**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and family interviews, the facility failed to complete accurate assessments and implement interventions for a resident to prevent the development of a Stage 4 pressure sore for 1 of 3 residents reviewed (Resident #1). Certified Nursing Assistant (CNA) staff identified a reddened area on a resident's coccyx in [DATE] and reported it to nursing staff. The record lacked assessments of the area, notification to the physician and treatment orders. On [DATE] an open area on the coccyx was identified and measured 1cm x1 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] the open area to the coccyx measured 1cm x 0.8 cm. The facility failed to assess the area, implement interventions, implement treatments and notify the physician and family. On [DATE] Resident #1 was admitted to the ER with a diagnosis of sacral decubitus ulcer, stage 4. The resident expired on [DATE] the Death Certificate showed immediate cause of death MRSA Cellulitis, buttock, due to sacral ulcer Stage 4. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 3:52 p.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: a. All residents received a full body skin review by RN Nurse Supervisor and no additional concerns were identified. b. All nursing staff were reminded of the importance of skin observations and following process on [DATE]. Additional education was provided on [DATE] and [DATE]. Notifications to physicians and family were included in this education and are on skin checklist packets. This was done by the Director of Nursing and or designees. c. Skin processes and status were reviewed at each huddle beginning [DATE] and this will continue using the huddle checklist. This was initiated by the Director of Nursing Services. d. All care plans were reviewed and updated as appropriate on [DATE] by RN supervisors. This was reviewed again on [DATE] by RN supervisors, Social Worker and Activity Director. e. A tracking tool was initiated that will be completed weekly to show all ulcers and surgical wounds. This will be reviewed at the weekly Risk meeting. This will be completed by the RN supervisor after wound rounds are completed. f. A weekly Risk meeting has been established. This meeting will include Administrator, Director of Nursing, RN Supervisors, Social Services, Activity Director, Quality Director, and Infection Preventionist. Residents with skin impairments will be reviewed to assist in identifying further interventions needed. Care plans will be updated with any changes noted. g. Reviews for each resident with ulcers and or surgical wounds will be reviewed daily for signs and symptoms of pain and infection. This will be noted on the residents treatment sheet. h. The Director of Nursing and or RN Supervisors will review the Matrix Even each day to review tasks and assessments that were completed as necessary. i. Audits to ensure skin observations are complete will be conducted weekly for 3 months by the Director of Nursing or designee. j. The tracking tool will be completed weekly going forward to track measurements, treatment and care plan updates. This will be done by an RN supervisor or designee. The scope was lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 48 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and 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 MDS assessment dated [DATE]showed Resident #1 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The diagnoses included non-Alzheimer's Dementia, diabetes mellitus and hypertension. The MDS included Resident #1 required partial to moderate assistance from staff for toileting hygiene, bathing, lower body dressing, putting on and taking off footwear, and personal hygiene. The Resident was at risk of developing pressure ulcers or injuries and did not currently have a pressure ulcer or injury and had a pressure reducing device for bed. Review of the Progress Notes revealed the following: On [DATE] at 8:25 a.m., Skin Observation on coccyx done, see observation. On [DATE] at 2:28 p.m., Resident wound on coccyx was bleeding a bit today. Review of the Care Plan dated [DATE] revealed the resident was at risk for pressure ulcer due to moisture. The Care Plan lacked information about any redness or open areas. Review of Bath Sheets revealed the following information: On [DATE]- completed with skin tears written on the sheet with a circle and line drawn to the coccyx area on the body diagram. Reddened areas noted to the buttocks and coccyx area with skin barrier cream applied to buttocks. On [DATE]- completed with reddened areas noted to the buttocks area. On [DATE]- completed with skin tears written on the sheet with a circle and line drawn to the coccyx area on the body diagram. Reddened areas noted to the buttocks and coccyx area with skin barrier cream applied to buttocks. On [DATE]- completed with reddened area noted to buttocks with circle and 2 x's on the buttocks/coccyx area hand written very red and sore. On [DATE]- completed with a reddened area noted to the buttocks with asterisk over the coccyx area. On [DATE]- completed with a reddened area noted to the buttocks and coccyx area with a circle around the coccyx area. On [DATE]- completed with no reddened area noted. Review of Skin Integrity Conditions assessment dated [DATE] at 10:12 a.m., completed by Staff R, Registered Nurse (RN) revealed a pressure sore to Resident #1's coccyx area that measured 1 centimeter (cm) x 1cm. Interventions listed were pressure reducing device in chair, pressure ulcer care and applications of ointments or medications. Review of the clinical record lacked any documentation of the pressure ulcer or pressure ulcer care started on [DATE] and notification of the physician or family. Review of the Care Plan lacked any new interventions for the care of the identified pressure ulcer. Review of the Skin Integrity Conditions assessment dated [DATE] at 8:22 a.m. revealed a pressure ulcer to Resident #1's coccyx area measuring 1cm x 0.8cm. No further details listed on the assessment. Review of the clinical record lacked any documentation of the pressure ulcer, pressure ulcer care and notification of the physician or family. Review of emergency room Encounter note dated [DATE] at 1:28 p.m., revealed exam of Resident #1 who presents to the emergency room with concerns of hypotension. Initial blood pressure 85/58. Fluids were ordered. Diagnosis included pressure injury of buttock, Stage 3 unspecified laterally. The assessment patient is minimally responsive. Findings included: wound present. Large sacral pressure wound characterized by redness, tenderness and purulent drainage. This morning when the staff attempted to get him up, the patient pointed to his bottom and they noticed a sore in the sacral area. Review of hospital admission History and Physical dated [DATE] at 8:33 a.m., under Assessment Plan Principle Problem with active diagnosis including sacral decubitus ulcer, Stage 4. On the day he was brought to the ER 1 day ago the staff noted sore on his bottom that he pointed to a complaint of pain. Unsure when that was initially noted or felt. Review of the hospital Discharge summary dated [DATE] at 8:35 p.m., revealed death summary diagnosis included sacral decubitus ulcer, Stage 4. The patient was admitted 2 days earlier for altered mentation and found to have decubitus ulcer and suspected of having sepsis likely from that. The family opted for keeping him comfortable. He was admitted in the care of his pain and discomfort and he died peacefully. The Death Certificate for Resident #1 showed immediate cause of death was MRSA Cellulitis, buttock, due to sacral ulcer Stage 4. Interview on [DATE] at 2:26 p.m., with Staff D, CNA revealed she knew Resident #1 had something on his coccyx area but was not sure what it looked like as there was always white cream on the area when she took care of him. Staff D expressed Resident #1 would complain about pain in his buttocks area. Interview on [DATE] at 2:47 with Staff E, CNA revealed she had seen the area on Resident #1's bottom and reported it to her medication aide that was working that day and she put a cream on the area. Interview on [DATE] at 2:50 p.m., with Staff A, RN revealed she had worked with Resident #1 and had received disciplinary action for a note she started in the Progress Notes and never followed up on the area. Staff A revealed she had seen a red area on Resident #1's buttocks area and had not done any interventions or a skin packet when she observed the area. Approximately a week and half to 2 weeks ago the CNA's told Staff A that Resident #1 had bright red blood on the toilet seat. Staff A had the CNA's give him a bath and when he was done she assessed his buttocks area and no areas were noted at that time. Interview on [DATE] at 3:05 p.m., with Staff F, RN revealed she had not seen the wound on Resident #1's buttocks but staff had reported it to her. Staff F revealed whoever the nurse working the hallway is responsible for the dressings and treatments on the hallway. Staff F had told another nurse to do the treatment but had not followed up with her to ensure the treatment and documentation was completed. Staff F further revealed she passed on to the next shift the concerns with Resident #1's coccyx area. Interview on [DATE] at 9:08 a.m., with Staff B, RN revealed she had cared for Resident #1 and had seen his coccyx area for the first time when it was red and not open but did not document the information. Staff B revealed she had seen the area when it was open and did not document it as she was under the understanding the nurse prior to her was aware of it and was going to document the area. Interview on [DATE] at 9:29 a.m., with Staff C, CNA revealed on [DATE] Staff A, RN had been in the room with the CNA's assisting with transfer and was unable to look at his coccyx area at that time due to resident transferring poorly. Staff C stated she had reported on [DATE] to the nurse the area looked like hamburger but the area was covered in cream and you could see the blood spots in the slits of the cream when she assisted with pulling up Resident #1's pants. Interview on [DATE] at 10:12 a.m., with Staff G, CNA revealed she had seen Resident #1's buttocks area and reported it to superior that day. Staff G described the area as a red openish area on the upper left buttock and on the upper right buttock there were 2 open areas and it was bleeding. The staff came and looked at it but was unsure if she measured the area and applied a duoderm dressing to the area. Interview on [DATE] at 10:21 a.m., with Staff H, CNA revealed Resident #1's buttocks area when he came wasn't very big at all but he did voice concerns of pain in the buttocks area and the area had been progressively getting worse. The last time she had assisted Resident #1 she stated the area on his buttocks looked absolutely awful. Staff H had reported to the nurse on duty the resident's color was off and he looked grey and purple. Staff H described the area was from the coccyx area where there were 2 blisters. On the way down there was bloody skin on both sides of the buttocks and continuing down looked like hamburger and went all the way down to the scrotum. Staff put cream on it as they were not sure what else to do. Staff H explained Resident #1 was incontinent towards the end and when the staff would change his brief it would stick to the area and when removed the resident would moan in pain. Interview on [DATE] at 10:30 a.m., with Staff I, RN revealed she was unaware of the area but wishes she would have known about it sooner. Interview on [DATE] at 10:35 a.m., with Staff J, RN revealed she was unaware of any skin areas on Resident #1 but was aware of the area now. Staff J revealed she understands he had an open area to the buttocks coccyx area and his groin was red and sore. Staff J denied ever seeing the open area to Resident #1 but the CNA had reported it looked like hamburger to her. Staff J revealed when it was reported to her the resident was in his recliner and staff had not cared for him yet and the meals were being served in the hallways so when staff went into assist him she was unable to go as she was assisting other residents. Staff J denied looking at the area when it was reported to her during her shift. Staff J reported she did not report the area to the next shift coming on. Staff J revealed looking back she wished she would have gone in and looked at the area or at least had someone go in and look at the area when it was reported to her. Interview on [DATE] at 1:58 p.m., with the Director of Nursing revealed the facility had nursing staff that received disciplinary action and some were suspended due to not following through with the skin. We are trying to do everything possible to prevent this from occurring again. Review of facility provided policy titled Pressure Ulcers with a reviewed date of [DATE] revealed; A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Residents will receive appropriate assessments and services to promote and maintain skin integrity. Review of facility provided policy titled Skin Assessment Pressure Ulcer Prevention and Documentation Requirements reviewed [DATE] revealed if a pressure ulcer is identified, cleanse the area prior to observations being made to allow the wound bed and depth to be more accurately observed. The licensed nurse records the location of the area, the measurements, and the ulcer/wound characteristics. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. Notify resident and/or family/representative of the pressure ulcer, orders and planned interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, the facility failed to appropriately perform assessments and interventions for the necessary care and services to maintain the residents' highest practical physical well- being for 5 out of 45 residents reviewed with signs and symptoms of COVID-19 (Residents #2, #3, #4,#5 and #6). Records showed 3 residents required hospitalization after emergency room (ER) visits, (Residents #2, #4 and #5). The failure to assess and test for COVID when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 4:49 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents with respiratory infection symptoms will be evaluated by the charge nurse. B. Any resident exhibiting any signs of symptoms of respiratory infection will be tested for COVID-19 and treated per physician directions. C. An evaluation of residents with respiratory symptoms and/or testing positive for COVID-19 will be conducted at least daily until symptoms have resolved. With updates to the physician as appropriate. D. All nurses were educated beginning [DATE] and completed on [DATE] related to the requirements for testing for COVID-19 and isolation of any resident with new respiratory symptoms. E. Audits on residents to ensure they are free of respiratory infection symptoms and completion of COVID-19. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnosis of stroke, hemiplegia and diabetes. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderately impaired cognition. Review of Progress Notes revealed the following: A. On [DATE] at 8:33 PM, Resident #2 reported he coughed all day like crazy, and requested cough medicine. Staff A Registered Nurse (RN) noted the resident presented with upper respiratory congestion with expiratory wheezing and rhonchi. No documented nursing assessments related to respiratory symptoms occurred from [DATE]-[DATE]. No test conducted to assess for COVID-19. B. On [DATE] the following Progress Notes revealed: a. At 5:02 AM Staff B, Licensed Practical Nurse (LPN), documented Resident #2 sounded horse and nasally. At 10:55 PM ([DATE]) guaifenesin with codeine administered per resident ' s request for cough and congestion. No respiratory assessment completed. No test conducted to assess for COVID-19. b. At 2:16 PM Staff C, LPN, documentation revealed Resident #2 reported not feeling good today, failed to eat breakfast or lunch, and stayed in his room all day. Staff C administered robitussin and acetaminophen at 10:58 AM. No respiratory assessment completed. No test conducted to assess for COVID-19. c. At 3:48 PM Staff D, RN, documented they were called to Resident #2 ' s room, resident unresponsive. The nurse noted drool in large amounts, incontinent of urine and oxygen saturation at 82%. Resident transported to the ER. The Hospital Discharge summary dated [DATE] for Resident #2 showed on admission the Principal Problem documented as pneumonia due to COVID-19 and Active Problem included hypoxia. 2. The MDS assessment dated [DATE] for Resident #3 documented diagnosis of dementia and diabetes. The MDS showed a BIMS score of 7 which indicated severe cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 3:04 PM, Staff E, RN, documented Resident #3 asked for a bottle of Listerine for a sore throat that started to hurt. The nurse explained Listerine is not used for a sore throat. Assessment completed. Resident #3 reported nasal congestion, a sore throat, and a headache. Lung sounds clear to auscultation bilaterally. Vital sign documented to be within normal limits. The nurse informed the resident that it is probably best for the resident to eat supper in their room. B. No documented nursing assessments related to symptoms occurred on [DATE]. No test conducted to assess for COVID-19. C. On [DATE] documentation revealed: a. At 8:40 AM, Staff E, RN, documented Resident #3 appeared to not feel well. Resident #3 reported a sore throat and a cold. The resident ' s family requested an appointment be made for Resident #3 to see their PCP. A clinic appointment made for 9:00 AM. b. At 12:48 PM, Staff B, LPN, reported the PCP notified the facility Resident #3 tested positive for COVID-19, and needed to be quarantined for 14 days. The PCP reported Resident #3 ' s symptoms started on [DATE]. 3. The MDS assessment dated [DATE] for Resident #4 documented diagnosis of diabetes. The MDS showed a BIMS score of 15 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 5:29 PM, Staff B, LPN, documented Resident #4 spent the afternoon in his room due to cold symptoms, mostly congestion, very little cough and hoarse voice. The nurse administered acetaminophen and congestion/cough medication. B. No documented nursing assessments related to respiratory symptoms occurred during the overnight hours on [DATE] or during the morning hours of [DATE]. No test conducted to assess for COVID-19. C. On [DATE] at 4:54 PM, Staff G, RN, documented Resident #4 continued to have cold symptoms, considerable upper respiratory congestion present with aches and chills. Resident #4 stated he felt terrible. D. On [DATE] Progress Notes revealed: a. At 4:33 AM Resident #4 continued to have cold symptoms, and a hoarse voice. At 3:45 AM requested and was given PRN Tylenol and PRN cough liquid. Resident requested assistance getting up and being walked to/from the bathroom. b. At 12:51 PM Resident #4 ' s family did not wish for residents to be seen in the clinic or ER would like to continue with cough medicine and pain medication if needed. c. No documented nursing assessments related to symptoms occurred after 4:33 AM on [DATE]. No test conducted to assess for COVID-19. d. At 4:00 PM Resident #4 taken to the ER per resident request due to increased weakness, family aware and agreed. Resident #4 was admitted to the hospital. The Hospital Records dated [DATE] for Resident #4 showed diagnoses COVID-19 and hypoxia present on admission. 4. The MDS assessment dated [DATE] for Resident #5 documented diagnosis of renal disease and Alzheimer ' s Disease. The MDS showed a BIMS score of 13 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] resident consents received for flu and RSV vaccines. Flu shot administered in left deltoid and RSv vaccine administered in right deltoid. B. On [DATE] at 2:20 AM Resident #5 requested cough medicine. Staff A, RN, documented Resident #5 heard coughing violently while walking and using the bathroom. Lungs are congested. Oxygen saturation at 93%. a. At 3:15 AM Resident #5 coughed occasionally but the cough was less severe than before the medication. Lungs continued to be congested. b. No documented nursing assessments related to respiratory symptoms occurred during the overnight hours from [DATE] at 3:15 AM to [DATE] at 10:30 PM. No test conducted to assess for COVID-19. C. On [DATE] at 10:30 PM, Resident #5 ' s family called the facility stating that her mother just called her and that she is not feeling good. On assessment resident alert and oriented, vitals and blood sugar within normal limits. D. No documented nursing assessments related to symptoms occurred during the overnight hours from [DATE] at 10:30 PM to [DATE] at 4:00 PM. No test conducted to assess for COVID-19. E. On [DATE] at 4:00 PM, Resident #5 found to be lethargic while sitting on the toilet that lasted approximately 1.5 minutes. Resident ' s pulse 131, and oxygen saturation 85%. Resident #5 taken to the ER then hospitalized . The Hospital Discharge summary dated [DATE] for Resident #5 showed pneumonia due to COVID-19 present on admission. 5. The MDS assessment dated [DATE] for Resident #6 documented diagnosis of non-traumatic brain disorder and Alzheimer ' s Disease. The MDS showed cognitive skills for daily decision making to be severely impaired. Review of Progress Notes revealed the following: A. On [DATE] at 6:45 PM, family of Resident #6 notified of the COVID-19 outbreak. Resident tested negative. B. On [DATE] at 10:54 AM, Resident #6 tested negative for COVID-19. C. On [DATE] at 4:54 PM, Resident #6 with a fever of 101.1. D. No documented nursing assessments after a known fever that developed during an COVID-10 outbreak occurred from [DATE] at 4:54 PM to [DATE] at 12:44 PM. No test conducted to assess for COVID-19. E. On [DATE] at 12:44 PM, the family of Resident #6 informed the resident test positive for COVID-19. The State of Iowa Certificate of Death showed Resident #6 expired on [DATE]. The immediate cause of death for Resident #6 documented as respiratory failure due to or as a consequence of COVID-19. In an interview on [DATE] at 9:14 AM, the facility PCP was asked if the COVID-19 vaccine caused a positive COVID test result, the provider replied, No, that has not been indicated. The PCP explained that the COVID vaccine and other vaccines, such as the flu and RSV could lower the immune system, making people more susceptible to contracting COVID. The PCP reported that she expected testing to occur when there are a combination of respiratory symptoms or any COVID symptom if the facility is in outbreak status. When asked if she expected staff to test a resident that reported coughing like crazy all day, had upper respiratory congestion with expiratory wheezing and rhonchi, the provider stated, Yes. I would have expected testing for that one. When asked if the PCP expected staff to test a resident that received cough medicine for a violent cough and congested lung sounds, the provided replied, yes. When asked if during a COVID outbreak would the provider expect a resident with a fever of 101.1 and sleepiness to be tested for COVID, the provider replied, I would expect a resident with any COVID symptom to be tested during an outbreak. In an interview on [DATE] at 10:27 AM, the Director of Nursing (DON) was asked to explain the assessment and testing expectations for respiratory signs and symptoms. The DON replied, we follow the policy. When asked what the policy stated, the DON replied, [NAME] ' t you know the regulations? In an interview on [DATE] at 12:17 PM, Staff B, LPN, reported herself and other nurses stopped reporting respiratory symptoms because nothing was done about it. Staff B explained, Nurses could not test residents, instead they were supposed to report signs and symptoms to the DON and Clinical Manager. The DON and Clinical Manager would then decide which residents to test. When asked if this impacted resident assessments, Staff B replied, Yes. The residents with symptoms weren't tested for COVID anyways. Leadership didn ' t want to be in outbreak. When we did report symptoms nothing was done. We were told to leave it alone. When asked what would happen if leadership wasn ' t present when a resident developed respiratory symptoms, Staff B replied, then staff would wait until morning to notify leadership. When asked if nurses were expected to complete ongoing assessments with the presence of respiratory symptoms or abnormal findings, Staff B replied, We didn ' t do anything about respiratory symptoms. Nothing was being done. The DON and Clinical Manager told us to leave it alone. In an interview on [DATE] at 12:39 PM, Staff A, RN, reported nursing staff could not assess the residents with a COVID-19 assessment unless the DON or Clinical Manager approved it. Staff A stated, They told us to ignore when residents had respiratory symptoms. Leadership didn ' t want the facility in outbreak status for COVID-19. Staff A further explained, when the nurses reported residents were getting sick, the DON and Clinical Manager would tell us to leave it alone because we weren't going to test for COVID. The Clinical Manager would say things like shh, no he's not sick and to leave it alone. When asked if nursing staff were expected to complete ongoing respiratory asssessments with the start of symptoms Staff A replied, we became desensitized to respiratory symptoms. We weren ' t allowed to test residents and couldn ' t test ourselves until after the shift ended. When Resident #2 first showed symptoms he was not tested, isolated or moved to a quarantined area. When Resident #4 first showed symptoms, I did not report it, because we were told to leave it alone and shh. We became desensitized to it. Everyone was desensitized. In an interview on [DATE] at 1:13 PM, the Infection Preventionist (IP) reported that she would have definitely tested Resident #2 on [DATE] for COVID because they were in a community outbreak as well. The IP stated, we talk about things like that in the daily safety briefing- all leadership meetings for the entire facility. That's where I shared things like that. The IP reported that she would have definitely tested Resident #3 on the first day of symptoms, [DATE]. The IP reported that she also would have tested Resident #4 on [DATE] and Resident #5 on [DATE]. The IP reported she would have tested Resident #6 on [DATE]. In an interview on 1/30/ 24 at 1:36 PM, Staff E RN, reported she asked the DON to assess Resident #3 after the resident reported congestion and a sore throat. Staff E reported, the DON decided not to test for COVID. When asked if the DON gave ongoing assessment instruction or if the symptoms prompted further assessments. Staff E stated, no. In an interview on [DATE] at 4:49 PM, the DON was informed of IJ concern. The DON replied, I figured that. When asked if she expected the IJ, the DON replied, Oh ya. When asked if she knew what the IJ was related to, the DON replied, COVID. In an interview on [DATE] at 9:32 AM, the Nurse Consultant reported the policy for assessment of respiratory symptoms is located in the Emerging Threats-Acute Respiratory Syndrome Coronavirus. In an interview on [DATE] at 1:15 PM, Staff A, RN, reported that starting today daily risk assessments are now completed on all residents. When asked what the assessment included, the nurse replied, we have to check the resident ' s pulse, lung sounds, and for other signs and symptoms of COVID. The nurses now test for COVID if the daily risk assessment is positive. In an interview on [DATE] at 1:46 PM, the Infection Preventionist reported that she expected nursing staff to complete ongoing assessments and documentation of all abnormal findings, including respiratory symptoms or signs and symptoms of COVID. The Emerging Threats-Acute Respiratory Syndrome Coronavirus policy last revised on [DATE] indicated for long term care facilities that residents are monitored for signs and symptoms of COVID-19 per routine practice. Residents with symptoms of COVID-19 will be isolated and tested immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to implement adequate infection control strategies and practices to mitigate the transfer of viruses by failure to test and isolate residents with respiratory signs and symptoms for 5 out of 45 residents reviewed (Residents #2, #3, #4, #5 and #6). Records showed three residents required hospitalization after emergency room (ER) visits, ( Residents #2, #4 and #5). The failure to test for COVID and isolate when signs and symptoms presented resulted in immediate jeopardy to resident health and safety. The facility identified a census of 45 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 5:09 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A. All residents who exhibit signs or symptoms of respiratory infection will be immediately evaluated by the charge nurse and isolated in their room in transmission-based precautions under suspicion of COVID-19 or other respiratory illness. A COVID-19 test will be performed to assist in diagnosing of COVID-19. 2 negative tests, 48 hours apart, will be required to rule out COVID-19 and other respiratory pathogens along with symptoms will be considered prior to discontinuing precautions. B. All COVID-19 positive residents will be treated according to physician ' s orders and placed in isolation in a private room, if able. If no private room is available, the resident will remain in their room with their roommate; the privacy curtain will be pulled. C. Whenever there is a COVID-19 positive staff member or resident, close contacts (residents) and higher risk exposures (staff) will be identified. The Director of Nursing/Designee and the Administrator will determine if exposed staff and residents can be determined through contact trace testing or if Broad based testing is warranted. D. Identified staff and residents will be tested on days 1, 3 and 5 following their exposure. E. Testing may be expanded based on results on additional testing. When additional residents and staff are testing positive with each round of testing, close contact exposures cannot be identified, or an outbreak is present on more than one unit or hallway, expanded outbreak testing will be implemented. All facility staff and residents will then be tested every 3 to 7 days until the facility has gone 14 days with no additional positive cases. F. Staff will be expected to test at the beginning of their shift. G. Staff use of PPE per policy (Emerging Threats) and Surveillance and Mitigation guide will be required, to include masks, N95s, gowns and eye protection based on location of Covid-19 positives in the facility and area of facility staff is assigned to work. Education to all staff began on the evening of [DATE] and completed on [DATE]. H. Any staff member that has not completed the education by the end of [DATE] will have education completed at the beginning of their next shift and will not be allowed to work until this has been completed. I. Audits on residents to ensure they are free of respiratory infection symptoms and completion of COVID- 19 testing if symptoms noted will be completed by the Director of Nursing or designee daily x 5 working days and then weekly x 4 weeks. Audits for appropriate use of PPE will be conducted daily during any time frame there are residents with suspected or confirmed Covid-19. J An Ad Hoc Quality Assurance meeting was held on [DATE] with Administrator, Director of NursingServices, Nurse Manager, Social Services, Medical Director and Region Clinical Director. IJ templates reviewed, discussion of removal plan and acceptance of plan by all team members present at Ad Hoc Quality Meeting. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Included: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnosis of stroke, hemiplegia and diabetes. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderately impaired cognition. Review of Progress Notes revealed the following: A. On [DATE] at 8:33 PM, Resident #2 reported he coughed all day like crazy, and requested cough medicine. Staff A Registered Nurse (RN) noted the resident presented with upper respiratory congestion with expiratory wheezing and rhonchi. Nursing staff failed to test for COVID and isolated the resident if needed. B. On [DATE] the following Progress Notes revealed: a. At 5:02 AM Staff B, Licensed Practical Nurse (LPN), documented Resident #2 sounded horse and nasally. At 10:55 PM ([DATE]) guaifenesin with codeine administered per resident ' s request for cough and congestion. Nursing staff failed to test for COVID and isolated the resident if needed. b. At 2:16 PM Staff C, LPN, documentation revealed Resident #2 reported not feeling good today, failed to eat breakfast or lunch, and stayed in his room all day. Staff C administered robitussin and acetaminophen at 10:58 AM. No respiratory assessment completed. Nursing staff failed to test for COVID and isolated the resident as needed. c. At 3:48 PM Staff D, RN, documented they were called to Resident #2 ' s room, resident unresponsive. The nurse noted drool in large amounts, incontinent of urine and oxygen saturation at 82%. Resident transported to the ER. The Hospital Discharge summary dated [DATE] for Resident #2 showed on admission the Principal Problem documented as pneumonia due to COVID-19 and Active Problem included hypoxia. 2. The MDS assessment dated [DATE] for Resident #3 documented diagnosis of dementia and diabetes. The MDS showed a BIMS score of 7 which indicated severe cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 3:04 PM, Staff E, RN, documented Resident #3 asked for a bottle of Listerine for a sore throat that started to hurt. The nurse explained Listerine is not used for a sore throat. Assessment completed. Resident #3 reported nasal congestion, a sore throat, and a headache. Lung sounds clear to auscultation bilaterally. Vital sign documented to be within normal limits. The nurse informed the resident that it is probably best for the resident to eat supper in their room. B. No documented nursing asessments related to symptoms occurred on [DATE]. No test conducted to assess for COVID-19. C. On [DATE] documentation revealed: a. At 8:40 AM, Staff E, RN, documented Resident #3 appeared to not feel well. Resident #3 reported a sore throat and a cold. The resident ' s family requested an appointment be made for Resident #3 to see their PCP. A clinic appointment made for 9:00 AM. Nursing staff failed to test for COVID and isolate the resident as needed. b. At 12:48 PM, Staff B, LPN, reported the PCP notified the facility Resident #3 tested positive for COVID-19, and needed to be quarantined for 14 days. The PCP reported Resident #3 ' s symptoms started on [DATE]. 3. The MDS assessment dated [DATE] for Resident #4 documented diagnosis of diabetes. The MDS showed a BIMS score of 15 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 5:29 PM, Staff B, LPN, documented Resident #4 spent the afternoon in his room due to cold symptoms, mostly congestion, very little cough and hoarse voice. The nurse administered acetaminophen and congestion/cough medication. Nursing staff failed to test for COVID and isolate the resident as needed. B. On [DATE] at 4:54 PM, Staff G, RN, documented Resident #4 continued to have cold symptoms, considerable upper respiratory congestion present with aches and chills. Resident #4 stated he felt terrible. Nursing staff failed to test for COVID and isolate the resident as needed. C. On [DATE] at 4:33 AM Resident #4 continued to have cold symptoms, and a hoarse voice. At 3:45 AM had requested was given PRN Tylenol and PRN cough liquid. Resident requested assisstance with getting up and being walked to/from the bathroom. a. At 12:51 AM Resident #4 ' s family did not wish for residents to be seen in the clinic or ER would like to continue with cough medicine and pain medication if needed. b. No documented nursing assessments related to symptoms occurred after 4:33 AM on [DATE]. No test conducted to assess for COVID-19. c. At 4:00 PM Resident #4 taken to the ER per resident request due to increased weakness, family aware and agreed. Resident #4 was admitted to the hospital. The Hospital Records dated [DATE] for Resident #4 showed diagnoses COVID-19 and hypoxia present on admission. 4. The MDS assessment dated [DATE] for Resident #5 documented diagnosis of renal disease and Alzheimer ' s Disease. The MDS showed a BIMS score of 13 which indicated no cognitive impairment. Review of Progress Notes revealed the following: A. On [DATE] at 2:20 AM Resident #5 requested cough medicine. Staff A, RN, documented Resident #5 heard coughing violently while walking and using the bathroom. Lungs are congested. Oxygen saturation at 93%. Nursing staff failed to test for COVID and isolate the resident as needed. a. At 3:15 AM Resident #5 coughed occasionally but the cough was less severe than before the medication. Lungs continued to be congested. B. On [DATE] at 11:20 AM nurse assisted resident to doctor appointment to clean ears. C. On [DATE] at 2:50 PM nurse assisted resident to to behavioral health appointment. Resident's daughter also at the visit. D. On [DATE] at 10:30 PM, Resident #5 ' s family called the facility stating that her mother just called her and that she is not feeling good. On assessment resident alert and oriented, vitals and blood sugar within normal limits, PRN Tylenol given. Nursing staff failed to test for COVID and isolate the resident as needed. E. On [DATE] at 4:00 PM, Resident #5 found to be lethargic while sitting on the toilet that lasted approximately 1.5 minutes. Resident ' s pulse 131, and oxygen saturation 85%. Resident #5 taken to the ER then hospitalized . The Hospital Discharge summary dated [DATE] for Resident #5 showed pneumonia due to COVID-19 present on admission. 5. The MDS assessment dated [DATE] for Resident #6 documented diagnosis of non-traumatic brain disorder and Alzheimer ' s Disease. The MDS showed cognitive skills for daily decision making to be severely impaired. Review of Progress Notes revealed the following: A. On [DATE] at 6:45 PM, family of Resident #6 notified of the COVID-19 outbreak. Resident tested negative. B. On [DATE] at 10:54 AM, Resident #6 tested negative for COVID-19. C. On [DATE] at 4:54 PM, Resident #6 with a fever of 101.1. Nursing staff failed to test for COVID. D. On [DATE] at 12:44 PM, the family of Resident #6 informed the resident test positive for COVID-19. The State of Iowa Certificate of Death showed Resident #6 expired on [DATE]. The immediate cause of death for Resident #6 documented as respiratory failure due to or as a consequence of COVID-19. In an interview on [DATE] at 10:27 AM, the Director of Nursing (DON) was asked to explain the assessment and testing expectations for respiratory signs and symptoms. The DON replied, we follow the policy. When asked what the policy stated, the DON replied, [NAME] ' t you know the regulations? In an interview on [DATE] at 12:17 PM, Staff B, LPN, reported herself and other nurses stopped reporting respiratory symptoms because nothing was done about it. Staff B explained, Nurses could not test residents, instead they were supposed to report signs and symptoms to the DON and Clinical Manager. The DON and Clinical Manager would then decide which residents to test. When asked if this impacted resident assessments, Staff B replied, Yes. The residents with symptoms weren't tested for COVID anyways. Leadership didn ' t want to be in outbreak. When we did report symptoms nothing was done. We were told to leave it alone. When asked what would happen if leadership wasn ' t present when a resident developed respiratory symptoms, Staff B replied, Then staff would wait until morning to notify leadership. When asked if nurses were expected to complete ongoing assessments with the presence of respiratory symptoms or abnormal findings, Staff B replied, We didn ' t do anything about respiratory symptoms. Nothing was being done. The DON and Clinical Manager told us to leave it alone. In an interview on [DATE] at 12:39 PM, Staff A, RN, reported nursing staff could not assess the residents with a COVID-19 unless the DON or Clinical Manager approved it. Staff A stated, They told us to ignore when residents had respiratory symptoms. Leadership didn ' t want the facility in outbreak status for COVID-19. Staff A further explained, When the nurses reported residents were getting sick, the DON and Clinical Manager would tell us to leave it alone because we weren't going to test for COVID. The Clinical Manager would say things like shh, no he's not sick and to leave it alone. When asked if nursing staff were expected to complete ongoing respiratory symptoms with the start of symptoms Staff A replied, We became desensitized to respiratory symptoms. We weren ' t allowed to test residents and couldn ' t test ourselves until after the shift ended. When Resident #2 first showed symptoms he was not tested, isolated or moved to a quarantined area. When Resident #4 first showed symptoms, I did not report it, because we were told to leave it alone and shh. We became desensitized to it. Everyone was desensitized. In an interview on [DATE] at 1:13 PM, the Infection Preventionist (IP) reported that she would have definitely tested Resident #2 on [DATE] for COVID because they were in a community outbreak as well. The IP stated, we talk about things like that in the daily safety briefing- all leadership meetings for the entire facility. That's where I shared things like that. The IP reported that she would have definitely tested Resident #3 on the first day of symptoms, [DATE]. The IP reported that she also would have tested Resident #4 on [DATE] and Resident #5 on [DATE]. The IP reported she would have tested Resident #6 on 10/15. In an interview on 1/30/ 23 at 1:36 PM, Staff E RN, reported she asked the DON to assess Resident #3 after the resident reported congestion and a sore throat. Staff E reported, the DON decided not to test for COVID. When asked if the DON gave ongoing assessment instruction or if the symptoms prompted further assessments. Staff E stated, no. In an interview on [DATE] at 4:49 PM, the DON was informed of IJ concern. The DON replied, I figured that. When asked if she expected IJ, the DON replied, Oh ya. When asked if she knew what the IJ was related to, the DON replied, COVID. In an interview on [DATE] at 9:32 AM, the Nurse Consultant reported the policy for assessment of respiratory symptoms is located in the Emerging Threats-Acute Respiratory Syndrome Coronavirus. In an interview on [DATE] at 1:15 PM, Staff A, RN, reported that starting today daily risk assessments are now completed on all residents. When asked what the assessment included, the nurse replied, we have to check the resident ' s pulse, lung sounds, and for other signs and symptoms of COVID. The nurses now test for COVID if the daily risk assessment is positive. In an interview on [DATE] at 1:46 PM, the Infection Preventionist reported that she expected nursing staff to complete ongoing assessments and documentation of all abnormal findings, including respiratory symptoms or signs and symptoms of COVID. The Emerging Threats-Acute Respiratory Syndrome Coronavirus policy last revised on [DATE] indicated for long term care facilities that residents are monitored for signs and symptoms of COVID-19 per routine practice. Residents with symptoms of COVID-19 will be isolated and tested immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #18). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 9:30 a.m The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: A staff member is to monitor the door at all times until the Wanderguard servicing agent arrives to assess the system. Maintenance also increased the distance for alarm to activate to 8 feet instead of 6 1/2 feet that it was previously set at. Increased to 10 feet on [DATE]. Maglock installation completed to the doors on [DATE]. Added an alarm speaker closer to the Nurse's Station. The resident was placed on 15-minute placement checks until reviewed by IDT and assess plan to decrease or discontinue. Care plan updated. Stopped 15 min checks [DATE] as all door and alarm adjustments have now been completed. All staff educated and return quiz completed upon clocking into their next scheduled shift on resident elopement policy/drills. Charge nurse on duty at time of event provided education along with review of incident, plan of correction, and if any learning opportunities resulted. When staff are unable to identify a person that is entering/exiting the door alarms including non-wanderguard alarms staff must physically go to the alarming area to investigate who passed through the door and if unable to identify the source of the alarm they must do a resident count immediately to ensure all residents are accounted for. Missing resident drill will be conducted over the next three shifts, starting on the evening shift on [DATE]. All residents will have an elopement risk assessment completed by [DATE] to ensure the current risk is current and wanderguard in place if identified need for one. All door wanderguard alarms were checked after the resident returned to the facility to ensure they were working. All doors alarms appropriately. Checking wanderguard placement and that it is working daily which is already in place and documented by the nurse. Activities will provide 1:1 visit with resident four times weekly. likes to fold clothes, sweep floors, and wipe tables. Care conference with daughter was held on [DATE] and discussed with daughter if she agrees to a 30-day trial of not taking resident out of the facility to monitor if anxious and agitated behaviors have fewer episodes. Family agrees. SBAR communication sent to the Doctor on [DATE] asking if lab work would be appropriate to rule out infection. Lab workup completed on [DATE]. Reviewed by primary care physician and no new orders received. Video camera views were reviewed, and it was determined that some screens could be removed from the monitor and replaced with more outside areas that would be better to monitor more sidewalks and outside areas around the facility. The North most door (closest to the exit doors) to the dining room to be closed all the time to divert residents to the two dining room doors to the south. Signage added to the door. The facility identified a census of 49 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 18 documented diagnoses of Non-Alzheimer ' s dementia, hypertension and hyperlipidemia. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed. Review of the MDS dated [DATE] revealed the following information: Under assessment for mental status short term memory seems to appear or recall after 5 minutes indicates memory problem. Under assessment for mental status for long term memory seems to appear or recall after 5 minutes indicates memory problem. Under behavior revealed the following; Wandering presence and frequency- behavior of this type occurred daily Wandering- impact Does the wandering place the resident at a significant of getting to a potentially dangerous place- Yes Does the wandering significantly intrude on the privacy or activities of others- Yes Review of Resident #18 ' s Progress Notes revealed the following: On [DATE] at 8:58 p.m., resident has been wandering up and down the halls today. She was given some towels to fold and was easy to redirect today. Staff assisted her to go to bed and she has not got up since. On [DATE] at 5:44 p.m., resident has wandered up to the nurse ' s desk a few times. States she just didn ' t feel good but is very vague as to why she doesn ' t feel well. On [DATE] at 3:39 p.m., resident has been wandering and has been to the door multiple times trying to get out. Wanderguard has sounded multiple times as the resident has crossed towards the exit. Redirection has been unsuccessful. Resident is finally taken outside with the activity director to enjoy the weather. On [DATE] at 11:45 p.m., hall nurse notifies that resident is not found to be able to give the resident her medications. Staff nurse has started to look in areas that the resident is noted to be seen in as she is often wandering or found in the bed of other residents. All staff that are currently available have started looking for the resident. Two other staff members were outside the building to walk the perimeter of the building. Call received from an officer with the police department stating that they were with the resident and asked if someone could go to the address to pick her up. Two staff members were sent to the location to pick the resident up. Call made by nurse to the daughter to notify of the incident. Nurse stated she will keep her updated. On arrival at the facility the nurse started the resident on 15 minute checks. Resident was wearing a light sweater and her church clothes, pants and a t-shirt. Complete head to toe assessment completed. Primary Care Physician notified by fax and on-call physician notified by phone. Interview on [DATE] at 12:53 p.m., Staff B, Licensed Practical Nurse (LPN), revealed she was working the day Resident #18 left the building. She went to give the resident her medication at approximately 10:30 a.m., and the resident was not in her room. Staff B revealed this is not uncommon as she normally wanders around the facility. Staff B revealed she did not tell anyone else right away but after she was unable to locate Resident #18, she alerted other staff that were working. Staff began looking around the facility as well as outside and were unsuccessful finding the resident. The facility received a phone call from the police department stating they had a confused resident. Staff B revealed a nurse and Certified Nursing Assistant (CNA) went to Resident #18 ' s location and picked her up and brought her back to the building. Interview on [DATE] at 12:57 p.m., Staff C, CNA, revealed she had seen Staff A looking around and asked her what she was doing. When Staff C was alerted Resident #18 was missing, she began searching the facility. Staff C revealed her and Staff H, LPN started at the end of the south hallway with one staff on each side of the hallway, looking in rooms, bathrooms, closets, linen closets, anywhere a person could get into. Staff C revealed her and Staff H moved over to the east hallway and looked in rooms, bathrooms and closets with no success. Staff C revealed she felt like they searched the facility for 45 minutes. Staff C and Staff G then moved to the outside of the facility. Staff C went around to the east and Staff H went around to the west and they met in the middle on the backside of the facility. Staff C revealed she was looking around corners and in and under bushes with no success in locating Resident #18. Staff C revealed when her and Staff H came into the building the police were on the phone and had Resident #18. Staff C revealed prior to knowing Resident #18 was missing, she had heard a faint alarm which was turned off quickly but was unable to verify which alarm had sounded. Staff C revealed Resident #18 does wander around the facility quite often and she has seen her get agitated and beat her hands on the east side doors stating she does not belong here and to let her out. Resident #18 does wander around the facility quite often and sets off the wanderguard alarm on a regular basis. Interview on [DATE] at 1:07 p.m., with Staff D, CNA revealed she was on break when the staff made her aware Resident #18 was unable to be located. Staff D revealed she clocked back in and immediately began looking for Resident #18. Staff D verified staff were not able to locate her within or around the facility. Staff D further revealed the police department called and had located Resident #18. Staff D revealed Staff H, LPN and Staff E, CNA went and got Resident #18 and brought her back to the building. Interview on [DATE] at 1:39 p.m., with the Director of Nursing (DON) revealed she had received a call from the facility that Resident #18 had eloped from the facility and the police found her approximately a half mile from the facility around a place where she used to live. She was told Resident #18 was sitting under a tree with a couple ladies and came back to the building with no concerns. The DON revealed Resident #18 went out the north doors and the wanderguard did not sound when Resident #18 exited the building but the door alarm did and the staff turned it off without checking the door. The DON further revealed the wanderguard was set to 6 ½ feet and sometimes it would catch the wanderguard and sometimes it would not and this is what the door had been set at since installation. The facility did extend the sensor feet after the incident. Interview on [DATE] at 1:49 p.m., with Staff E, CNA revealed she had been on lunch break and when she came back she found out Resident #18 was unable to be found. Staff E revealed she immediately began looking for Resident #18. The facility received a phone call from the police station regarding Resident #18 and they needed someone to come and pick her up. Staff E and Staff H left the facility to pick her. Staff E revealed when they arrived to pick up Resident #18 she was sitting under a tree with some ladies having a glass of water. She smiled at the staff when she was addressed. Staff E confirmed Resident #18 was wearing her wanderguard. Resident #18 returned to the facility with Staff E and Staff H with no incident. Upon entering the facility the wanderguard alarm sounded when Resident #18 entered the facility. Staff E revealed she had given Resident #18 a bath earlier in the day and she was agitated during the bath to the point she tried to crawl out of the bathtub. Staff E confirmed she was wearing her wanderguard during her bath. Staff E further revealed Resident #18 does wander around the facility towards the doors and watches the doors but usually is easy to redirect away from the door. Interview on [DATE] at 1:59 p.m., with Staff F, Registered Nurse (RN), revealed she was the charge nurse on the day of the incident. Stated she was made aware when Staff A went to Resident #18 ' s room to give her medications. Staff A was unable to locate Resident #18 and alerted the other staff. All staff immediately began looking for Resident #18 inside the facility and around the facility premises. Staff F received a phone call from the police department that they had Resident #18 and needed someone to pick her up. Staff E and Staff H went and brought Resident #18 back into the building. Staff F was unsure how Resident #18 exited the building. When Resident #18 re-entered the building and the wanderguard alarm sounded. Staff F assessed the resident with no concerns noted. Staff F noted the resident was a little more anxious than usual and wanted to get out of the building after returning. Staff F notified the family of the incident, primary care physician, on-call physician and received no new orders. Resident #18 was placed on 15 minute checks for her safety. Staff F revealed she took direction from the leadership on the interventions put into place. The facility immediately began educating staff after the incident. Interview on [DATE] at 2:05 p.m., with Staff G, CNA, revealed they didn ' t know much about the situation. Stated that Resident #18 does walk around the facility a lot and she got out the back door. Staff G further revealed you can just push the doors open and they will alarm but you can just walk out. Interview on [DATE] at 2:38 p.m., with Staff H, LPN revealed Staff A came down her hallway asking if she had seen Resident #18 and she told Staff A she had not seen her recently. Staff H revealed all the staff began looking around the facility and then they headed outside. Staff H revealed her and Staff C went to look outside on the grounds. Staff H revealed she headed west around the grounds and Staff C headed east around and they met at the back of the building unable to locate Resident #18. Staff H revealed when she came back in from outside Staff F was on the phone with someone and they revealed Resident #18 was with them and they needed someone to pick her up. Staff H and Staff E went to where Resident #18 was. Staff H stated when the staff arrived Resident #18 was sitting under a tree with a couple of ladies having a glass of water and smiled at them and said hello. Staff H and Staff E returned to the building with Resident #18 with no concerns. Staff H confirmed Resident #18 was still wearing her wanderguard and the alarm sounded upon re-entering the building. Review of Resident #18 ' s Care Plan with a revision date of [DATE] revealed the following information: Potential for elopement from the facility related to dementia, wanderguard placed on left ankle Watch resident closely throughout the day especially when family and staff are leaving the facility. Wanderguard program. Redirect resident when attempting to go out the doors. Dated [DATE] Resident is more anxious and upset when she is looking for her deceased family members or the girls. Looking at the front door more often for her family to pick her up. Resident resists care related to her dementia. Resident is unable to participate in BIMS related to diagnosis of dementia. Resident is at risk for falling related to wandering and dementia. Review of facility provided untitled and undated information revealed the following regarding the incident: Resident #18 received her bath around 9:30 a.m., on [DATE] given by Staff E, CNA, and was noted to be agitated and anxious and at one point attempted to climb out of the tub and made statements about her family coming to pick her up. The wanderguard was also noted to be on her left ankle at this time. Upon leaving the tub/shower room Resident #18 started to wander about the facility which is normal for her. Staff on shift stated that the wanderguard alarm did alarm once by the front door where they found Resident #18 and redirected her away from the door. According to video footage at 10:00 a.m., Resident #18 was at the front door and the wanderguard alarm sounded and CNA and Staff F, RN responded and redirected Resident #18 away from the door then reset the alarm. Staff F stays at the front door as she saw visitors approaching and let them enter the facility. The wanderguard alarm at the front door alarmed again at 10:01 a.m., by Resident #18 and staff responded and redirected Resident #18 a second time. Resident #18 then goes toward East Hall then turns back and goes into the dining room and leaves the dining room from the north dining room door, turns left to the alarmed double doors exiting out and turns right exiting outside at 10:05 a.m The North double doors alarmed that it opened. Staff F had just approached the nurse's desk and simultaneously turned to reset the alarm and then she looked up at the camera to monitor door activity. The wanderguard alarm did not activate at that time as no staff responded to manually reset code to turn off the alarm when viewing the video. The Maintenance Director entered the nursing home through those same doors at 10:13 a.m., and he stated there was no alarm going off at that time. The Wanderguard Log from that door and the first alarm that activated was at 11:34 a.m., which was after the time resident returned (returned at 11:26 per video) and staff took Resident #18 to the North door to test the wanderguard alarm and it did activate the alarm at that time. Review of facility provided policy titled Elopement with a revision date of [DATE] revealed the following information: The location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. All residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and follow-up will be completed as required by state and federal regulations. Interview on [DATE] at 1:39 p.m., with the DON revealed the staff working should have physically checked the alarm instead of resetting it.