interview when discussing why it took so long to review the 8/4/21 fall in IDT, as it was not reviewed until 8/16/21. The same issue was seen in documentation for the 7/29/21 fall being reviewed on 9/2/21. (See fall investigations above). The DON said she knew they did review these falls and did not know what happened when the assessments were locked. The DON checked to see if new interventions were in place after 8/4/21 fall and said she did not see any new interventions in place after that fall. She said she thought the problem was not officially reviewing the falls in a timely manner and closing them out. III. Resident #72 A. Resident status Resident #72, under the age of 65, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included malignant neoplasm of the cervix, cirrhosis of the liver and anxiety disorder. The 9/7/21 MDS assessment identified the resident's cognition was moderately impaired with a BIMS score of eight out of 15. The resident has a wandering behavior that occurred one to three of the days during the assessment look back period. The MDS revealed Resident #72 ' s wandering placed her at significant risk of getting to a potentially dangerous place, such as stairs or outside of the facility. According to the MDS, Resident #72 required minimal assistance for all of her activities of daily living (ADLs) with supervision of ADLs with set up help only. The MDS did not identify exhibited behaviors physically or verbally or directed at others. B. Record review The 9/9/21 facility investigative report for Resident #72 was provided by the NHA on 11/10/21. The report revealed Resident #72 eloped from the facility on 9/9/21. The resident was reported missing between 3:50 p.m. and 4:20 p.m. Resident #72 was found by staff a few blocks away from the facility without injury. The report identified the resident was under one on one supervision of a certified nursing aide (CNA) prior to the elopement. According to the report, the CNA sat at the nurses station and watched the resident through a slightly ajar door. The CNA could not see the restroom door or the window from her position. The CNA believed the resident entered the restroom in her room at 3:40 p.m. She did not see the resident return from the restroom. A nurse entered the room of Resident #72 and identified the resident was not in her room and the room window was open with the screen removed. The report revealed the resident had attempted elopement several times. The facility determined the elopement attempts were related to agitation and her end-of-life decline. The investigative report for Resident #72 indicated facility policies and procedures were not followed. According to the report the SBAR (situation, background, assessment and recommendation was incomplete, the care plan did not include elopement or wanderguard, and sliding door/window locks were not in place, allowing the window to be opened more than six inches. Resident #72 was a new admission to the facility from the hospital. The hospital medication orders, signed on 9/1/21, read Resident #72 was admitted to hospice with an expected decline. The care plan for behavior initiated on 9/7/21 read Resident #72 had anxiety with agitation related to EOL (end of life). She exhibited pacing and wandering to the point of exhaustion with exit seeking behavior. Interventions included to anticipate and meet the resident ' s needs, encourage her to express her feelings appropriately and staff to provide opportunities for positive interaction and attention by stopping and talking with Resident #72 as they pass by. The care plan for elopement risk/wandering was initiated on 9/10/21. -The care plan was not initiated after the risk was identified on 9/5/21 or on 9/8/21, after continued exit seeking and elopement attempts. According to the care plan, Resident #72 was at risk for elopement and wandering due to a confusion related to malignant cancer. The care plan read the resident had a recent elopement where she jumped out of her bedroom window. The care plan identified the resident was on one-on-one supervision with interventions and needed emotional and psychological support, orientation to environment and re-orientation with validation and redirection as needed. The 9/5/2021 nursing note read Resident #72 observed walking outside in front of the facility door. Staff in the parking lot observed the resident and assisted her back inside the facility. According to the note, the resident was confused, wandering throughout the hallway and needed constant redirection to her room. The note revealed Resident #72 attempted to go out the front door twice prior to this incident. The note indicated a wanderguard was activated after she was found outside and staff would continue to monitor the resident. The note did not identify when the resident attempted to exit through the front door prior to the identified incident. The 9/5/21 phone order written at 3:19 p.m. identified orders to check the wanderguard for placement and function at every shift for wandering. The 9/8/2021 behavior note read Resident #72 was observed by a CNA on the phone behind the nurses statio[TRUNCATED]