Every finding on record at Aberdeen Village

Based on observation, record review, and interviews, the facility failed to provide individualized care and services related to dementia care (a progressive mental disorder characterized by failing memory and confusion) for Resident (R)1, who displayed wandering behaviors into other resident's rooms. Findings Included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia, need for continuous supervision, adjustment disorder (a short-term, intense emotional or behavioral reaction to a stressful life change that is disproportionate to the event), muscle weakness, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), Post-Traumatic Stress Disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and cognitive communication deficient (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 required setup or clean up assistance for eating and oral hygiene. R1 required partial to moderate assistance for showers and bathing. The MDS documented R1 was independent for other Activities of Daily Living (ADLs) and mobility. The MDS documented R1 exhibited wandering behavior daily. The MDS documented the wandering behavior did not significantly intrude on the privacy or activities of others. The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 01/23/26, documented R1 was at risk for potential alterations in his cognitive status. The CAA documented R1 had poor adjustment disorder with anxiety and PTSD. The CAA documented R1 used a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) due to exit seeking. R1's 01/21/26 Care Plan documented R1 was at risk for potentially leaving the neighborhood or facility unsupervised related to dementia, and anxiety. The Care Plan documented the following interventions:01/21/26 - directed staff to attempt redirection as needed. If R1 became aggressive, staff were to make sure he was safe and monitor him from a distance. The intervention directed staff to reapproach when R1 was calm.01/21/26 - WanderGuard placed on right wrist. WanderGuard for personal safety.01/21/26 - directed staff to check WanderGuard bracelet placement and function daily. Other care plan WanderGuard intervention directed staff to replace the WanderGuard as needed and change it every three months.01/21/26 - directed staff to notify R1's primary care provider (PCP) as needed for concerns or an increase in his behaviors. R1's 01/29/26 Care Plan documented R1 stayed on the facility's memory care unit. The Care Plan documented R1 had cognitive loss and had exit seeking behavior due to his diagnosis of dementia. The Care Plan documented the following interventions:04/28/26 - documented R1 had a desire to help some of the female residents in his neighborhood. The intervention directed staff to attempt to redirect R1 when it happened and notify R1's PCP as needed.05/15/26 - directed staff to call R1's daughter or his spouse if R1 became agitated or exhibited exit seeking behaviors. R1's 01/29/26 Care Plan documented R1 was at risk for potential alteration in cognitive function and mood related to dementia, adjustment disorder, anxiety, and PTSD. The Care Plan documented R1 stayed on a secure memory unit for his safety. The Care Plan documented the following interventions:01/29/26 - directed staff to engage R1 in simple, structured activities that avoid overly demanding tasks.01/29/26 - directed staff to provide R1 with cueing, reorient, and supervise as needed.01/29/26 - Directed staff to provide a program of activities that accommodates R1's abilities. The intervention recorded R1 loved walking.The Care Plan lacked interventions that addressed R1's wandering into other resident's rooms. A Social Services note dated 01/19/26 documented R1 was very confused in the late afternoon and wandered in and out of other resident's rooms. A Behavior Note dated 01/28/26 at 04/24 PM documented R1 was exit seeking, banged on exit doors, and wandered in other resident's rooms. A Social Services note dated 01/28/26 at 05:31 PM documented care team met with R1's daughter and wife by phone. The note documented R1 was fairly calm during the day but became exit seeking and anxious as the day progressed. The note documented R1 would either look for his car or wanted to go home. The note documented R1 may wander in other residents' rooms. A Behavior Note dated 03/13/26 at 02:28 PM documented R1 was observed walking out of the room next to his without pants on. The note recorded R1 had a shirt and pull-up on. The note recorded R1 was taken back to his room and the bathroom was covered in bowel. The note documented R1 used pull-up to wipe himself and threw it in the toilet. The note further recorded his trash can was full of urine and he was taken to the shower room and cleaned up by staff. A Health and Status Note dated 04/12/26 at 04:34 AM documented R1 was alert to self with confusion per baseline. The note documented R1 was observed wandering in the hallway and had entered other residents' rooms at the beginning of the shift, around 11:00 PM. The note further recorded R1 stated he was looking for his keys so he could leave. The note further recorded R1 was not easy to redirect as he was agitated with redirections. A facility investigation document dated 04/27/26 with intake number of 2992524 recorded on 04/22/26, Certified Nurse Aide (CNA) M entered R2's room and witnessed R2 laying in bed with her pants down to her thighs. The document recorded R1 was observed standing next to R2's bed and appeared to be touching R2's abdominal area. The document further recorded CNA M went to get a nurse and they entered the room together to try and get R1 to leave R2's room. The document recorded R1 refused to leave the room and stated R2 was his wife. The document recorded staff explained they needed to take R2 to the restroom and they were able to escort R1 out of the room. The document recorded camera footage revealed R1 entered R2's room approximately 10 minutes after R2 had gone into her room. The document recorded it was estimated R1 was in R2's room for approximately five minutes prior to CNA M entering the room. The document recorded CNA M reported neither resident appeared to be in distress. R1 was placed on 15 minute checks for 72 hours following the incident and a urine analysis (UA - diagnostic test that examines a urine sample) was ordered for R1. A Health Status Note dated 04/23/26 at 12:51 PM documented R1 remained on 15-minute checks. The note documented R1 was observed wandering in and out of other residents' rooms but was easily redirectable. A Health Status Note dated 04/23/26 at 10:39 PM documented R1 was on 15-minute visual checks. The note documented R1 continued to wander in the hallway and other resident's rooms. The note documented redirection had been successful. A Behavior Note dated 04/25/26 at 09:07 PM documented R1 was very restless and exit seeking at the beginning of the shift. The note documented R1 was ambulating up and down the hallway and at times was peeking in other residents' rooms. The note documented R1 was redirected each time. The note recorded R1 ambulated without his walker, and staff would offer his walker and redirect him. The note recorded R1 was observed to have been visibly agitated and asked how he could get out of there. A Health Status Note dated 04/27/26 at 04:20 PM documented it was reported that R1 had wandered into another resident's room with another resident. The note documented that the residents were redirected to the day area and staff would continue to monitor. A notarized witness statement for CNA M, with a signed date of 04/28/26, documented CNA M responded to the resident's call light and found R2 lying in her bed with her pull-up and pants halfway down. The witness statement documented R1 was present and touched R2. CNA M documented when she asked R1 why he was touching her R1 stated he was helping her. CNA M documented she asked R1 to step out and he refused, stating R2 was his wife. CNA M documented she prioritized R2's safety and notified the Certified Medication Aide (CMA) immediately. An untitled document with R1' name at the top and dated 05/02/26 recorded 15-minute rounding checks for R1. The document recorded a note from 07:45 PM to 09:00 PM that R1 was wandering in the hallway, exit seeking. The note further recorded R1 was wandering in and out of other residents' rooms. A Health Status Note dated 05/03/26 at 01:54 AM documented R1 continued on 15-minute checks throughout the evening and night shift. The note recorded R1 wandered in the hallway seeking an exit and in and out of other residents' rooms during the evening shift. The note documented redirection was successful. A Health Status Note dated 05/08/26 at 08:15 AM documented 15-minute checks had been discontinued as of 05/06/26. Interdisciplinary Team (IDT) reviewed and discussed. Note documented R1 continued to wander but has been redirectable when going into other residents' rooms. UA was collected and awaiting results. The note recorded that the provider would treat if indicated. On 05/20/26 at 02:33 PM, R1 sat in a recliner in the common area with other residents and staff, listening to music. On 05/20/26 at 01:50 PM, CNA M stated when the incident occurred on 04/22/26, she was in another room helping a resident. She stated once she finished with that resident, she went to the nurse's station and saw R2's call light was on. She stated she went to answer R2's call light and found them in the room together. She stated she had no idea R1 was in R2's room until she walked in. She stated R2's pants were pulled down to about her knees. She stated R2 was lying in bed and R1 was standing next to the bed, touching R2. She stated she asked what R1 was doing, and R1 stated he was helping R2. She stated she asked R1 to stop, and he stated R2 was his wife and he was helping her. CNA M stated R2 was not reacting negatively to the situation and appeared to behave as she always did. She stated R1 refused to leave the room at first. She stated she told R1 she had to take R2 to the bathroom and R1 sat in a chair in R2's room. She stated when she came out of the bathroom, R1 was no longer in the room. She stated she reported it to a CMA and they told the nurse, and it was reported up the chain. She stated staff cannot force R1 out of other residents' rooms and if they try to make him leave, he gets agitated. CNA M stated she has worked with these residents since the incident and R2 has not shown any signs of distress or behavioral changes that she has observed. CNA M stated R1 still goes into other residents' rooms and if staff tell him to leave R1 will state that it is his room and that he has been there for 10 years. She stated he would get agitated and angry so the nurse will usually tell staff to leave him alone and let him stay in the room, as he will come out by himself. She stated so that is what they do. She stated if he is observed trying to go into other rooms or heading toward R2's room, she will try to guide him back to his room. She stated R1 sometimes tried to physically help other residents and there have been times he thought other residents were his wife. CNA M stated R1 wanders a lot, has tried to get off the unit, and would kick the doors to escape. She stated he did this prior to the incident and still does it. CNA M stated the only intervention she knew of was the 15-minute checks were added. She stated she did not know if there was something else planned for R1 as far as interventions. She stated staff do check on him more frequently. She stated sometimes R2 will stand up, look at R1 and head to her room. She stated R1 will stand up and follow her. She stated staff called out and tried to guide him to his room. She stated R1 an R2 used to do that a lot but now only do it once in a while. On 05/20/26 at 02:07 PM, Licensed Nurse (LN) G stated R1 wanders a lot. She stated when he wanders, other residents tend to follow him because they also want to leave. She stated, in reference to the note she documented on 04/27/26 at 04:20 PM, R1 was wandering the halls and had gone into a room that was not his, came out, and then went into another room that was not his. She stated CNA N came and told her to come down the hall to the room they were in. She stated when she entered the room R3 was lying in the bed, and CNA N was between the residents. She stated the room did not belong to R3 either but R3 was in bed. She stated the residents that these rooms belonged to were not in the rooms at the time. She stated R3 entered the room then R1 entered after her. She stated she believed the residents were trying to find a way out of the unit. She stated CNA N told her she found R1 hovering over R3 while she was in the bed. She stated she did not observe that when she entered the room as CNA N was already between them. LN G stated R3's room is right across from R1's room, and when he leaves his room, he often goes right into her room. She stated she did not know if R1 realized it was her room or not. She stated she does not know if R1 knew enough to know which room belongs to which resident. She stated she was only speculating. She stated staff keep an eye on R1 and redirect him as needed. On 05/20/26 at 02:21 PM, LN H stated she worked with R1 while he was on 15-minute checks she worked the memory care unit frequently. She stated R1 wandered prior to the incident between him and R2. She stated R1 frequently goes into other resident rooms as he never really knows where his room was. She stated they have cameras at the nurse's station and if she saw R1 go into another resident room she would get up and redirect him. She stated any staff in the hall would redirect him if they saw R1 go into another resident room. LN H stated she knew of one other time R1 tried to go into R2's room. She stated she saw R1 head that direction and she got up to follow him down there. She stated by the time she got down there R1 was in the foyer and had not made it all the way into R2's room. She stated she noticed R2 did not come out of her room and join activities as much for three days after the incident between the two of them. She stated she was not sure if it was related to the incident or not as R2s family spent more time with her via FaceTime and in person during that period. She stated R2 has been out to activities and has been at her baseline since. She stated with R1 staff were doing what they always did without the 15-minute checks. She stated staff just observe R1, and if he was not in a common area or if staff saw him wandering, someone would check to see where he was going. On 05/20/26 at 03:20 PM, CNA N stated she worked full time and was familiar with the residents on the memory care unit. She stated R3 was following R1 on 04/27/26. She stated when she walked into the room R1 was hovering over R3 while R3 was in the bed. She stated they were fully clothed. She stated R3 was lying in the bed somehow. She sated R3 does not ambulate well, R3 can sit down but cannot lay herself down. She stated she did not know how R3 got laid down in the as R3 did not have the strength to swing her legs up into the bed to lay down. She stated she thought R1 my have put R3 in the bed, but that was only an assumption since R3 could not do it on her own. She stated she did not witness any touching, only that she saw R1 hovering over R3 when she entered the room. She stated R1 tried finding a way out of the facility and R3 was going with him. She stated R1 kept saying they were going to get out together. CNA N stated R1 had a lot of agitation to leave the unit. She stated exit seeking was normally for R1 prior to the incident between R1 and R2 and R1 frequently tired to get into other resident rooms. She stated R1 constantly tired to find a way out. She stated when R1 wanders and exit seeks, other residents will follow him at times. She stated R3 had tried to exit seek on her own, but it was not as frequent. She stated R1's wandering has riled up other residents and they would exit seek more often when he did and they would follow each other. She stated she did not believe R1 focused more on the female residents. She stated she was not aware of any other interventions for R1. She state they had him on 15 minute checks previously. She stated staff always try to watch R1 and redirect him as needed. She stated it was a dementia unit and it was hard for staff to stop resident behaviors. She stated even if they closed the doors R1 would open them. She stated staff were basically just watching R1 and redirecting as needed. On 05/20/26 at 04:08 PM, Administrative Nurse D stated the facility provider assessed R1 the day following the incident between R1 and R2. She stated the provider ordered labs and they put R1 on 15-minute checks. She stated the 15-minute checks were discontinued on 05/06/26 as R1 had not tried to go into other resident rooms and did not have any further physical contact with other residents. She stated R1 did wander a lot and did occasionally go into other resident rooms. She stated R1 was not difficult to redirect. She stated staff kept an eye on him to make sure he was not going into other residents' rooms. She stated other than that there has been no real medication changes or anything. Administrative Nurse D stated there were no other specific interventions. She stated since admission R1 has slowed down some on the exit seeking. She stated he still does it but not as much as when he first arrived. She stated R1 was being followed by a psych provider, and they were aware of the incident between R1 and R2. She stated there was nothing added specifically due to the incident as the psych provider was seeing R1 more for his physical behaviors and agitation. She stated R1 was really trying to get out of the facility. She stated she was unaware of the incident where R1 was hovering over R3 while she was in bed. She stated she was told about an incident where R1 tried to help transfer another resident, but not him hovering. She stated there was no specific all staff education done related to the incident. She stated staff responded appropriately to the situation. She stated they discussed the expectation for staff to watch R1 more closely, but they did not do ANE with staff due to the incident. On 05/20/26 at 04:34 PM, Administrative Staff A stated they had the 15-minute checks to make sure R1 was not exhibiting similar behaviors toward anyone else. He stated R1 was not so there was not a need to continue them. Administrative Staff A stated R1 has wandered into other resident rooms, and it was common behavior for people on that unit. He stated he felt like staff responded appropriately to the incident between R1 and R2. He stated staff followed policy and procedures at the time. He stated they intervened, reported it and did everything they should have. Administrative Staff A stated R1's aggression has kind of subsided compared to when he first arrived in the facility. He stated the expectation for staff was to redirect R1 out of other residents' rooms and not allow him to stay in them. The facility's Hazardous Wandering and Elopement (Unwitnessed Exit) policy with a revised date of 04/06/26, documented Definition of wanderer: Aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment, or intruding in inappropriate places. To minimize risks associated with wandering is to identify wandering-prone individuals on admission. Residents who display wandering behavior after admission to the community will be assessed and appropriate interventions included immediately in the Health Service Plan or Negotiated Service Agreement or Care Plan. Individualized reassessments, evaluations and individualized interventions will be ongoing, as appropriate for the residents.

The facility identified a census of 54 residents. The sample included 19 residents, with five sampled reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist's (CP) recommended a Centers for Medicare and Medicaid Services (CMS) approved indication related to Resident (R) 20's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (difficulty sleeping), and major depressive disorder (major mood disorder). R20's Quarterly Minimum Data Set (MDS) dated 01/16/26 noted a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS indicated she was independent with meals, oral hygiene, toileting, bathing, dressing, transfers, and bed mobility. The MDS indicated no behaviors were exhibited during the observed period. The MDS noted she took an antipsychotic medication. R20's Psychotropic Drug Use Area Assessment (CAA) completed 12/22/25, noted she took antipsychotics and was at risk for adverse effects related to her Seroquel (antipsychotic medication). R20's Care Plan initiated 04/28/25 documented the following interventions:04/28/25- The plan indicated she had behaviors of resisting care and yelling out related to her depression, anxiety, and dementia. The plan noted she took Quetiapine (Seroquel) related to these behaviors and instructed staff to monitor her for medication side effects.04/28/25- The plan instructed staff to encourage R20s to participate in her daily care activities, provide clear explanations with choices during each interaction, and praise appropriate behaviors. R20's Care Plan lacked psychiatric indications for her Quetiapine medication. R20's EMR under Physician Orders indicated a renewed order (dated 05/15/25) for staff to administer 12.5 milligrams (mg) of Quetiapine Fumarate by mouth once daily related to unspecified dementia with psychotic disturbances. The EMR indicated R20 admitted to the facility on the medication on 04/15/25. A review of R20's EMR lacked behavioral monitoring related to her antipsychotic medication usage. A review of R20's Consultant Pharmacist Recommendation to MD forms from 05/2025 to 02/2026 revealed the following: 12/10/26 - The Consulting Pharmacist (CP) recommended R20's Quetiapine medication for a gradual dose reduction to achieve the lowest possible effective dose. The form indicated the medical provider declined the recommendation due to a risk of decompensation (increased risk of side effects and behaviors). The recommendations did not address the use of R20's antipsychotic medication with the indication of dementia. The facility was unable to provide a documented rationale for the continued use of R20's Quetiapine medication without an appropriate Centers for Medicare and Medicaid Services (CMS) indication, as requested on 02/10/26. On 02/09/26 at 10:15 AM, R20 sat in a recliner in the television day room. She was calm and engaged in the group activity. No behaviors were observed. On 02/10/26 at 10:30 AM, Consultant GG stated R20 admitted to the facility on her antipsychotic medication, but her representative refused to allow changes or discontinuation of the medication. She stated the resident required the medication for dementia related hallucinations and delusions. On 02/10/26 at 01:29 PM, Licensed Nurse (LN) G stated antipsychotic medication was not indicated for dementia treatment. She stated the medication required a psychiatric reason or diagnosis for use. On 02/10/26 at 01:45 PM, Administrative Nurse D stated she spoke with R20's representative numerous times to change the medications indications, but they refused. She stated dementia was not an indication to use the medication, but R20 admitted to the facility with the medication and diagnosis of dementia. The facility's Drug Regimen Review policy (revised 04/2025) indicated the faciltiy will collaborate with a licensed pharmacist to provide ongoing monthly medication reviews to identify irregularities and ensure safe medication practices.

The facility identified a census of 54 residents. The sample included 19 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 20 remained free from chemical restraint related to the use her antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) without a Centers for Medicare and Medicaid Services (CMS) approved indication. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (difficulty sleeping), and major depressive disorder (major mood disorder). R20's Quarterly Minimum Data Set (MDS) dated 01/16/26 noted a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS indicated she was independent with meals, oral hygiene, toileting, bathing, dressing, transfers, and bed mobility. The MDS indicated no behaviors were exhibited during the observed period. The MDS noted she took an antipsychotic medication. R20's Psychotropic Drug Use Area Assessment (CAA) completed 12/22/25, noted she took antipsychotics and was at risk for adverse effects related to her Seroquel (antipsychotic medication). R20's Care Plan initiated 04/28/25 documented the following interventions:04/28/25- The plan indicated she had behaviors of resisting care and yelling out related to her depression, anxiety, and dementia. The plan noted she took Quetiapine (Seroquel) related to these behaviors and instructed staff to monitor her for medication side effects.04/28/25- The plan instructed staff to encourage R20s to participate in her daily care activities, provide clear explanations with choices during each interaction, and praise appropriate behaviors. R20's Care Plan lacked psychiatric indications for her Quetiapine medication. R20's EMR under Physician Orders indicated a renewed order (dated 05/15/25) for staff to administer 12.5 milligrams (mg) of Quetiapine Fumarate by mouth once daily related to unspecified dementia with psychotic disturbances. The EMR indicated R20 admitted to the facility on the medication on 04/15/25. A review of R20's EMR lacked behavioral monitoring related to her antipsychotic medication usage. A review of R20's Consultant Pharmacist Recommendation to MD forms from 05/2025 to 02/2026 revealed the following: 12/10/26 - The Consulting Pharmacist (CP) recommended R20's Quetiapine medication for a gradual dose reduction to achieve the lowest possible effective dose. The form indicated the medical provider declined the recommendation due to a risk of decompensation (increased risk of side effects and behaviors). The recommendations did not address the use of R20's antipsychotic medication with the indication of dementia. The facility was unable to provide a documented rationale for the continued use of R20's Quetiapine medication without an appropriate Centers for Medicare and Medicaid Services (CMS) indication, as requested on 02/10/26. On 02/09/26 at 10:15 AM, R20 sat in a recliner in the television day room. She was calm and engaged in the group activity. No behaviors were observed. On 02/10/26 at 10:30 AM, Consultant GG stated R20 admitted to the facility on her antipsychotic medication, but her representative refused to allow changes or discontinuation of the medication. She stated the resident required the medication for dementia related hallucinations and delusions. On 02/10/26 at 01:29 PM, Licensed Nurse (LN) G stated antipsychotic medication was not indicated for dementia treatment. She stated the medication required a psychiatric reason or diagnosis for use. On 02/10/26 at 01:45 PM, Administrative Nurse D stated she spoke with R20's representative numerous times to change the medications indications, but they refused. She stated dementia was not an indication to use the medication, but R20 admitted to the facility with the medication and diagnosis of dementia. The facility's Psychoactive Psychopharmacological Medications policy (revised 04/2025) indicated the faciltiy will closely monitor usage of all psychotropic drugs. The policy indicated the faciltiy will review and ensure the medications were used with specific diagnoses and prevent interactions or contraindications (unwanted effects). The policy indicated the faciltiy will provide ongoing psychotropic monitoring.

The facility identified a census of 55 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R)1, who required staff assistance for activities of daily living (ADL) including safe ambulation with her walker and was at risk for falls. On 10/17/24 between 04:00 AM and 04:30 AM, Certified Nurse Aide (CNA) M heard R1's toilet flush, entered R1's bathroom, and asked R1 if she needed anything. R1 responded No and CNA M left to assist another resident without assisting R1 back to bed as CNA M assumed the resident would go back to bed. At approximately 04:40 AM, per camera footage, R1 ambulated to the elevator, took the elevator to the first floor, walked to a set of double doors, passed through them into the main lobby area, and proceeded to exit the main entrance doors on the south side of the facility without staff knowledge or supervision. At approximately 05:30 AM, Licensed Nurse (LN) G received a call informing her that Law Enforcement (LE) was with R1 at a nearby gas station. LN G confirmed R1 was a resident of the facility and at 05:22 AM LE returned R1 to the facility. Staff assessed R1 and noted her temperature to be 97.5 degrees Fahrenheit and her oxygen saturation was 94 percent (%) on room air (normal range is 97-100 %). She wore pajamas, shoes, and a jacket. The temperature outside on 10/17/24 was 36 degrees Fahrenheit at 04:53 AM and 34 degrees Fahrenheit at 05:53 AM. The lack of supervision allowed R1 to exit the facility without staff knowledge or supervision placing R1 in immediate jeopardy. Findings Included: - R1's Electronic Medical Record (EMR) documented diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), syncope and collapse (fainting or passing out), and history of falling. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The MDS documented R1 used a walker and required supervision or touching assistance during ambulation. The MDS further documented R1 required partial, or moderate assistance with dressing and personal hygiene. The MDS documented R1 had no wandering behaviors. The ADL Functional/Rehabilitation Potential CAA, dated 05/07/24, documented R1 was admitted from home due to the need for 24-hour care and supervision related to Alzheimer's disease. The CAA documented staff provided supervision and limited assistance with daily care tasks. The CAA further documented R1 used a walker, due to an unsteady gait, and R1 forgot to use the walker at times and needed to be reminded by staff. The CAA documented R1 had orders for physical therapy (PT) and occupational therapy (OT) for strengthening, ambulation, and ADL training to reach the highest level of function and safety possible. R1's Falls CAA, dated 05/07/24, documented R1 had Alzheimer's disease and was not a reliable historian about recent falls; however, R1 reported they had a fall within the last 30 days where R1 had a loss of balance. The CAA documented staff noted R1 had an unsteady gait and R1 was provided with a walker which helped when walking, but R1 often did not remember to use it and needed reminders. The CAA documented R1 worked on balance and ambulation using the walker as well as strengthening and safety with ADLs reducing R1's risk for falls with PT and OT. The CAA further documented staff offered toileting throughout the day and night to reduce incontinence and attempts to take herself to the bathroom without assistance. R1's Care Plan with a start date of 05/14/24, documented R1 had an alteration in thought processes, memory problems, and impaired decision-making that impacted R1's communication related to Alzheimer's disease. The care plan, with a start date of 05/14/24, documented R1 had a self-care deficit. An approach with a start date of 05/14/24, documented R1 used a walker with ambulation and an assist of one. An approach with a start date of 05/14/24 documented R1 required supervision for bed mobility, transfers, and ambulation and limited assistance of one with dressing, grooming, and toileting. The approach further documented R1's ability may fluctuate due to cognition and episodes of elevated blood pressure. R1's Care Plan with a start date of 05/14/24 documented R1 was at risk for falls, due to a history of falls and syncope. R1 had Alzheimer's disease, impaired safety awareness, increased risk for fractures from falls due to osteoporosis, and R1's blood pressure ran high at times which could have caused R1 to fall. R1's plan of care did not address elopement potential prior to R1's elopement. An Elopement Risk Screen dated 04/29/24, documented R1 had a score of eight which indicated R1 was not at risk for elopement. The Elopement Risk Screen documented R1 had no elopement attempts in the previous 90 days. A Fall Risk Assessment Tool completed on 04/29/24 documented R1 had a total fall risk score of seven and was a moderate fall risk. An Elopement Risk Screen dated 10/17/24, after the incident, documented R1 had a score of 16 which indicated R1 was a risk for elopement. A Registered Nurse (RN) Note dated 10/17/24 at 05:54 AM, documented at approximately 05:30 AM, the nurse received a telephone call from the assisted living (AL) nurse reporting that LE called and were asking if staff knew R1, and said R1 was at a gas station. The note documented the nurse called dispatch back and confirmed that the staff knew R1 and R1 resided at the facility. LE brought the resident back to the main entrance door and staff assisted R1 back to her room. The note documented R1 was noted with her walker, wearing top and bottom pajamas, a black jacket, and shoes. Staff assessed R1 for injuries, with no injury or skin issues noted on the assessment. The note further documented R1 stated she was just walking around the neighborhood and was going to the gas station. R1 also stated she did not know how she got out the door. The note further documented the facility initiated a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) and placed it on R1's left arm for elopement risk. The note documented R1's representative was notified, and they stated R1 had that problem at home and that was one of the reasons the representative brought R1 to the facility. The note documented vital signs were obtained as follows: 127 millimeters of mercury (mmHg) over 59 mmHg, pulse 80 beats per minute, temperature 97.5 degrees Fahrenheit, respirations 18 breaths per minute, and oxygen saturation was 94 percent on room air. Undated investigation documents provided by the facility recorded that on the morning of 10/17/24 at approximately 05:30 AM, the facility received a phone call from LE that reported R1 was at a gas station in front of the property. LE returned R1 to the facility. Upon return to the building, R1 was asked by the RN what she was doing and R1 told the RN she was going for a walk and went to the gas station. R1 was wearing pajamas, shoes, and a jacket and had her walker with her. RN performed a physical and skin assessment on R1 and did not identify any physical concerns, R1's representative and her durable power of attorney (DPOA- a legal document that named a person to make healthcare decisions when the resident was no longer able to), physician and administration were notified. The investigation documents recorded that a WanderGuard was applied to R1's left wrist. The investigation documents further recorded that R1 scored an eight on the BIMS indicating moderately impaired cognition. The investigation documents recorded staff interviews revealed that R1 was last seen by staff between 04:00 AM to 04:30 AM. CNA M had been assisting a resident directly across the hall from R1's room. CNA M heard a noise in R1's room and went over to investigate. R1 was in the bathroom and was pulling her pajama pants up after toileting. CNA M asked R1 if she needed assistance with anything else, and R1 replied No. CNA M went back across the hall to finish with the resident in the other room. The investigation documents recorded that neither CNA M nor the charge nurse had noticed R1 behaving any differently than usual prior to this and R1 had no recent illness or medication changes. When the administrator arrived at the facility, R1's actions were confirmed by video as having left the facility via the main front entrance. R1 has had no previous attempts to leave the facility. The investigation documents recorded staff reported that in conversation with R1's representative, her representative informed the staff that R1 had episodes like that when she lived in the community. The investigation documents record it was the first time that information related to elopement behaviors was shared with the facility. The investigation documents further recorded R1 was seen on video leaving the front entrance at 04:40 AM and re-entering the facility at 05:22 AM accompanied by LE. It was estimated that R1 ambulated approximately 1,018 feet, the weather conditions were clear, parking lot lights were on, the wind was [NAME] at nine miles per hour, and the temperature was 36 degrees Fahrenheit. CNA M's Witness Statement with a signed date of 10/21/24, documented CNA M was working on R1's neighborhood the night shift of 10/17/24. Sometime between 04:00 AM and 04:30 AM CNA M was in the room across the hall from R1's room when CNA M heard some noise and a toilet flush. CNA M documented they left the room and entered R1's room and found R1 in the bathroom pulling her pants up and it appeared R1 had finished toileting. CNA M documented they asked R1 if she needed some help with anything else and R1 stated No. CNA M documented they thought R1 was going back to bed as R1 usually did and CNA M went back across the hallway to finish assisting the resident in that room. CNA M documented they did not see or hear anything from R1's room while assisting the other resident. Licensed Nurse (LN) G's Witness Statement with a signed date of 10/21/24, documented LN G was scheduled for night shift on 10/17/24. LN G first saw R1 at 11:00 PM when LN G did their first rounds and R1 was asleep in her bed. LN G documented they next checked on R1 again around 01:00 AM and R1 was in bed asleep. LN G documented that at approximately 04:30 AM CNA M called LN G to a room via walkie-talkie to help her with a bed that wasn't working. LN G documented staff worked on the bed for a while and when they couldn't fix it, they decided to move a bed from an empty room to accommodate the resident until maintenance could fix the bed. LN G documented that at approximately 05:15 AM to 05:30 AM LN G received a call from an assisted living nurse informing LN G that LE had called and asked about R1. LN G returned the call to LE and confirmed R1 was our resident. LE escorted R1 back to the building and LN G performed a physical assessment and did not observe anything unusual for R1. LN G documented they asked R1 where she had been. R1 stated she was just taking a walk through the neighborhood and went to the gas station. LN G documented they asked R1 how she got out and R1 stated she didn't know. R1 was then assisted back to her room, and she went to sleep. LN G documented they notified R1's family, the doctor, and the nurse manager. On 10/22/24 at 10:41 AM, an observation was made inside the facility along the route R1 took to exit the facility with Administrative Staff A. Administrative Staff A stated the route inside the facility was verified by a review of camera footage. Administrative Staff A walked from R1's room down to the unit elevator and took it down to the first floor. Administrative Staff A stated the elevator was the only way off the unit without an access code. All exit doors on the unit were noted to have access keypads. The elevator had a WanderGuard alarm and Administrative Staff A stated if a resident had a WanderGuard the elevator would not function or allow the resident to access the other floor. Administrative Staff A then walked to a set of double doors on the first floor. Administrative Staff A stated the double doors had a WanderGuard alarm as well and would stop access to residents that had a WanderGuard on; however, if a resident did not have a WanderGuard they could walk through the door by pressing it or pressing an access button on the wall. Administrative Staff A stated this was the door R1 accessed to get out into the main lobby area and out the main entrance doors of the facility. The double doors did not have a keypad lock and opened when an access button was pressed on the wall. All other doors en route to the main entrance had locks or keypad access on them. Observation of the facility's South (front) parking lot, and surrounding area, revealed the main entrance door opened to a sidewalk that ran South along the edge of the facility driveway. To the [NAME] of the sidewalk, there were several bushes and a steep hill that went down to another section of the facility. A curb ran the length of the East side of the sidewalk. The facility's main driveway continued South and connected to a smaller facility drive that ran East and West. The south end of the facility drive connected to a busy road with two lanes of traffic that ran East and two lanes that ran West. The two-lane roads had a posted speed of 45 mph. The smaller facility driveway that ran East and [NAME] sat between the South side (front) of the facility and the North (rear) side of the gas station R1 was found at by LE. The facility drive that traveled East and [NAME] had a posted speed of 25 mph and had to be crossed to get to the gas station parking lot. The East and [NAME] facility drive are attached to other access roads near the gas station and these other access roads are connected to apartment complexes, other local businesses, and the two-lane road on the South side of the facility with a posted speed of 45 mph. On 10/22/24 at 03:28 PM, R1 sat out in a common area, with another resident, and watched TV. R1 had a walker within reach and a WanderGuard bracelet was on her right wrist. On 10/22/24 at 10:22 AM a joint interview was conducted with Administrative Nurse D and Administrative Staff A. Administrative Nurse D stated no one saw the R1 leave the unit or facility. Administrative Nurse D stated R1 went down to the first floor and accessed a set of double doors that opened into the main lobby area and then left through the main entrance facility entrance. Administrative Nurse D stated the facility was in the process of installing a keypad for the double doors R1 went through so that the doors cannot be accessed without a code in the future. Administrative Nurse D stated R1 now has a WanderGuard in place and the elevator would not work if a resident with a WanderGuard attempted to access it. Administrative Nurse D stated the other doors on the unit all had keypads and required a code for access. Administrative Nurse D further stated once the door on the main level is coded, even if a resident made their way downstairs, the resident would not be able to gain access to the main entrance doors without a code. Administrative Nurse D stated there was no one at the main lobby desk after 01:00 AM and no one would have been down there to witness R1 leave the facility when she did. Administrative Nurse D stated they had staff that acted as security, but that staff left at 01:00 AM. Administrative Nurse D stated R1 had no history of elopement at the facility and R1 has never gone outside without staff or family. Administrative Staff A stated R1 had never attempted to elope from the unit or facility since admission. Administrative Staff A stated he reviewed the camera footage and confirmed R1 had made it outside of the facility. Administrative Staff A stated he contacted the contractor the facility used for the facility doors, and the facility's maintenance staff, to inspect the locks on the other doors on the unit to ensure there were no other points of failure. Administrative Staff A stated now that R1 had a WanderGuard R1 would not be able to access the elevator to exit the unit. Administrative Staff A stated the double doors R1 accessed to get out into the main lobby area were inspected and the facility ordered parts to have that door coded with a keypad so it could not be accessed by residents in the future. Administrative Staff A stated he believed the contractor planned to install the new keypad locks for the double door on 10/29/24. On 10/22/24 at 04:17 PM Administrative Nurse D stated she had provided staff education related to elopement, wandering, and missing residents to staff after the event; however, she stated she had not met with all the facility staff. Administrative Nurse D stated she believed there were about 20 more staff that needed to complete that education. Administrative Nurse D stated the WanderGuard was placed on R1 when she was brought back to the facility, another elopement screening was completed and her elopement score was changed to reflect the new risk. Administrative Nurse D stated staff updated R1's care plan to reflect the use and monitoring of the WanderGuard. The facility's Hazardous Wandering and Elopement (Unwitnessed Exit) policy with a revised date of 10/12/22, documented the community will define what constitutes a risk for injury of a resident based on the physical location and attributes of the manor and identification of residents at risk. The community will exercise reasonable care to prevent injuries and ensure a secure environment for residents. The unwitnessed exit policy procedure will be reviewed with each staff member during orientation and reviewed thereafter, at least annually. On 10/22/24 at 04:46 PM, the facility received the Immediate Jeopardy [IJ] Template and was informed that the facility failed to provide adequate supervision to prevent R1, who was cognitively impaired, required staff assistance for ADLs including safe ambulation with her walker and was at risk for falls, from exiting the facility without staff supervision or knowledge and entering an unsafe location placed R1 in IJ. The facility submitted an acceptable plan of corrective actions for removal on 10/22/24. The plan included the following actions: A WanderGuard was placed on R1 with orders to monitor and document function each shift. R1's care plan was updated to include an intervention and monitoring for R1's WanderGuard. Staff completed an updated Elopement screening on R1 to reflect R1's new risk and behavior. The facility contacted maintenance and the facility door contractor to inspect the unit door's locking systems to ensure there was no other point of failure. The facility ordered parts to have a set of double doors R1 went through on 10/17/24 coded with a keypad lock to prevent future elopements through those doors. Administrative Nurse D was in the process of providing education for all staff related to elopement, wandering, and missing residents. Implementation of the corrective actions and removal of the immediacy was verified during the onsite survey on 10/22/24 at 04:17 PM. The deficient practice remained at a scope and severity of D.

The facility identified a census of 56 residents, one kitchen, four serving areas, and dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Findings include: - On 05/13/24 at 08:09 AM during the initial tour, observation revealed the following: Bowls were stored upright on the rack by the delivery doors instead of inverted. Three refrigerator and four freezer temperature logs lacked evidence staff checked the temperature on Sunday, 05/12/24 in the main kitchen. The walk-in freezer had breaded chicken breasts that were uncovered and not dated. The commercial meat slicer was uncovered but not in use. The dishwasher temperature logbook lacked evidence staff checked the water temperature on 05/09/24 and 05/11/24. The cottage cheese and milk were open and not dated. On 05/15/24 at 11:40 AM Dietary Staff (DS) CC prepared the pureed food. DS CC did not do hand hygiene before beginning the food preparation task. DS CC donned gloves and then touched unclean surfaces which included the preparation counter and the warmer handle as well as unclean utensils. Wearing the same gloves, DS CC grabbed the ham loaf directly from the pan with her gloved hand and placed it in the blender. DS CC then doffed her gloves and without performing hand hygiene, proceeded to wipe the counter and sink. On 05/15/24 at 11:50 AM DS CC used her ungloved hand to get a spatula from the hanging rack by grabbing the spatula by the end that touched food. On 05/15/24 at 11:51 AM DS BB stated staff were expected to ensure clean hygienic food preparation and use clean utensils while serving or preparing meals. DS BB stated staff were to store cooking utensils and plates and bowls with the eating surface downward. She stated staff were expected to check refrigerator and freezer temperatures every shift; dishwasher temperatures should be checked before each meal. DS BB stated she expected staff to do hand hygiene and wear gloves to protect residents from potential foodborne illnesses and cross-contamination. She said staff were expected to check stored food to ensure opened items were labeled and dated. A review of the facility's [NAME] Hospitality Operations policy and procedure dated 9/2022 indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be labeled/dated and stored safely. The policy noted all kitchen and dining equipment be stored in a manner that prevents soiling or contamination of clean items. A review of the facility's Hand Hygiene policy and procedure dated 10/07/22 indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility reported a census of 56 residents. The facility identified one medication room and four medication carts. Based on observations, record review, and interviews, the facility failed to store medications and biologicals appropriately when the facility failed to lock the medication room and additionally failed to appropriately label Resident (R)31's insulin (a hormone that lowers the level of glucose in the blood) medication once opened. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: -On 05/13/24 at 08:15 AM a walkthrough of the facility's second floor was completed. An inspection of the medication room revealed the entry door was not locked. The room contained a secured digital medication storage system for the facility's prescription medications, a locked medication refrigerator, and a shelf with unsecured stock (over-the-counter medications) medications. The room was secured by Licensed Nurse (LN) J upon completion of the medication room inspection. On 05/14/24 at 08:47 AM an inspection of Northgate hallway's medication cart was completed with LN G. An inspection of R31's insulin (hormone that lowers the level of glucose in the blood) revealed one opened Basaglar (long-acting insulin) pen and one opened Novolog (fast-acting insulin) pen were not dated when opened. LN G immediately removed the unlabeled insulin pens from the medication carts. On 05/13/24 at 08:20 AM LN J stated staff were expected to pull the medication room door fully shut and ensure it was always locked. She stated residents should never have access to medications and nursing equipment stored within the medication room. On 05/14/24 at 08:47 AM LN G stated insulin pens should be labeled with the open date once opened and discarded within 28 days after being opened. On 05/15/24 at 12:26 PM Administrative Nurse D stated the medication rooms were expected to be locked at all times. She stated staff were expected to ensure the doors closed properly upon exiting the rooms. She stated insulin pens were to be labeled with an open date once opened and stored in the medication carts. The facility's Medication Storage policy revised 05/2021 indicated all medications and biologicals were to be stored safely following the manufacturer's storage recommendations. The policy indicated medications should be properly labeled with the recommended expiration dates and stored in a manner appropriate for the specific medication. Medlineplus.gov documents opened, unrefrigerated vials or pens of Basaglar and novolog insulin can be used within 28 days; after that time they must be discarded. The facility failed to store medications and biologicals appropriately when the facility failed to lock the medication room and additionally failed to appropriately label R31's insulin medication once opened. This deficient practice placed the residents at risk for unnecessary medication and administration errors.

The facility identified a census of 56 residents. The facility identified six residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) and one resident on contact precautions (transmission-based precautions for infectious disease that may spread with direct or indirect contact). Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards related to following enhanced barrier precautions, wearing personal protective equipment (PPE), and indwelling catheter maintenance (tube placed in the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 05/13/24 at 08:11 AM an inspection of Resident (R)6's room revealed no enhanced barrier precaution signage or personal protective equipment was posted in or around his room for his wound care. On 05/13/24 at 08:13 AM an inspection of R14's room revealed no enhanced barrier precaution signage or personal protective equipment was posted in or around his room for his indwelling urinary catheter. On 05/13/24 at 08:14 AM an inspection of R24's room revealed no enhanced barrier precaution signage or personal protective equipment (PPE) was posted in or around his room for his indwelling urinary catheter. On 05/13/24 at 08:16 AM an inspection of R31's room revealed no enhanced barrier precaution signage or personal protective equipment was posted in or around his room for his indwelling urinary catheter. On 05/13/24 at 10:30 AM enhanced barrier precaution signage and PPE were placed outside R6, R14, R24, and R31's rooms. On 05/14/24 at 01:45 PM, an inspection of R40's room revealed a contact isolation sign and PPE posted outside her room. Certified Nurse Aide (M) entered the room at 01:45 PM and completed peri-cares without donning the required PPE to prevent exposure to R40's bacterial urinary infection. On 05/13/24 at 10:35 AM Licensed Nurse (LN) L stated the enhanced barrier precautions signs indicated residents were at risk for infections and staff were expected to wear gloves and gowns while providing high contact care. She stated the signs and PPE should be placed in a room for residents on enhanced barrier precautions. On 05/15/24 at 06:57 AM R31 slept on his bed. His urinary catheter bag contained dark amber urine and laid directly on the floor at the foot of R31's bed. On 05/14/24 at 01:45 PM, CNA M acknowledged they should have donned PPE while entering R40's room and providing peri-cares to her. CNA M stated R40 had just been placed on contact precautions. On 05/15/24 at 12:46 AM Administrative Staff B stated each room identified on enhanced barrier precautions should have the signage and personal protective equipment. She stated that PPE should be utilized when performing direct care for residents with open wounds, stomas (surgically made holes in the body), and catheters. She stated staff had an infection control related skills fair the previous month that covered enhanced barrier precautions, PPE, hand hygiene, and contact precautions. She stated staff were educated and should have been aware of the appropriate precautions. She stated catheter bags should always be hung below the level of the bladder and never allowed to touch the floor. The facility's Infection Control policy dated 04/2024 indicated facility will educate and ensure staff follow the facility's training related to providing, maintaining, and wearing the proper personal protective equipment for residents with special precautions. The policy indicated enhanced barrier precautions will be implemented on residents at risk for wound or indwelling medical device infections. The facility's Catheter Care-Urinary Foley policy last reviewed on 10/08/21 documented that catheter care is performed appropriately by qualified nursing staff to prevent complications caused by the presence of an indwelling urethral catheter. The facility failed to follow sanitary infection control standards related to enhanced barrier precautions, wearing PPE, and indwelling catheter maintenance. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 56 residents. The sample included 15 residents with four reviewed for siderails. Based on observations, record review, and interviews, the facility failed to identify Resident (R)47's low air-loss mattress and bolstered overlay as possible risks on R47's side rail assessment. This deficient practice placed R47 at risk for inadequate care due to unidentified care needs. Findings Included: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder), pressure ulcer, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). R47's Significant Change Minimum Data Set (MDS) completed 04/02/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS noted she required substantial to maximal assistance for bed mobility, transfers, personal hygiene, dressing, bathing, and toileting. The CAA indicated she had a Stage 3 pressure ulcer (full-thickness pressure injury extending through the skin into the tissue below). The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS indicated no restraints were in use. The MDS indicated she received hospice services (end-of-life comfort care). R47's Pressure Ulcer Care Area Assessment (CAA) completed 04/03/24 noted R47 received hospice services and had a stage three pressure ulcer on her coccyx (area at the base of the spine). The CAA indicated hospice provided a low air-loss mattress for her bed and a pressure-reducing cushion for her wheelchair. The CAA indicated the care plan will include wound management interventions. R47's Fall CAA completed 04/03/24 indicated she had a history of falls related to her impaired safety awareness and attempts to self-transfer without assistance. The CAA indicated she had a bolstered overlay mat placed on her low air-loss mattress to assist with positional awareness in her bed. R47's Care Plan dated 03/07/24 indicated she was at risk for impaired nutrition, falls, activity of daily living (ADLs) decline, and pressure ulcers. The plan indicated she required staff assistance with grooming, dressing, toileting, bathing, transferring, and locomotion. The plan indicated R47's hospice service provided a low air-loss mattress to reduce pressure on her body. The plan indicated she had a bolstered overlay on her low air-loss mattress to help R47 distinguish the perimeter of her mattress. The plan indicated she required the use of bilateral transfer bars on her bed for repositioning, transfers, and bed mobility. R47's EMR under Physician Orders revealed an order dated 02/19/24. The order instructed staff to check the functioning of her low air-loss mattress and ensure it was suitably set and adjusted based on her weight. R47's EMR under Physician Orders revealed an order dated 02/19/24. The order indicated she had bilateral transfer assist bars placed on her bed to assist with mobility and transfers. R47's EMR under Forms revealed an Assistive Device for Bed Screening completed on 02/19/24. The form indicated she had a history of falls and difficulty with balance. The form indicated she required repeated use of the bed rails during transfers. The form indicated the device was in working condition and she had a high/low bed. The form did not identify the low air-loss mattress or bolstered mattress overlay on her bed as a risk. No other device screenings were completed for R47. On 05/13/24 at 07:03 AM R47 slept in her bed. R47's low air-loss mattress was set to 280 lbs. R47's bed had bilateral transfer bars installed on both sides of her bed and bolstered mats positioned next to the assist bars. On 05/15/24 at 09:20 AM Licensed Nurse (LN) I stated the bed's side rails and attachments were assessed upon R47's admission to the facility. She stated she was not sure if the risk assessments differentiated between mattress types and overlays. On 05/15/24 at 12:46 PM Administrative Nurse D stated the charge nurse completed the risk assessments on the bed rails. She stated the assessment should identify the type of mattress and adaptive equipment used on the bed. She stated the assessment should be used to identify possible risks related to gaps between the rail and bed, possible strangulation hazards, and the effectiveness of the assist rails. The facility's Assistive Devices Used for Bed policy dated 06/2023 indicated the facility would provide continual assessment for assistive devices attached to beds to ensure safety and the need for use. The policy indicated the evaluation would include environmental hazards to identify potential risks to the resident's implemented interventions, and goals to improve mobility. The facility failed to identify R47's low air-loss mattress and bolstered overlay as possible risks on R47's side rail assessment. This deficient practice placed R47 at risk for inadequate care due to unidentified care needs.

The facility identified a census of 56 residents. The sample included 15 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 5's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R5 at an increased risk for respiratory infection and complications. Findings included: - R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), obstructive sleep apnea (an open airway during typical breathing during sleep and a blocked airway), and glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R5 was dependent on staff for all activities of daily living (ADLs). R5's Functional Abilities Care Area Assessment (CAA) dated 09/29/23 documented R5 required moderate to extensive assistance for all ADLs with the assistance of one to two staff members. R5 worked well with skilled therapy to improve her functional abilities. R5 had edema to the left lower extremity and an ace wrap was applied for edema; the left lower extremity was elevated on a pillow. R5 was able to feed herself after setup. R5 was not ambulatory with nursing and was wheelchair-bound. She required staff assistance to propel her wheelchair. R5's Care Plan lacked staff direction for the care of R5's CPAP mask. R5's EMR dated 09/25/24 under the Orders tab revealed the following physician orders: Apply CPAP at bedtime; staff to take off the mask in the morning. On 05/13/24 at 01:58 PM, R5 sat in the commons area in her wheelchair watching TV. R5's CPAP mask was laid directly on her bedside table without containment. On 05/14/24 at 07:08 AM R5 laid in her bed, with the head of the bed elevated. R5's CPAP mask was laid directly on the bedside table without containment. On 05/15/24 at 06:47 AM Certified Nurse's Aide (CNA) P stated staff removed R5's CPAP mask in the mornings and placed it on the bedside table. CNA P stated she had never seen the mask stored any other way. On 05/15/24 at 09:20 AM Licensed Nurse (LN) I stated that CPAP masks were to be stored in a dated plastic bag, not laid on the bedside table. On 05/15/24 at 12:44 PM, Administrative Nurse D stated CPAP masks should be stored in a bag and dated; the mask should not be laid over the bedside table. She stated the masks were cleaned by the house staff. The facility's Oxygen Therapy policy revised on 10/08/21 documented that when the device is not in use, stored in plastic or other bag to keep tubing and the device off the floor. The facility failed to ensure R5's CPAP was stored in a sanitary manner. This placed R5 at increased risk for respiratory infection and complications.

The facility identified a census of 56 residents. The sample included 15 residents. Based on observation and interview, the facility failed to ensure residents' rights and dignity were respected by staff when staff failed to honor Resident (R) 37's request during dining. The facility further failed to ensure R46's dignity was maintained during care provided in the common area. This placed the residents at risk for decreased self-esteem and decreased self-worth. Findings included: - On 05/14/24 at 08:19 AM R37 sat in his wheelchair at the dining table with other residents and was a given chocolate shake. On 05/14/24 at 08:21 AM R37 sat in his wheelchair in the dining room. R37 asked staff if he could go into the TV room to eat. R37 asked staff repeatedly to take him to the TV room. Licensed Nurse (LN) H, Certified Nurse Aide (CNA) N, and Certified Medication Aide (CMA) R continued to stay seated assisting other residents. On 05/14/24 at 08:26 AM, CNA N gave R37 some apricots. R37 asked staff if he could go to the TV room. The staff did not respond to R37. R37 stated he was not able to move his wheelchair. Observation revealed the wheelchair was locked. The staff did not assist him in moving his wheelchair. On 05/14/24 at 08:30 AM, R37 continued to ask staff if he could go into the TV room. Staff told R37 that he needed to wait for his breakfast to be served. On 05/14/24 at 08:41 AM, CNA N asked R37 if he wanted his coffee warmed. CNA N got up from assisting another resident and warmed up R37's coffee. On 05/14/24 at 08:46 AM R37 asked staff again if he could go to the TV room. Staff ignored R37's request and did not reply. On 05/14/24 at 08:47 AM R37 pointed at CMA R and asked the CMA if he could go over to the recliner and pointed at the recliner. CMA R did not answer R37. On 05/14/24 at 08:48 AM LN H N served R37 bacon and eggs. On 05/14/24 at 08:53 AM R37 took his napkin and wiped food from the table onto the floor. On 05/14/24 at 08:51 AM R37 asked twice for some water. CNA N came to get R37's water cut and filled it for him. On 05/14/24 at 08:54 AM R37 began to cough as he ate his bacon. R37 spit out his bacon. A male resident at another table asked if R37 was okay. R37 stated the staff didn't care. On 05/14/24 at 08:55 AM R37 asked CNA N what her name was. CNA N told R37 her name. R37 continued to cough and LN H continued to sit and assist another resident to eat. CNA N told R37 to take a drink of water. On 05/14/24 at 08:57 AM LN H approached R37 and stood next to him while he continued to cough. On 05/14/24 at 08:59 AM LN H cleaned off R37's lap which was full of crumbs and then walked away. LN H made no vocal interaction with R37. On 05/14/24 at 09:01 AM Social Services X started talking to R37 at the dining table. R37 told Social Services X he wanted to go to the TV room. Social Services X propelled R37 in his wheelchair to the TV room. On 05/14/24 at 09:04 AM Social Services X asked R37 to talk about when he played in his band. On 05/14/24 at 01:26 PM, CNA N stated staff should be interacting with the residents at meals and should respond when the resident speaks to them. CNA N stated that in the locked unit, staff was not always able to assist a resident right away if the staff was assisting another resident at that time. On 05/15/24 at 08:17 AM LN H stated staff on the locked unit tried their best to interact at meals with the residents. LN H stated several residents required staff assistance with eating, so staff would assist other residents as they were able to. LN H stated R37 was restless a lot and did not like to stay in one place very long. On 05/15/24 at 12:45 PM Administrative Nurse D stated she expected staff to interact with the residents and try to accommodate a choice or request by a resident to go to another room. Administrative Nurse D stated staff tried not to overstimulate the residents in the locked unit but should still be conversing with them at meals and be attentive to a resident's request when voiced. The Resident Rights and Responsibilities policy last revised on 11/16/21 documented that the community would ensure the residents' right to a dignified existence, self-determination, and person-centered care access to persons and services inside and outside the community. The community would protect and promote the rights of each resident. The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The community would provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. The community would support the resident in the exercise of his or her rights. The community would ensure a resident could exercise his/her rights without interference, coercion, discrimination, or reprisal. The facility failed to ensure that R37's rights and dignity were respected when staff failed to acknowledge R37's request to go to another room. This placed the resident at risk for decreased self-esteem and decreased self-worth. 41037 - R46's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum staff assistance with chair-to-chair transfers and rolling left and right. R46's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/22/24 documented she had a diagnosis of dementia and she could make some of her needs known to the staff; staff would anticipate her other needs. On 05/13/24 at 09:26 AM R46 sat in her wheelchair in the common TV area, Licensed Nurse (LN) G placed a gait belt around R46's abdomen. LN G stood in front of R46 and asked her to stand. R46's knees were bent and her heels were off the floor with only the tips of her toes touching the floor. LN G lifted R46 from the wheelchair and the gait belt slid upward, which raised R46's shirt upward and exposed R46's skin from her waist to her breast area during the transfer. No pivot disc or walker was used during the transfer. On 05/14/24 at 09:29 AM LN G pushed R46 in her wheelchair from the dining room area to the TV common area. LN G placed a gait belt around R46's abdomen and asked R46 to stand. LN G lifted R46 with the gait belt. R46 did not bear weight as LN G transferred her from the wheelchair. During the transfer from the wheelchair to the recliner the gait belt slid upward pulling R46's shirt up and exposing her back from the waist to her shoulders. No pivot disc or walker was used during the transfer. On 05/15/24 at 10:00 AM, Certified Nurse Aide (CNA) M stated a resident should never be exposed in a common area. CNA M stated they should be covered to ensure their dignity. On 05/15/24 at 10:15 AM, Licensed Nurse (LN) G stated never should a resident be exposed in a common area. LN G stated he had realized she had become exposed during the transfer and that should have not happened. On 05/15/24 at 12:45 PM, Administrative Nurse D stated never should any resident be exposed in a common area. The facility's Resident Rights and Responsibilities policy last revised on 11/16/21 documented that the community would ensure the residents' right to a dignified existence, self-determination, and person centered care with access to persons and services inside and outside the community. The community would protect and promote the rights of each resident. The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The community would provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. The community would support the resident in the exercise of his or her rights. The community would ensure residents can exercise his/her rights without interference, coercion, discrimination, or reprisal. The facility failed to ensure R46 was treated with respect and dignity. This deficient practice placed R46 at risk for negative psychosocial outcomes and decreased autonomy and dignity.

The facility identified a census of 56 residents. The sample included 15 residents with four residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 46 received the necessary assistive services for transfers. This deficient practice placed R46 at risk for loss of independence, decreased self-esteem, and impaired dignity. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R46 required substantial to maximum staff assistance with chair-to-chair transfers and rolling left and right. R46's Fall Care Area Assessment (CAA) dated 02/22/24 documented she had right-sided weakness related to a past stroke. R46's diagnosis of dementia placed her at a higher risk for falls. R46's Care Plan dated 03/05/24 documented R46 used a pivot disc and walker for transfers. On 05/13/24 at 09:26 AM R46 sat in her wheelchair in the common TV area, Licensed Nurse (LN) G placed a gait belt around R46's abdomen. LN G stood in front of R46 and asked her to stand. R46's knees were bent and her heels were off the floor with only the tips of her toes touching the floor. LN G lifted R46 from the wheelchair and the gait belt slid upward, which raised R46's shirt upward and exposed R46's skin from her waist to her breast area during the transfer. No pivot disc or walker was used during the transfer. On 05/14/24 at 09:29 AM LN G pushed R46 in her wheelchair from the dining room area to the TV common area. LN G placed a gait belt around R46's abdomen and asked R46 to stand. LN G lifted R46 with the gait belt. R46 did not bear weight as LN G transferred her from the wheelchair. During the transfer from the wheelchair to the recliner the gait belt slid upward pulling R46's shirt up and exposing her back from the waist to her shoulders. No pivot disc or walker was used during the transfer. On 05/15/24 at 10:00 AM, Certified Nurse Aide (CNA) M stated the staff would know how a resident was to be transferred from the care plan. CNA M stated R46 was transferred with the assistance of a gait belt and one staff person. CNA M stated R46 had declined; she may have used a pivot disc and walker before her decline but she had not used a pivot disc or walker for a long time. On 05/15/24 at 10:15 AM, Licensed Nurse (LN) G stated R46 was transferred with the assistance of a gait belt and one staff assistance. LN G stated he was unsure if therapy was working with R46 for transfer training using a pivot disc and walker. LN G stated R46 had difficulty with transfers. On 05/15/24 at 12:45 PM, Administrative Nurse D stated staff would find how much assistance and how each resident was to be transferred from the Care Guide (a nursing tool that gives a brief overview of the care needs of each resident) which contained information from the care plan. Administrative Nurse D stated staff should follow the guide when care is provided. Administrative Nurse D stated if a resident's status had changed nursing staff should notify her to ensure the resident was evaluated for a significant change. The facility's Resident Rights and Responsibilities policy last revised on 11/16/21 documented that the community would ensure the residents' right to a dignified existence, self-determination, and person centered care with access to persons and services inside and outside the community. The community would protect and promote the rights of each resident. The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The community would provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. The community would support the resident in the exercise of his or her rights. The community would ensure residents can exercise his/her rights without interference, coercion, discrimination, or reprisal. The facility failed to ensure R46 was provided with the necessary assistive devices for transfers. This deficient practice placed R46 at risk for loss of independence, decreased self-esteem, and impaired dignity.

The facility identified a census of 56 residents. The sample included 15 residents with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)47's pressure-reducing interventions were implemented correctly when the low air-loss mattress pump was set at an inaccurate weight for the resident. The facility additionally failed to complete weekly wound assessments on R37. This deficient practice placed all affected residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder), pressure ulcer, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). R47's Significant Change Minimum Data Set (MDS) completed 04/02/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS noted she required substantial to maximal assistance for bed mobility, transfers, personal hygiene, dressing, bathing, and toileting. The CAA indicated she had a Stage 3 pressure ulcer (full-thickness pressure injury extending through the skin into the tissue below). The MDS indicated she had pressure-reducing devices for her bed and wheelchair. The MDS indicated no restraint in use. The MDS indicated she received hospice services (end-of-life comfort care). R47's Pressure Ulcer Care Area Assessment (CAA) completed 04/03/24 noted R47 received hospice services and had a Stage 3 pressure ulcer on her coccyx (area at the base of the spine). The CAA indicated hospice provided a low air-loss mattress for her bed and a pressure-reducing cushion for her wheelchair. The CAA indicated the care plan will include wound management interventions. R47's Care Plan dated 03/07/24 indicated she was at risk for impaired nutrition, falls, activities of daily living (ADL) decline, and pressure ulcers. The plan indicated she required staff assistance with grooming, dressing, toileting, bathing, transferring, and locomotion. The plan indicated she required the use of bilateral transfer bars on her bed for repositioning, transfers, and bed mobility. The plan indicated R47's hospice service provided a low air-loss mattress to reduce pressure on her body. The plan instructed staff to check her bed function and settings each shift. The plan indicated she had a bolstered overlay on her low air-loss mattress to help R47 distinguish the perimeter of her mattress. R47's EMR indicated she weighed 107 pounds (lbs.) on 05/08/24. R47's EMR under Physician Orders revealed an order dated 02/19/24. The order instructed staff to check the functioning of her low air-loss mattress and ensure it was suitably set and adjusted based on her weight. A review of the low air-loss mattress manufacturer's operation guide (ProActive Protekt Aire 6000) indicated the pump and mattress were intended to reduce the incidence of pressure ulcers while optimizing comfort. The guide indicated that firmness can be adjusted based on the recommendations of the health care professional and the patient's weight. On 05/13/24 at 07:03 AM R47 slept in her bed. R47's low air-loss mattress was set to 280 lbs. The mattress pump had fixed weight settings of 80lbs, 120lbs, 160lbs, 200lbs, 240lbs, 280lbs, 320lbs. and 350lbs. R47's bed had bilateral transfer bars installed on both sides of her bed and bolstered mats loosely next to the assist bars. On 05/14/24 at 2:03 PM, R47 slept in her bed. Her low air-loss mattress remained set at 280lbs. On 05/15/24 at 09:20 AM R47's low air-loss mattress was set to 280lbs. Licensed Nurse (LN) I stated the low air-loss mattresses were set by the resident's current weight. She stated nurses were expected to check the pump settings each shift. She stated R47's bed should be set at 120 lbs. per her current weight. On 05/15/24 at 12:46 PM Administrative Nurse D stated staff were expected to set the low air-loss mattress pumps to the closest weight range. She stated the pump should be set by R47's current weight. The facility's Skin Integrity: Pressure Ulcers/Injury Prevention policy revised 10/2022 indicated the facility will utilize therapeutic support surfaces along with nutrition, repositioning, and clinically proven treatment regimens to manage wounds. The policy indicated the facility was to ensure the appropriate usage of pressure redistribution support surfaces per the manufacturer's guidelines and the medical provider's intended orders. The facility failed to ensure that R47's low air-loss mattress pump was appropriately set to her current weight. This deficient practice placed R47 at risk for complications related to skin breakdown and pressure ulcers. 41713 - The electronic medical record (EMR) for R37 documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), early onset Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), psychosis (any major mental disorder characterized by gross impairment in reality perception), and hemiplegia (weakness and paralysis on one side of the body). R37's Significant Change Minimum Data Set (MDS) dated [DATE] documented R37 had a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. R37 required maximal assistance from staff for upper body dressing. R37 was dependent on staff for activities of daily living (ADLs). R37 was at risk of developing pressure ulcers. A formal and clinical assessment had been completed for R37. R37 had a pressure-reducing device for his chair and his bed. R37's Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. R37 was dependent on staff for his ADLS. R37 was at risk for pressure ulcers and had one unhealed Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters). R37 used a pressure-reducing device for his chair and bed. R37 received pressure ulcer care and the application of ointments or medications. R37's Pressure Ulcer Care Area Assessment (CAA) dated 01/11/24 documented R37 was at risk for skin breakdown and pressure injury related to incontinence and his decreased mobility. R37 had a pressure-reducing mattress and pressure-reducing cushion in his wheelchair. Staff was to toilet R37 before and/or after meals and activities. R37 was working with skilled therapies on functional ADLs and increased mobility. R37's Pressure Ulcer Care Plan last updated 05/01/24 directed staff to ensure he had a cushion in his wheelchair and switch it to the recliner and dining room chair with transfers. Staff was to assist R37 with repositioning hourly when in a wheelchair or recliner and every two hours when in bed. Staff was to apply Magic Butt Paste (a medicated cream used to treat skin issues) twice daily to buttocks. The care plan lacked staff direction for weekly skin or wound assessments. R37 Physician Orders documented an order dated 12/29/23 that directed staff may use skin and wound care treatment guidelines and an order dated 04/30/24 to apply Magic Butt Paste to bilateral buttocks twice daily for redness/excoriation until healed. R37's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documented a score of 13, which indicated a moderate risk for pressure ulcer development. A Skin Evaluation Form dated 03/05/24 for R37 documented a full-thickness pressure wound to the right buttock. The evaluation lacked measurements for the wound. R37's EMR lacked evidence of further wound assessment from 03/05/24 until 03/19/24, 14 days later. A Skin Evaluation Form dated 03/19/24 for R37 documented a circular-shaped superficial wound. The wound bed had 100 percent (%) red granulation tissue (new tissue formed during wound healing). Wound measurements were one centimeter (cm) in length and one cm in width. The wound was a stage two wound. The treatment was an Aquacel foam dressing (a medicated dressing used for wound healing). R37's EMR lacked evidence of further wound assessment from 03/19/24 to 04/23/24, 34 days later. A Skin Evaluation Form dated 04/23/24 at 01:49 PM for R37 documented a partial thickness pressure wound. The resident returned from hospitalization with a superficial open area. The resident returned with an order for a topical cream/ointment. The resident's wife was updated on the wound's progress and treatment change. Wound measurements were 2.0 cm in length, 0.6 cm in width, and 0.1 cm in depth. The treatment was to apply Magic Butt Paste twice daily. R37's EMR lacked evidence of a weekly wound assessment from 04/24/24 through the review date of 05/13/24. On 05/14/24 at 07:38 AM R37 sat in his wheelchair in the TV room. A cushion was present in the seat of the wheelchair. On 05/14/24 at 09:33 AM R37 lay in bed resting. R37's call light was within reach; the bed was in a low position. On 05/14/24 at 08:17 AM Licensed Nurse (LN) H stated that she typically was responsible to do the weekly skin assessments on the unit. LN H stated the wound care nurse should come around weekly to check R37's wound. On 05/14/24 at 12:45 PM Administrative Nurse D stated that the unit charge nurse should be doing weekly skin checks on the residents. Administrative Nurse D stated the wound nurse should come weekly to assess any active wounds and document the findings appropriately. Administrative Nurse D stated that R37 was not always cooperative with his wound care and those missed assessments should have been documented. Administrative Nurse D stated she had inadvertently missed R37's assessment on 05/07/24. The Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment policy last revised on 10/28/22 documented that skin integrity and tissue tolerance would be evaluated. Staff was to identify residents at risk for pressure ulcer/injury development. Staff would implement pressure ulcer/injury preventative measures to maintain intact skin. Staff would initiate and implement wound treatment orders when pressure ulcers/injuries and/or wounds were present or acquired. Staff was to do a full skin evaluation on admission and weekly by a licensed nurse. The facility failed to ensure staff appropriately assessed and monitored R37's pressure injury at least weekly. This placed R37 at risk for complications related to skin breakdown and pressure ulcers.

The facility identified a census of 56 residents. The sample included 15 residents with three residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 31 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent the drainage bag from resting on the floor. This deficient practice placed R31 at risk for catheter complications including infection. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bladder cancer, dementia (a progressive mental disorder characterized by failing memory, and confusion), and urinary retention (lack of ability to urinate and empty the bladder). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R31 had an indwelling catheter during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of three which indicated severely impaired cognition. The MDS documented that R31 had an indwelling catheter during the observation period. R31's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 07/25/23 documented R31 required an indwelling catheter related to his diagnosis. R31 required assistance from staff for proper hygiene related to the care of his indwelling catheter. R31 had a recent hospitalization related to a UTI. R31's Care Plan dated 01/19/24 documented staff would provide R31 with catheter care per facility policy. R31's EMR under the Orders tab revealed the following physician orders: Catheter care per facility policy every shift for urinary retention dated 06/20/23. R31's EMR under the Medication Administration Record (MAR) reviewed from 04/01/23 to 05/13/24 revealed the following physician orders: Macrobid (antibiotic) 100 milligrams (mg) capsule, give one capsule by mouth two times daily for five days for UTI dated 04/10/23. Macrobid 100 mg capsule give one capsule by mouth daily for 60 days for UTI prophylaxis (preventative in nature) dated 04/15/23. Cefuroxime axetil (antibiotic) 250 mg tablet give one tablet by mouth every 12 hours for 10 days for UTI dated 06/21/23. Cipro (antibiotic) 250mg give one tablet by mouth two times a day times seven days for UTI dated 09/28/23 and discontinued on 09/29/23. Cipro 250mg give one tablet by mouth two times a day times seven days for UTI dated 01/16/24. Doxycycline hyclate 100mg capsule give one capsule by mouth two times daily times 10 days for UTI dated 01/17/24. Doxycycline hyclate 100mg capsule give one capsule by mouth two times daily times seven days for UTI dated 02/13/24. Doxycycline hyclate 100mg capsule give one capsule by mouth two times daily times seven days for UTI dated 03/12/24. Doxycycline hyclate 100mg capsule give one capsule by mouth two times daily times seven days for UTI and pneumonia (inflammation of the lungs) dated 05/05/24. On 05/15/24 at 06:57 AM R31 lay on his bed. His urinary catheter bag contained dark amber urine. The bad lay directly on the floor at the foot of R31's bed. On 05/15/24 at 07:10 AM, Certified Nurse Aide (CNA) M stated R31's catheter drainage bag should never be placed on the floor. CNA M stated the catheter bag should be placed in a dignity bag and attached to the bed not touching the floor. On 05/15/24 at 10:15 AM, Licensed Nurse (LN) G stated R31's catheter drainage bag should never be stored on the floor. LN G stated the catheter drainage bag should be placed on the bed off the floor. On 05/15/24 at 12:45 PM, Administrative Nurse D stated to prevent infections, R31's catheter drainage bag should never be placed on the floor. The facility's Catheter Care-Urinary Foley policy last reviewed on 10/08/21 documented catheter care is performed appropriately by qualified nursing staff to prevent complications caused by the presence of an indwelling urethral catheter. The facility failed to prevent the catheter drainage bag from touching the floor for R31 who had frequent UTIs. This deficient practice placed R31 at risk of catheter-related complications and further UTIs.

The facility had a census of 49 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the 13 cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents. Findings Included: - On 09/21/22 at 07:10AM an observation of the secured memory care unit revealed an unlocked sink cabinet in the kitchenette area accessible to the dementia care (progressive mental disorder characterized by failing memory, confusion) residents. Further investigation revealed two quart-size bottles which contained bleach disinfectant. The label stated, keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 09/22/22 at 07:30AM an inspection of the sink cabinet revealed the door to be secured. Licensed Nurse (LN) H stated that staff should be checking the cabinets and drawers daily before and after meal services to ensure they were locked. In an interview on 09/27/22 at 02:30PM Licensed Nurse (LN) G identified that hazardous chemicals should always be secured in a locked area and not accessible to the residents. In an interview on 09/27/22 at 03:13PM Administrative Nurse E stated the facility had been educating staff on the importance of ensuring that potential hazardous materials were secured and had installed magnetic locks on the door and cabinets to protect the residents from access to these chemicals. A review of the facility's Routine Cleaning and Disinfectant policy revised 04/2020 indicated that all hazardous cleaning solutions be locked while in resident care area and should never be left unattended. A review of the facility's In-service training indicated that the facility has annual hazardous chemical training scheduled in December 2022. The facility failed to store chemical disinfectant in a secure area placing the 13 cognitively impaired independently mobile residents at risk for injury.

The facility identified a census of 49 residents. The sample included 15 residents with two residents reviewed for dementia care (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services which included adequate supervision and activities to support Resident (R)43 and R49's highest practicable level of well-being. This deficient practice placed the residents at risk for decreased quality of life and impaired well-being due related to dementia. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment The MDS noted that he required extensive assistance from one staff member for all activities of daily living (ADL's) and utilized a wheelchair for locomotion. The MDS indicated he had hallucinations (sensing things while awake that appear to be real, but the mind created) but no other behaviors. A review of R43's Dementia Care Area Assessment (CAA) dated [DATE] indicated that he had advanced cognitive impairment with forgetfulness and hallucinations. The CAA indicated that staff should anticipate his needs and provide reorientation as needed. R43's Falls CAA dated [DATE] indicated that he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CAA noted that staff should provide toileting assistance throughout the day and night to prevent unassisted attempts and wandering. A review of R43's Care Plan dated [DATE] noted that he had an alteration of thought processes, memory problems, and impaired decision making related to dementia. The care plan noted that he had poor safety awareness and required extensive assistance with dressing, grooming, toileting, bathing, transferring, and locomotion. The care plan noted that staff should provide activities, meal choices, and social interactions to decrease depression, anxiety, or hallucination symptoms. The care plan noted that R43 did wander around the unit exploring the area but was not exit seeking. The plan instructed staff to assist R43 with locating his room and to talk about things of interest to him such as his family or his cats to help reorient him to his environment. A review of R43's Nursing Note dated [DATE] revealed that he attempted to exit the memory care unit by attempting to open the patio doors to go outside. The note indicated that he became agitated when staff moved him into the television room. The note indicated he continued to exhibit exit seeking behaviors the rest of the day and received his ordered medication for anxiety with no improvement. The note lacked documentation showing that non-pharmacological interventions were offered or attempted. On [DATE] at 07:58AM R43 wandered the unit hallway, confused. R43 said he was looking for his wife. He entered R9's (cognitively impaired resident) room, looked around and then exited. He then wandered back up the hall and toward the main entry area to the memory care unit. He entered R49's (cognitively impaired resident) room and sat for five minutes. He then exited the room and went to the dining room area. On [DATE] at 11:11AM R43 led R49 throughout the unit searching for an exit. R43 continued to ask for the exit while going throughout the halls until he entered R29's (cognitively impaired resident) room. R43 watched R29 sleeping in her recliner for five minutes then exited the room. R43 rejoined R49 in the hallway and continued to search for an exit. On [DATE] at 11:58 AM R43 returned back to R29's room. R43 remained in her room until housekeeping staff found him while delivering clean clothing and brought him back out to the main dining area at 12:09PM. R43 had acquired a blue ink pen which he carried while he remained in a state of confusion. At 12:15PM R43 went to the rear exit and pushed on the exit door. R43 then came back down the hallway and sat outside his room. R43 punched towards the hallway's handrail twice without making contact to the railing and staff finally met with him. On [DATE] at 02:00PM R43 wandered the memory care unit again leading R49 in search of an exit. At 02:08PM R43 went into R21's (cognitively impaired resident) room and sat watching her as she slept in bed. R43 exited the room after three minutes and returned to wandering with R49. In an interview on [DATE] at 02:30PM with Certified Medication Aid (CMA) R, he stated that R43 did wander around and looked for his wife. He stated that R43 was often easily redirected and participated in activities such as music and exercise groups when engaged by staff. He stated that sometimes the memory care unit got busy with the needs of the residents and often staff were preoccupied with providing care but most of the time the staff was available to supervise the common areas and hallways. He stated that R43 did go into other resident's roomd but should not. In an interview on [DATE] at 02:47PM with Licensed Nurse (LN) G reported that R43 was often confused when he was wandering and often searched for his wife. She stated that staff reoriented him with which room was his and showed him the names and room numbers on the doors to help him understand where he was. She stated that unit activities were provided to keep the residents interested and engaged. She stated that staff provided distractions for wandering residents to help reorient them to the unit such as snacks, games, music, or one to one attention. She stated that staff provided frequent restroom breaks and offer daily cares to the residents. A review of the facility's Behavioral Health Services policy revised ,d+[DATE] noted that the facility will provide meaningful activities that encourage engagement with staff, families, and other residents. The policy noted that the necessary and person-centered care will be provided with dignity, autonomy, choice, and safety. The facility failed to provide dementia care and services to include adequate levels of supervision and activities to support R43's highest practicable level of well-being. This deficient practice placed him at risk for decreased quality of life and impaired well-being due related to dementia. - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's Quarterly MDS dated [DATE] indicated a BIMS score of one indicating severe cognitive impairment. The MDS indicated that she had physical behaviors one to three days a week and verbal behaviors four to six days a week but did not indicate hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS noted no wandering behaviors. The MDS noted she required extensive assistance for dressing, transfers, locomotion, toileting, personal hygiene, and bathing from one staff member. A review of R49's Dementia CAA dated [DATE] noted that she often yells help but cannot articulate what she needs but can make her needs known to staff. The CAA noted for staff to learn her routine and anticipate her needs. R49's Psychosocial Well-Being CAA dated [DATE] noted she was still adjusting to the neighborhood. The CAA noted she could be anxious and easily agitated. The CAA noted that she usually calmed down with direct staff attention and provided activities. R49's Behavioral CAA dated [DATE] noted that that she was anxious much of the time and became combative with attempts to hit staff. The CAA noted that she is easily calmed when staff interact with her or provide one to one attention. A review of R49's Care Plan created [DATE] noted the she would become agitated and resistive to care . The plan instructed staff to ensure her safety and give her space to calm down. The plan noted that R49 would see her deceased cousin and yell out for her, become physical aggressive , entering other resident's rooms, and hitting the exit doors. The plan instructed staff to remain calm ensure she has a consistent routine, offer activities and conversations, and give her an item she can fold or fiddle with for entertainment. On [DATE] at 11:11AM R49 was observed in the memory care unit hallway following R43 (severely cognitively impaired resident) down the memory hallway towards room eleven. R49 continued to yell out loudly what am I doing and where will I go. R49 continued yelling out for help; no staff responded to her. She then followed R43 up the hallway to the other end of the memory care unit. She continued to ask R43 for help and repeatedly referred to him as [NAME]. No staff were not observed in the hallways or common areas during this timeframe. At 11:46AM R49 remained outside of R29's room as R43 entered the room. R49 yelled out for R43 to get out of the room [NAME] several times before making her way back down the hall to the dining room. At 11:56AM R49 called out for help and stated [NAME] we need to leave now several times to R21. At 11:58AM R49 yelled out I need to go to the bathroom, but staff did not respond. At 12:16PM R49 aggressively grabbed R21's arm and stated, we need to leave now. Staff intervened and moved R49 to the area on the opposite side of the room. R49 continued to ask for help and then grabbed R24's wheelchair armrest asking R24 to help her get out of here. On [DATE] at 02:08PM R49 followed R43 down the memory care hallway to R21's room. R49 remained outside the room yelling come out of there [NAME] to R43. R49 returned then wandered the hallways toward the main entry door. R49 continued to call out for help until staff returned to the hallway at 02:45PM. In an interview on [DATE] at 02:30PM with Certified Medication Aid (CMA) R, he stated that R49 often yelled out when wanting attention or someone to talk to. CMA R stated that R49 was easily calmed down if someone sat down and gave her attention. He stated that sometimes the residents wandered the units but residents should never be going into peer's rooms. He stated staff needed to ensure the residents had frequent restroom breaks and were assisted with their basic care needs to reduce wandering. He stated that the residents were often provided activities and entertainment to prevent behaviors. In an interview on [DATE] at 02:47PM with Licensed Nurse (LN) G reported that R49 often wandered the unit yelling out for help. She stated that R49 called out the name [NAME] when she became anxious or agitated. LN G stated that staff often sat with her and gave her direct attention. She stated that R49 was easily redirected when agitated and she often seeked company when wandering the unit. She stated that R49 liked country-gospel music, snacks, and one to one interaction with staff rather then being around groups of people. A review of the facility's Behavioral Health Services policy revised ,d+[DATE] noted that the facility will provide meaningful activities that encourage engagement with staff, families, and other residents. The policy noted that the necessary and person-centered care will be provided with dignity, autonomy, choice, and safety. The facility failed to provide dementia care and services which included adequate supervision and activities to support R49's highest practicable level of well-being. This deficient practice placed her at risk for decreased quality of life and impaired well-being due related to dementia.

The facility identified a census of 48 residents. There were four residents on puree diet (diet that are mechanically altered to a pudding-like consistency) in the facility. Based on observations, record reviews, and interviews, the facility failed to follow puree diet recipes during puree meal preparation and failed to ensure hot foods were held at 135 degrees Fahrenheit (F) or higher on the steam table. Findings included: - In an observation on 05/04/21 at 10:36 AM, Dietary DD pureed beef stroganoff with milk, no puree recipe observed. She stated she did not know what a puree recipe was. In an observation on 05/05/21 at 07:15 AM, Dietary CC prepared pureed cinnamon roll. She placed eight cinnamon rolls, measured three-fourths cup of milk, and poured some melted butter into the food processor. She stated it was about half an ounce of butter. Puree recipe laid on the prep surface in staff's view. In an observation on 05/05/21 at 07:24 AM, Dietary CC prepared pureed western scrambled eggs. She emptied a plastic container of prepared scrambled eggs into the food processor then added a measured one-fourth cup of milk. She stated she placed around two cups of scrambled eggs into the food processor and that she measured them before she placed them in the plastic container. Puree recipe laid on the prep surface in staff's view. In an observation on 05/05/21 at 07:29 AM, Dietary CC prepared pureed sausage patties. She grabbed 11 sausage links with gloved hand from a container and placed in the food processor. She looked for a tablespoon but was unable to locate one. She added half a cup of hot water then pureed the sausage links; she added another half a cup of hot water then continued to puree. Puree recipe laid on the prep surface in staff's view. In an observation on 05/05/21 at 08:18 AM, Dietary FF used a food thermometer to test the temperatures of breakfast food items on hall B. Mechanical soft bacon temperature was 100 degrees F, mechanical soft sausage was 120 degrees F, pureed oatmeal was 120 degrees F, pureed sausage was 120 degrees F. The facility's Pureed Cinnamon Roll recipe for five servings called for five cinnamon rolls, three-fourths cup of milk, and one-half ounce of margarine. The facility's Pureed Western Scrambled Eggs recipe for five servings called for two and a half cups of western scrambled eggs and one-fourth cup of milk. The facility's Pureed Sausage Patty recipe for five servings called for five sausage patties, one-half cup of hot water, and one-fourth teaspoon of ham or pork base. In an interview on 05/04/21 at 10:36 AM, Dietary EE stated the puree recipes were in the office, but she was unable to pull them out. In an interview on 05/06/21 at 11:23 AM, Dietary CC stated she asked whoever was in charge how to prepare a puree meal and that sometimes a puree recipe was available and sometimes she followed it. She stated food temperatures were monitored before they left the kitchen then once again before serving on the neighborhoods. She stated if a food item was not at the required temperature, she would have heated the food item up. In an interview on 05/06/21 at 12:04 PM, Dietary BB stated there was a recipe book that dietary staff had access to and referred to. He stated he expected dietary staff to follow the puree recipe and that staff made substitutions if needed. He stated food temperatures were monitored when food was pulled out of the ovens, when delivered to the neighborhoods, and once again before food was served. He stated holding temperature was 145 degrees F and he expected staff to remove an item that was below acceptable holding temperature and heat up before they returned it to the service line. The facility's Food Production Activities policy, last revised 03/07/19, directed standardized recipes were used for all menu items and food was prepared according to the census and type of diets ordered. The facility's Food Handling Practices for Potentially Hazardous Foods and Time/Temperature Controlled Foods policy, last revised 03/07/19, directed dietary staff were aware of critical food handling practices that helped prevent foodborne illness, including cooling procedures, thawing procedures and temperature maintenance, proper internal cooking temperatures and reheating foods. The policy directed foods were cooked to the proper internal cooking temperature and verified with a thermometer before removing for service. The facility failed to ensure dietary staff followed recipe during puree diet preparation and failed to ensure food was held at 135 degrees F at the steam table before serving. This deficient practice had the risk for altered nutritional status, unpalatable food, transmission of food-borne illness to residents, and unwarranted physical complications.

The facility identified a census of 48 residents. Based on observations, record reviews, and interviews, the facility failed to ensure expired milk was discarded, dishes were stored inverted, and food was handled in a sanitary manner. Findings included: - An observation on [DATE] at 07:50 AM revealed there were two unopened half gallons of two percent milk that expired on [DATE] and three gallons of unopened whole milk that expired on [DATE] in the walk-in refrigerator. An observation on [DATE] at 07:59 AM revealed dishes on a storage cart in the employee serving line were not inverted or covered. There was an opened gallon of whole milk that expired [DATE] in the refrigerator in the employee serving area. There were dishes stored under the steam tables in the employee serving area that were not inverted or covered. An observation on [DATE] at 07:29 AM revealed Dietary CC grabbed container of sausage links and bacon out of warmer then donned (put on) gloves, no hand hygiene performed before donning. She grabbed sausage links with her gloved hand and placed in food processor. An observation on [DATE] at 07:52 AM revealed dishes under steam tables in the employee serving line were not inverted or covered. An observation on [DATE] at 08:31 AM revealed Certified Nurse Aide (CNA) M performed hand hygiene, donned gloves, removed plastic from food containers then opened drawer to grab food scooper, then grabbed Styrofoam containers. CNA M grabbed sausage and bacon with her gloved hand and placed on Styrofoam container. She grabbed bacon and cinnamon roll with gloved hand and placed on another Styrofoam container. She placed a scoop of oatmeal into a bowl, opened the container of brown sugar and scooped sugar into oatmeal bowl, and opened two creamer packets into bowl of oatmeal. While she wore same gloves, she placed a scoop of eggs onto a Styrofoam container, grabbed a slice of bread from the bag and placed in toaster, then grabbed bacon with hands to place on Styrofoam container. She doffed gloves and passed Styrofoam containers to two residents. An observation on [DATE] at 08:39 AM revealed CNA M donned gloves without hand hygiene, grabbed bacon and cinnamon roll with gloved hand, placed on Styrofoam container. An observation on [DATE] at 11:21 AM revealed dishes under steam tables in the employee serving line were not inverted or covered. In an interview on [DATE] at 07:56 AM, Dietary EE stated the dishwasher staff checked for expired containers on Tuesdays and Fridays. In an interview on [DATE] at 08:02 AM, Dietary EE stated the dishes under the employee serving line needed to be taken out and the dish storage cart in the employee serving area was usually covered. In an interview on [DATE] at 11:23 AM, Dietary CC stated she washed her hands after she removed her gloves. She stated the dietary staff member who put away the truck shipment checked for expired items. She stated dishes were always covered on the storage cart and dishes were to be stored upside down. She stated the dishes under the employee serving line were not safe from contamination. In an interview on [DATE] at 11:50 AM, CNA M stated food should not have been touched after touching other surfaces while wearing same gloves. In an interview on [DATE] at 12:04 AM, Dietary BB stated hand hygiene was performed after changing gloves and touching food. He stated food items should have been checked daily for expired items but were checked thoroughly on delivery days on Tuesdays and Fridays. He stated dishes were stored upside down and the dishes under the employee serving line were not safe from contamination. In an interview on [DATE] at 12:46 PM, Licensed Nurse (LN) G stated staff did not touch food after touching other surfaces with same gloves. In an interview on [DATE] at 01:04 PM, Dietary BB stated staff should not have touched food with gloves after touching other surfaces with same gloves. In an interview on [DATE] at 01:16 PM, Administrative Nursing Staff D stated he expected staff not to touch the food directly after touching other surfaces while wearing the same gloves. The facility's Food Storage policy, last revised [DATE], directed food was stored on shelves in areas which provided the best preservation and stored at a proper temperature for appropriate lengths of time. The policy lacked direction on expired products. The facility's Food Handling Practices for Potentially Hazardous Foods and Time/Temperature Controlled Foods policy, last revised [DATE], directed dietary staff were aware of critical food handling practices that helped prevent foodborne illness, including cooling procedures, thawing procedures and temperature maintenance, proper internal cooking temperatures and reheating foods. The facility did not provide a policy on dish storage. The facility failed to ensure expired milk was discarded, dishes were stored inverted, and food was handled in a sanitary manner. This deficient practice had the risk to spread food-borne illness and infection to residents and staff.

The facility reported a census 48 residents. The sample included 15 residents. Based on observations, record reviews and interviews, the facility failed to ensure staff practiced standard infection control practices regarding appropriate hand hygiene and use of personal protective equipment (PPE) in order to prevent the spread of infection. This had the potential to increase the residents' risk for transmission of infectious disease. Findings included: - On 05/04/21 at 08:40 AM Activity Staff Z washed her hands with soap and water, cut an orange into pieces, placed the pieces in a cup, rinsed the knife off with water, dried it with a paper towel, and placed the knife in a drawer. Activity Staff Z covered the oranges with plastic wrap, placed them on a wheeled cart, walked to the meal service counter and looked through papers, filled a glass of water and placed it on the cart and took the cart down the hall. Activity Staff Z did not don gloves or sanitize her hands. On 05/04/21 at 09:15 AM a female staff member unwrapped a utensil package and placed the utensils on R 23's bowl and plate. She filled two Styrofoam cups with ice as she held them with two fingers inside the cup. She dispensed utensils to a female resident and gave the resident a bite of food. She then walked to the meal counter, received a bowl and plate and took to another female resident. She walked back to the kitchenette placed something in the cabinet, took a juice container from the refrigerator and poured a glass of juice to a resident. She did not sanitize her hands or don gloves. She placed the juice back in the refrigerator and washed her hands with soap and water. On 05/04/21 at 09:18 AM an unidentified staff member placed meal trays in the dirty container and proceeded to assist a female resident with breakfast and did not perform hand hygiene. On 05/05/21 at 07:15 AM Dietary Staff (DS) CC donned gloves, pureed cinnamon rolls, butter, and milk, doffed gloves, donned new gloves, placed the pureed food in three containers, took a wet cloth from a red disinfectant container, doffed gloves, donned new gloves, and did not perform hand hygiene. On 05/05/21 at 07:44 AM Licensed Nurse (LN) H washed hands with soap and water, donned gloves, detached the tabs from the left side of R20's incontinence brief, took the soiled bandage off of her pressure wound (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), placed it on R20's brief, removed packing from the inside of the wound with a clean cotton tipped swab, placed on the soiled bandage, cleaned the wound with spray wound cleanser and gauze pad, placed the cleanser bottle on the bed and checked the wound with the soiled cotton tip swab, placed the swab on top of the soiled gauze, doffed gloves, donned a new pair of gloves and did not sanitize hands. LN H took a pair of scissors out of his pocket, cut a strip of calcium alginate (a dressing used to soak up loose debris from a wound and provide an optimal environment for healing), placed it in the wound with a new cotton tipped swab, placed a clean bandage on the wound, took a pen out his pocket and wrote the date on the bandage, wrapped the soiled items in his gloves as he doffed. LN H placed the gloves on a clean box of bandages, then on the bedside table, and then disposed them in the trashcan. LN H washed his hands with soap and water. On 05/05/21 at 08:31 AM Certified Nurse Aide (CNA) M performed hand hygiene and donned gloves. CNA M removed plastic wrap from some food, retrieved sausage, bacon, and a cinnamon roll with her hands and placed them on a food tray, placed a scoop of oatmeal in a bowl, opened a brown sugar container and two creamer containers into the oatmeal, placed a scoop of eggs on a plate, placed a slice of bread in a toaster and did not sanitize her hands. On 05/06/21 at 07:14 AM LN H took a Dynamap (machine used to measure blood pressures and pulses) into R12's room. LN H placed a glucometer (machine used to test blood sugar levels), an alcohol pad, and a bottle of test strips (used to obtain the blood sample used to measure blood sugar levels) on top of R12's bedspread, obtained the blood sample, placed the glucometer and test strip bottle in a plastic bag and placed in the Dynamap basket. LN H doffed gloves and placed the soiled test strip and lancet (needled device used to obtain a blood sample) in the soiled gloves, placed the soiled gloves on R12's bedspread, donned new gloves, did not sanitize hands, and gave an insulin injection (medication used to treat diabetes-when the body can't use glucose, not enough insulin is made, or the body can't respond to the insulin), doffed the gloves and washed with soap and water. LN H took the Dynamap to the dining room and took a female resident's blood pressure with a wrist cuff, placed the cuff back in the Dynamap basket, wrote something on a piece of paper, and proceeded to take another resident's blood pressure with the wrist cuff. Neither the Dynamap nor wrist cuff were sanitized between residents. LN had not sanitized hands or donned gloves. On 05/06/21 at 08:54 AM an unidentified female staff ate food while she served food in the kitchenette on Friendship Heights. She had her protective mask under her chin with her nose and mouth exposed. On 05/06/21 at 11:04 AM LN H stated he had received in-services on donning/doffing PPE and hand hygiene. The administrative staff had done spot checks on the staff's techniques for donning/doffing and hand hygiene. Hand sanitizer was used between tasks like medication administration, before treatments and doffing gloves, and soap and water were used when hands were visibly soiled. Sani-wipes (disinfecting cleaning cloths) were used to clean reusable equipment after use. On 05/06/21 at 11:23 AM DS CC stated a staff member showed her how to perform hand hygiene properly. Hands were sanitized between tasks and after gloves were doffed On 05/06/21 at 01:32 PM Administrative Nurse D stated staff sanitized their hands during meals, before and after providing resident cares, and after doffed gloves. The facility staff had received in-services on hand hygiene, donning/doffing PPE and sanitizing reusable medical equipment. The reusable medical equipment should be sanitized after each use. The facility's Emergent Infectious Disease (EID) Outbreak Management policy dated 04/15/21 documented part of routine education of staff included methods of prevention such as hand hygiene and PPE usage. Measures to contain, control, and or prevent infections included but, were not limited to the use of PPE. The facility failed to ensure staff practiced standard infection control precautions in order to prevent the spread of infection when staff failed to perform proper hand hygiene and PPE use. This had the potential to increase the risk for transmission of infectious disease to residents.

The facility identified a census of 48 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff placed residents, dependent upon staff for locomotion, at the dining table for extended period of time prior to meals being served and also used disposable plates and utensils on the Friendship Heights unit. Findings include: - Observation on 05/04/21 at 08:05 AM Staff wheeled Resident (R)15 in Broda chair (a specialized wheelchair with the ability to tilt and recline) from her room and placed her at a dining table. No food or drink noted on the table. At 08:40 AM R15 received a drink, 35 minutes later. At 09:13 AM R15 received a bowl of pineapple tidbits, one hour and eight minutes after arriving in the dining room. At 09:16 AM a staff member sat down next to R15 to assist with eating. Observation on 05/04/21 at 08:39 AM, revealed R29 sat at the dining room table in a wheelchair. No food or drink noted on the table in front of R29. At 09:14 AM, R29 was given a bowl of fruit, 35 minutes after being in the dining room. Observation on 05/05/21 at 07:33 AM revealed R15 and R32 sat in Broda chairs at the dining room tables. R32 had a drink on the table. No food or drink was noted on the table for R15. At 08:26 AM, R15 and R32 were given a shake supplement to drink, 53 minutes later. At 08:49 R15 and R32 were given a breakfast meal, one hour and 16 minutes after being in the dining room. Observation on 05/05/21 at 08:00 AM revealed R29 sat at the dining room table in a wheelchair. At 08:36 AM R29 was given a coffee to drink, 36 minutes later. At 08:49 R29 was given a breakfast meal, 49 minutes after being in the dining room Observation on 05/05/21 at 08:39 AM revealed that the meal trays were prepared with disposable plates and disposable utensils. Interview on 5/6/21 at 12:34 PM revealed Certified Nurse Aide (CNA) N stated residents that were in the dining room before meals were served drinks and shake supplements. CNA N also stated that staff offered sips of drinks to those residents that were unable to feed themselves while waiting for meals. Interview on 5/6/21 at 12:35 PM revealed Licensed Nurse (LN) G stated that residents in the dining room before meals were served drinks and shake supplements. She stated staff were to assist any resident that needed assistance by offering sips of drinks until meals were served. She also stated that they did not provide activities for anyone in the dining room prior to the meals being served. Interview on 5/6/21 at 01:16 PM with Administrative Nurse D revealed that the expectation was for a resident to have a drink within 15 minutes of arrival in the dining room and have a meal served within 45 minutes of arrival into the dining room. Administrative Nurse D stated that over an hour is too long of a wait time and that the staff should have at least offered something while waiting. Administrative Nurse D also stated that he is unsure of how the determination was made of which residents are brought out to the dining room and when they are brought out based on the level of assistance needed. The facility's Dining Profile policy revised on April 26, 2019, documented that a Dining Profile will be completed by conducting a resident interview to determine resident dining and food preferences, and gathering nutritional data. The facility failed to provide a dining environment that promotes dignity and respect for their residents. This put the residents at both potential nutritional and psychosocial risks.

The facility identified a census of 48 residents. The sample included 15 residents; one resident reviewed for activities. Based on observations, record reviews, and interviews, the facility failed to consistently provide personalized, resident-centered activities to Resident (R) 10. Findings included: - The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R10 had a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. R10 had activity preferences documented that it was very important to have magazines, newspapers, and books to read; music to listen to; keep up with the news; do things with groups of people, do her favorite activities; go outside for fresh air when weather is good; and participate in religious services. R10 required limited physical assistance with one staff member for walking and extensive physical assistance with one staff member for transfers. The Quarterly MDS dated [DATE] documented R10 had a BIMS score of three which indicated severe cognitive impairment. R10 required limited physical assistance with one staff member for walking and extensive physical assistance with one staff member for transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/25/20 documented R10 had dementia and struggled with short term memory. Staff attempted to anticipate R10's needs and recognized at times she required more supervision for safety purposes. The Life Enrichment Care Plan dated 09/10/19 documented R10 had a potential for low attendance/participation in activities due to personal preferences with interventions that R10 enjoyed listening to music, staff provided crosswords for R10 to challenge her brain and for her enjoyment, R10 attended Catholic services, and R10 loved to watch sports of all kinds on the television. The Daily Point of Care (POC) Charting tab of R10's EMR documented activity participation. R10 participated in activities five out of 28 days in February 2021, six out of 31 days in March 2021, eight out of 30 days in April 2021, and one out of five days in May 2021. In an observation on 05/04/21 at 02:40 PM, R10 sat in recliner in day area, eyes open. Tray table with cup of water in front of R10, television on but R10 was not watching it. No activities observed. In an observation on 05/04/21 at 04:05 PM, R10 sat in recliner in day area, eyes closed. Tray table with cup of water to the side of the recliner. No activities observed. In an observation on 05/05/21 at 08:52 AM, R10 sat in recliner in day area, tray table in front of her with breakfast on it. R10 appeared comfortable and ate breakfast independently. No activities observed. In an observation on 05/05/21 at 02:29 PM, R10 sat in recliner in day area, eyes closed, appeared to be resting comfortably. No activities observed. In an observation on 05/05/21 at 02:47 PM, R10 ambulated with walker and staff assistance from recliner in day area to restroom in hallway. In an observation on 05/05/21 at 02:56 PM, R10 ambulated with walker and staff assistance from restroom in hallway back to recliner in day area. In an observation on 05/05/21 at 03:27 PM, R10 sat in recliner in day room, eyes closed. R10 appeared to be resting comfortably. No activities observed. In an observation on 05/06/21 at 07:47 AM, R10 sat in recliner in day room, eyes open. R10 appeared to be comfortable with no signs of distress and watched television on and off. In an observation on 05/06/21 at 09:14 AM, R10 sat in recliner in day room, eyes open. R10 ate breakfast independently and without signs of distress. No activities observed. In an interview on 05/06/21 at 11:50 AM, Certified Nurse Aide (CNA) M stated the aides charted on activities and the activities staff also charted on activities. She stated the activity director oversaw activities. In an in interview on 05/06/21 at 12:46 PM, Licensed Nurse (LN) G stated the activity staff member for that unit was responsible for activities. In an interview on 05/06/21 at 01:06 PM, Activity staff AA stated she was responsible for activities and the activity assistants charted on activities. She stated R10 really liked music, visits with family, naps, and group activities. She stated she expected activities to be provided to residents in the morning and afternoon every day. She stated activities were charted in POC and she encouraged her activity staff to chart a progress note too. In an interview on 05/06/21 at 01:16 PM, Administrative Nursing Staff D stated he expected activities to be provided at least daily. The facility's Life Enrichment Programming policy last revised 04/26/19 directed an ongoing program of activities were designed to meet the interests and physical, mental, and psychosocial well-being of residents. The policy directed the program of activities included a combination of large and small groups, one-to-one, and self-directed activities and staff recognized that there were times residents preferred not to participate in any planned Life Enrichment programming but would prefer to sit idly independent which was appropriate as long as it was the resident's choice, was not prolonged, and was not the result of lack of appropriate stimulation. The facility failed to provide consistent activities for R10 which had the risk for a decline in physical, mental, and psychosocial well-being and independence.

The facility had a census of 46 residents. The sample included 17 residents. Based upon observation, record review and interviews the facility failed to develop and implement timely and effective interventions to prevent a pressure ulcer for 1 (#72) of 3 residents reviewed for pressure ulcers, who developed an unstageable pressure ulcer. Findings included: - Review of the admission Minimum Data Set ((MDS) dated [DATE] identified resident #72 had a Brief Interview for Mental Status (BIMS) of 9 (which indicated a moderately impaired cognition) required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and required setup help only with eating. The MDS noted no pressure ulcers, however the resident was at risk for pressure ulcers. Review of the quarterly MDS dated [DATE] identified the resident had a BIMS of 9 and required extensive assistance with bed mobility, transfers, dressing, locomotion on and off the unit, eating, toilet use, and personal hygiene. The MDS recorded the resident weighed 116 pounds, had experienced a weight loss of 5 percent (%) in 1 month or 10% in 6 months, was not on a physician regimen weight loss program and received a regular diet. The MDS recorded the resident had a pressure ulcer identified as a Stage 2 (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) dated 06/21/16. Review of resident #72's significant change MDS dated [DATE] identified the resident had a BIMS of 6 (which indicated severely impaired cognition). The resident required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident was totally dependent on staff for locomotion on and off the unit. The MDS noted an unstageable pressure ulcer, measuring 1.5 centimeter (cm) x 0.5 cm with slough (dead tissue separating from living tissue) on the coccyx (small triangular bone at the base of the spine). The resident's care area assessment (CAA) dated 12/25/15 documented cognitive loss/dementia triggered due to [DIAGNOSES REDACTED]. The resident received medications to manage his/her depression and increase appetite. The resident's pressure ulcer CAA dated 12/25/15 triggered due to the resident's post surgery, poor appetite and he/she received supplements for increased calories and protein. The CAA for the significant change dated 07/08/16 revealed pressure ulcer triggered due to a pressure ulcer of the coccyx that was unstageable due to slough (necrotic tissue separated from the living structure) in the base of the wound. Staff cleansed the area with Saf Clens and covered with [MEDICATION NAME] AG (wound dressing) daily and as needed. The resident recently admitted to hospice for protein-calorie malnutrition as evidenced by weight loss which contributed to the development of wounds. The resident had a decline in function and required extensive assistance for activities of daily living (ADL) tasks. He/she spent most of his/her time sleeping in bed or the recliner. Hospice provided a low air loss mattress and gel cushion for his/her wheelchair to reduce pressure. The staff assisted with turning and repositioning but he/she could be agitated at times and may not cooperate. The resident's admission care plan dated 12/21/15 recorded the resident required 1 to 2 staff assistance for toileting and transfers; and 1 person assist for bathing. The physician order [REDACTED]. The care plan dated 12/31/15 had the resident at risk for pressure ulcer with interventions of a pressure reducing mattress and assist of 1 to 2 persons with transfers. The care plan did not address repositioning. The care plan for pressure ulcers dated 07/19/16 recorded the resident had an unstageable wound to the coccyx. Interventions included: low air loss mattress; reposition every 2 hours in bed and hourly in wheelchair or recliner and as needed; gel cushion in wheelchair and saddle cushion in recliner; administer pain medications to reduce pain during treatment/dressing changes/evaluations. Evaluation of needs/recommendations/interventions for nutrition care dated 06/20/16 documented the resident's skin was intact. The nutrition note dated 06/29/16 noted the resident had a new stage 2 pressure ulcer to his/her coccyx. The resident started on protein shakes 120 milliliters (mL) daily. The nutrition note dated 07/15/16 documented the resident had a stage 2 pressure ulcer to coccyx. Review of the resident's Medication Administration Record [REDACTED]. Further review revealed the facility did not record the percentage of supplement the resident consumed. Review of the resident's monthly weight report revealed the following weights: 12/28/15: 146 pounds 01/04/16: 145 pounds 01/11/16: 143 pounds 01/18/16: 139 pounds 01/25/16: 134 pounds From 02/02/16 through 04/18/16 the resident had physician orders [REDACTED]. 02/11/16: 134 pounds 03/07/16: 131 pounds 04/04/16: 126 pounds 05/02/16: 121 pounds 06/06/16: 116 pounds On 06/29/16 the physician ordered protein shake 120 mL to be given daily. 07/04/16: 113 pounds 08/01/16: 114 pounds The certified nurse aide (CNA) Skin Screening Detail from 03/01/16 through 06/20/16 documented the resident had no skin issues. On 06/21/16 on the CNA skin screening detail sheet the resident had a suspected pressure ulcer on the buttocks which staff reported to a licensed nurse. The physician order [REDACTED]. The physician order [REDACTED]. On 6/21/16 the (initial) Wound report recorded: coccyx wound measured 1.5 cm x 0.5 cm; serosanguinous drainage (containing or relating to both blood and the liquid part of blood (serum)); and slough. Interventions put in place included: Turn schedule - every 2 hours; use chair/seat cushion; pressure-reducing/relieving devices; and administer a multivitamin with minerals daily. On 7/4/16 the Wound report recorded: coccyx wound 1.2 cm x 0.5 cm; low drainage; slough. Cleanse wound, cover with [MEDICATION NAME] AG, change daily & PRN. Interventions: Continue care plan. On 7/11/16 the Wound report recorded: coccyx wound 0.9 cm x 0.6 cm; low drainage; slough. Cleanse wound, pat dry and cover with [MEDICATION NAME] AG every 3 days and PRN. Interventions: Continue care plan. On 7/18/16 the Wound report recorded: coccyx wound 1.0 cm x 0.5 cm; no drainage; slough. Interventions: Continue current treatment. On 7/25/16 the Wound report recorded: coccyx wound 0.8 cm x 0.5 cm; low drainage; slough, [MEDICATION NAME] (sheet of cells that covers a body surface or lines a body cavity). Interventions: Continue current treatment. On 8/1/16 the Wound report recorded: coccyx wound 0.8 cm x 0.3 cm; low drainage; granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during healing process), slough; pain assessed and medicated as indicated Interventions: Continue current treatment. On 8/8/16 the Wound report recorded: coccyx wound 0.5 cm x 0.3 cm; low drainage; granulation, slough; pain assessed and medicated as indicated Interventions: continue with current treatment. Observation on 08/10/16 revealed the following: At 1:54 PM, the resident sat in a recliner, sleeping in the living room, slightly leaning to the right side slightly, with his/her eyes closed. The resident was able to move some in the chair on his/her own, with his/her legs bent at the knee and his/her feet rested on the recliner footrest. The resident moved only slightly, not enough be considered repositioned. At 2:10 PM, the resident sat in a recliner, both feet resting on the footrest with legs bent at the knees. Resident was sleeping, leaning to the right side. At 2:21 PM, Staff O came up to resident asleep in the recliner, right leg was resting on the arm of the recliner; straightened the resident's legs and covered the resident with a fleece blanket. At 2:35 PM, the resident sat in a recliner and had his/her right leg bent at the knee, and foot resting on the footrest, sleeping. At 2:50 PM, the resident slept in the recliner has right leg bent at the knee with foot flat on the leg rest and the left leg bent with left foot resting on the right foot, leaning on left hip, and sleeping. At 3:05 PM, the resident was in a recliner, sleeping. The resident's right leg was bent at the knee, foot flat on the footrest. Left leg slightly bent at the knee and with outside of left foot resting on the footrest. At 3:20 PM, the resident slept in the recliner. The resident's right leg bent at the knee, left leg slightly bent. At 3:35 PM,the resident was asleep in the recliner. The resident's right leg bent at the knee with foot flat on the footrest. Left leg bent at the knee and turned out to the left (hip open). At 3:50 PM, the resident was sleeping in the recliner with both knees bent, legs leaning to the left side, sleeping. At 4:05 PM, the resident was in a recliner with both knees bent, legs leaning to the left side, and was sleeping. At 4:10 PM, Surveyor requested a skin check for the resident who remained in the same position in the recliner. 08/10/2016 4:12 PM Both CNAs, direct care staff V and another CNA transferred the resident up into his/her wheelchair using a gait belt and took the resident to bathroom in his/her room. Direct care staff V removed the resident's dry brief and assisted the resident to the toilet. Observation revealed the resident did not have a dressing in place to the coccyx wound; which was visualized with yellow slough in the base. The resident did not urinate, and staff transferred the resident back into the wheelchair. The resident continued to lean to the left side. On 08/11/2016 at 11:04 AM licensed staff H and direct care staff R entered the resident's room and removed the resident's brief. A dressing dated 8/10/16 was in place. Staff removed the dressing and revealed a pencil eraser sized wound with small amount of yellow slough in the center. Licensed staff H used Saf Clens and 4x4 gauze to clean the wound and applied skin prep wipe to the area around the wound. Staff H applied the [MEDICATION NAME] pad to the wound area, ensured a good seal all the way around on skin. During an interview on 08/10/2016 at 4:27 PM direct care staff V stated staff took the resident to the restroom before dinner in the evening, after dinner and around 8:00 PM. The resident went to bed around 10:30 PM before evening shift left, so staff took him/her to the bathroom again. Probably twice during those checks the resident would have already urinated. Each time we check him/her, we also reposition the resident to try to keep the weight off him/her bottom. During an interview on 08/11/2016 at 9:53 AM Direct care staff T stated the family requested to let the resident sleep as long as he/she would like. If he/she wake up before lunchtime then staff would order whatever he/she would like from the kitchen or staff could make him/her toast since we keep bread on the unit. He/she does better with finger foods rather than utensils and staff have to feed him/her often. CNAs do not record a percentage of food eaten. Most of the time the nurse attempted to get the resident to drink the Boost, but he/she refused that a lot of times. On a good day, the resident normally ate 50% of his/her food with assistance/cues. If staff doesn't assist the resident then he/she probably only eats 15% and a lot of food ends up in his/her lap. During an interview on 08/10/2016 at 4:31 PM licensed staff K referred to the Treatment Administration Record (TAR) book and stated the physician order [REDACTED]. Direct care staff should reposition and provide incontinence care every hour or two hours when in the recliner and try to ensure that they shift weight from one side to the other to offsite at each position change. During an interview on 08/09/16 at approximately 2:00 PM licensed staff H stated either he/she changed the dressing as ordered or there was a wound nurse could also perform dressing changes. During an interview on 08/11/2016 at 10:16 AM licensed staff H stated the resident's pressure ulcer occurred after his/her mobility declined and he/she stopped walking. Staff obtained wound measurements weekly. The most current order directed staff to change the dressing every 3 days, but due to the area involved, staff usually changed the dressing daily. Nurses do not measure the wound at each dressing change. The wound nurse measured the wound during the assessment. The resident doesn't like sweet flavors, and he/she refuses the Boost shake. The resident likes coffee and sometimes juice. During an interview with Administrative staff D on 08/11/2016 at 1:07 PM he/she stated the facility had a weekly risk meeting, and each neighborhood nurse identified their residents weight losses and brought them to the meeting. The Certified Dietary Manager (CDM) also ran a report for weight loss and brought it to the meeting. Any resident who had a weight loss or risk of weight loss - interventions were collaborative and individual to the residents. The resident began receiving CIB shakes in January twice daily (BID). There was a product change in April to fortified shakes BID, which were discontinued on June 20th. Boost between meals three times daily (TID) ordered 06/23/16. Hospice and the family asked us to not do anything that the resident did not want us to do when the resident hit the 5% weight loss mark from the previous months. We compare monthly weight up to 6 months prior. In March the resident was under the cutoff for requiring weekly weights. However, by April since the resident was at 9.75% weight loss from admission then he/she should have been initiated for weekly weights. Staff recorded meal intake percentage by exception. The system flagged if residents ate less than 75% of meals in the previous 24 hours. The facility did not complete any meal tracking for the resident in the last 6 months. The risk meeting involved the neighborhood staff who worked with the resident every day. The staff on the floor began assisting the resident to eat starting in May, and dietary staff provided more finger foods because at times he/she did not want staff assistance. During an interview with Consultant dietary staff II on 08/15/16 at 10:30 A.M. he/she stated that he/she began consulting in June. He/she was at the facility once a month, sometimes more if a resident needed to be seen immediately such as in cases of weight loss, or a hospice admission. The dietary manager gave a printed report of new residents; use this list to review in the facility to look for weight loss, new pressure ulcers, new to hospice care and annual reviews. He/she also got a copy of Risk meetings of possible concerns. In regards to a significant weight loss, his/her standard would be to speak to the resident, ask if he/she had trouble chewing or swallowing, and if he/she liked the foods being served. If the resident was unable to speak, then I would speak to the family or nurse to find out what types of food the resident enjoys or if the resident was having any trouble eating. He/she also review the need for assistance at meals. Interventions were recommended based on the interview process for what would work best for that particular resident. He/she review weights to ensure that there was a true trend versus triggering for a fluctuation in weight. During an interview with consultant medical staff KK on 08/15/16 at 10:00 A.M., staff KK stated he/she was at the facility three times a week and that nursing staff usually reported to him/her while at the facility and he/she was also available by fax to receive resident updates. The resident was usually seen by another provider. If a resident is refusing supplements, then I would expect to be notified. However, I wouldn't expect a percentage of supplement intake to be recorded. During an interview with consultant medical staff JJ on 08/15/16 at 10:05 A.M., staff JJ stated if significant weight loss occurred it would have triggered the dietician to see him/her. The resident was difficult to treat due to his/her dementia and refusing medications. His/her general resistance to cares made it difficult to prevent weight loss. In regards to weight loss causing a pressure ulcer, it was a component but his/her resistance to cares was more likely the culprit. Review of Skin integrity policy dated July 2013 revealed that nursing staff would assess skin integrity, implement preventative measures as indicated and treat skin breakdown. The primary care provider (PCP) admission orders [REDACTED]. Dressing changes were performed by a licensed nurse. Nurses may delegate minor skin treatments and preventative treatments on closed areas to certified medication aides (CMA) who have received the appropriate skin care training. The facility failed to develop and implement timely and effective interventions for this cognitively impaired dependent resident to prevent the development of an unstageable pressure ulcer.

The facility had a census of 46 residents. The sample included 17 residents. Based upon observation, record review and interviews the facility failed to develop and implement timely interventions to prevent weight loss for 1 (#72) of 4 residents sampled for nutrition. Resident #72 lost 16.55% of his/her weight in a 6 month period. Findings included: - Review of resident #72's admission Minimum Data Set ((MDS) dated [DATE] identified the resident had a Brief Interview for Mental Status (BIMS) score of 9 and required setup help only with eating. The MDS noted that the resident required no special nutritional approaches and had no chewing or swallowing problems. The MDS recorded the resident weighed 141 pounds with no weight loss or weight gain. Review of the resident's quarterly MDS dated [DATE] identified the resident had a BIMS of 9 and required extensive assistance with eating. The MDS noted the resident required no special nutritional approaches and no chewing or swallowing problems. The MDS recorded the resident weighed 116 pounds, had experienced a weight loss of 5 percent (%) in 1 month or 10% in 6 months, was not on a physician ordered regimen weight loss program, and received a regular diet to be adjusted on level of alertness. The resident's care area assessment (CAA) dated 12/25/15 revealed nutrition did not trigger. The CAA dated 12/25/15 revealed cognitive loss/dementia triggered due to [DIAGNOSES REDACTED]. The CAA dated 12/25/15 revealed pressure ulcer triggered due to resident was status [REDACTED]. The resident's admission care plan documented the resident was at risk for alterations in nutrition related to recent [MEDICAL CONDITION], history of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and short term memory impairment. An entry dated 12/23/15 revealed the resident preferred a regular diet and could make his/her needs known and that sometimes he/she forgot he/she had already eaten. Staff weighed the resident weekly while on Med A services (post acute care rehabilitation). The 12/23/16 care plan documented the resident was to be offered CIB shakes twice daily between meals. On 01/28/16 it was documented on the care plan for the resident to have a regular diet adjusted by level of alertness. Staff revised the care plan revised 03/28/16 revealed the resident preferred a regular diet and could make his/her needs known. Staff provided assistance with meal setup as needed and were to weigh monthly. Staff updated the care plan on 04/18/16 to change CIB shake order to fortified milk shake 120 milliliter (mL) by mouth twice daily between meals for weight loss. On 06/20/16 CIB shakes/fortified shakes were discontinued; the physician ordered Boost 90 mL supplement three times a day in replacement and added fortified foods at meals. The nutritional progress note dated 02/01/16 revealed the resident had an 8.08% weight loss change in 30 days per weight report and noted insidious (denoting a disease that progresses gradually with inapparent symptoms) weight loss in 180 days. The resident received a regular diet with fair intake. A functional decline note - discussed with nursing that the resident had increased lethargy/drowsiness and needed cueing at meals. He/she received CIB shake twice daily which he/she accepted well per nursing. The clinical record lacked evidence of additional interventions to prevent weight loss. The risk meeting note for the week of 04/28/16 through 05/04/16 documented that staff discussed the resident's weight loss. Interventions put in place included a fortified shake twice daily, staff offered and provided snacks, speech evaluation and treament, offer more sweet items and the family provided ginger snap cookies. The evaluation of needs/recommendations/interventions for nutrition care dated 06/20/16 revealed the resident's weight on 06/06/16 was 115.5 pounds, a 4.3% loss in 30 days, 11.6% loss in 90 days, 17.9% loss in 180 days. The resident received a regular diet, and fortified shakes twice daily. The resident's intake varied per nursing. The resident was lethargic, became agitated when awakened to eat and ate very little. Staff recommended to discontinue shakes and try Boost 90 mL three times daily. Staff may need to consider alternate nutrition if appropriate. The nutrition note dated 06/29/16 noted the staff started the resident on a protein shake 120mL daily. The dietary screening for significant change dated 07/08/16 revealed the resident's weight was 112.8 pounds which indicated a 22% decline in 180 days. The resident received a regular diet with thin liquids, and supplement Boost three times daily. The staff reported/observed meal consumption as less than 75% on all meals and the resident's dental status was adequate. Staff were to offer snacks between meals. Review of the resident's Medication Administration Record [REDACTED]. The clinical record lacked evidence the resident received CIB from 12/23/15 through 02/02/16 as planned. Further record review revealed the facility did not record the percentage of supplement the resident consumed. Review of the resident's monthly weight report revealed the following weights: 12/19/15: 139 pounds at time of admission. 12/28/15: 146 pounds 01/04/16: 145 pounds 01/11/16: 143 pounds 01/18/16: 139 pounds 01/25/16: 134 pounds Upon review of the Medication Administration Record [REDACTED]. 02/11/16: 134 pounds 03/07/16: 131 pounds 04/04/16: 126 pounds On 04/18/16 physician ordered CIB shakes changed to fortified milk shake. 05/02/16: 121 pounds 06/06/16: 116 pounds On 06/20/16 physician ordered to discontinue CIB and fortified milk shake and replace with fortified foods and Boost three times daily. On 06/29/16 physician ordered protein shake 120 mL daily. 07/04/16: 113 pounds 08/01/16: 114 pounds The record lacked evidence the resident was reassessed for continued weight loss. Labs reviewed from admission. The resident was assessed for [MEDICATION NAME] levels on 4 occasions and [MEDICATION NAME] once. On 01/19/16 [MEDICATION NAME] level was 3.5, the normal level is 3.5 to 5.7. On 03/19/16 [MEDICATION NAME] level was 3.6. On 06/20/16 [MEDICATION NAME] level was 3.7. On 06/29/16 [MEDICATION NAME] level was 3.3. On 06/29/16 [MEDICATION NAME] level was 16, the normal value is 17 to 34. On 08/11/16 the resident stayed in bed until approximately 11:20 A.M., when direct care staff R transferred the resident to the wheelchair and wheeled the resident into the living room area where an activity was going on. The staff did not give or offer the resident anything to eat. On 08/11/2016 at 1:22 PM direct care staff Q stated the resident ate teriyaki chicken and rice, green beans, and lentil soup and stated the resident ate 100%. The resident sat in his/her high back wheelchair and stated lunch was bleh. Staff Q assisted the resident to eat a small bowl of ice cream. The resident ate 50% of the ice cream. During an interview on 08/11/16 at 9:53 A.M., direct care staff T stated the resident's family requested to let the resident sleep as long as he/she would like to. If he/she woke up before lunchtime then staff ordered whatever he/she would like from the kitchen or staff could make him/her toast. Staff had to feed the resident a lot of times. The certified nurse aides (CNA) did not record a percentage of food eaten. Most of the time the nurse attempted to get the resident to drink the Boost, but the resident often refused. On a good day, the resident ate approximately 50% of his/her food with assistance and cues. If he /she did not get assist, then he/she only ate approximately 15% and a lot of food ended up in his/her lap. Staff obtain weights on the first Monday of every month, reported to the nurse and the nurse compared the weight to the month before. During an interview on 08/11/16 at 10:16 A.M., Licensed staff H stated that the resident did not like sweet flavors, so he/she refused the Boost shake. If he/she refused, staff tried different foods. Staff H offered Magic Cup a dietary supplement, a couple of times. Weights are obtained once a month. CNAs weighed the residents and they reported to the nurse. The nurses entered the weights in to the computer, and it sent an alert to the Dietician and the assistant director of nursing (ADON). The dietician came down that day to assess a weight loss and any recommendations would be started instantly. Weight issues would be addressed weekly at the Risk meeting. If there was a problem, the dietician reviewed the information then the physician or nurse practitioner would put in new orders if necessary. During an interview with Administrative staff D on 08/11/2016 at 1:07 PM he/she stated the facility had a weekly risk meeting, each neighborhood nurse identified their residents weight losses and brought them to the meeting. The Certified Dietary Manager (CDM) also ran a report for weight loss and brought it to the meeting. Any resident who had a weight loss or risk of weight loss interventions were collaborative and individual to the residents. The resident began receiving CIB shakes in January twice daily (BID). There was a product change in April for fortified shakes BID. Fortified shakes were discontinued on June 20th and implemented Boost between meals three times daily (TID). Hospice and the family asked us to not do anything that the resident did not want us to do when the resident hit the 5% weight loss mark from the previous months. We compare monthly weight up to 6 months prior. In March the resident was under the cutoff for requiring weekly weights, however by April since the resident was at 9.75% weight loss from admission then he/she should have been initiated for weekly weights. Staff recorded meal intake percentage is done on exception, the system flagged if they were eating less than 75% of meals in the previous 24 hours. The facility did not complete any meal tracking for the resident in the last 6 months. Staff involved the neighborhood staff in the risk meetings, they work with the resident every day. The staff on the floor began assisting the resident to eat starting in May, and dietary provided more finger foods because at times he/she did not want staff assistance. During an interview on 08/15/16 at 10:30 A.M. consultant dietary staff II stated that he/she was at the facility once a month, sometimes more if a resident needed to be seen immediately such as in cases of weight loss, or being placed on hospice. The dietary manager gave him/her a printed report of new residents. He/she used the list to review in the facility to look for weight loss, new pressure ulcers, new to hospice care and annual reviews. Consultant staff II also received a copy of Risk meetings of possible concerns. In regards to a significant weight loss, his/her standard would be to speak to the resident, ask if he/she was having trouble chewing or swallowing, and if he/she liked the foods being served. If the resident was unable to speak, then consultant staff II spoke to the family or nurse to find out what types of food the resident enjoyed or if they are having any trouble eating, and also reviewed the need for assistance at meals. He/she would then recommend interventions based on the interview process for what would work best for that particular resident. During an interview on 08/15/16 at 10:00 A.M., consultant medical staff KK stated he/she was at the facility three times a week and nursing staff usually caught him/her while at the facility and he/she was available by fax to receive resident updates. The resident was usually seen by another provider. If a resident refused supplements, then he/she would expect staff to notify him/her. During an interview on 08/15/16 at 10:05 A.M., consultant medical staff JJ stated he/she was on leave from March through June. If significant weight loss occurred it would have triggered the dietician to see the resident. The resident was difficult to treat due to his/her dementia and he/she refused medications. His/her general resistance to cares made it difficult to prevent weight loss. The nutritional status policy dated February 2008 stated that a comprehensive assessment by the facility would ensure that the resident maintained acceptable parameters of nutritional status such as body weight and protein levels, unless the resident's clinical condition demonstrated this was not possible. The facility failed to develop and implement timely and effective interventions for this cognitively impaired, dependent resident who experienced a significant weight loss.

The facility reported a census of 54 residents and there were 5 sampled residents. Based on observation, interview, and record review the facility failed to provide adequate supervision and implement timely and appropriate interventions, and failed to provide interventions as planned (toileting every 2 hours) to prevent a fall with a neck fracture (broken bone) and subdural hematoma (an injury when blood collects on the brain's surface beneath the skull as a result of a head injury) for 1 of 3 residents (# 1) sampled for accidents. Findings included: - Review of resident #1's physician order [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 1/9/2016 documented a BIMS (Brief Interview for Mental Status) score of 8, which indicated moderate cognitive impairment. The resident required extensive assistance of 2 or more staff with transfers; extensive assistance of one staff with bed mobility, walking, dressing, and toileting; had poor balance; and used a walker and a wheelchair for mobility. He/she was occasionally incontinent of bowel and bladder. The resident had 1 non injury fall and 1 injury fall. Review of Fall CAA (Care Area Assessment) dated 1/11/2016 documented the resident had falls prior to admission, was at continued risk for falls, and had a history of [REDACTED]. The resident had impaired balance, an unsteady gait, confusion, forgot to use his/her call light for assistance, and used a wheelchair for long distances due to he/she forgot to use his/her walker. Review of a quarterly MDS dated [DATE] documented the a BIMS score of 9, which indicated moderate cognitive impairment. The resident required extensive assistance of one staff with toileting and personal hygiene; limited assistance of 1 staff with bed mobility, transfers, walking, locomotion on and off the unit, dressing; had poor balance; and used a walker and wheelchair for mobility. He/she was frequently incontinent of urine. The resident had 2 non injury falls. Review of the care plan dated 12/13/2015 documented the resident had a history of [REDACTED]. The care plan directed staff to ensure the resident's call light was within reach and remind him/her to use the call light for assistance, monitor the resident hourly for attempts to get out of bed by him/herself, and check on the resident every 15 minutes to one hour and re-educate the resident on call light use. The care plan revealed the resident required extensive assist with transfers, and ambulation/locomotion. The care plan further instructed staff to monitor for scooting, crawling from bed to recliner, toilet, and keep walker in reach, and do not leave unattended in living room area, especially during time of restlessness. The care plan further directed the staff to offer toileting every two hours. Review of a fall risk assessments on 3/2/15, 6/2/15, 10/7/15, and 12/19/15 all revealed the resident was at high risk for falls. Review of fall risk investigations documented the following: Staff found the resident on the floor in his/her room on 4/11/15, 6/17/15, and 7/23/15. Staff found the resident on the floor outside his/her room on 8/29/15. Staff found the resident on the floor in the living room area on 6/1/15 and 10/13/2015. On 6/1/15 the facility educated staff to supervise the resident, especially in the living room. On 6/17/15 staff documented the resident had multiple falls from bed. Review of a nursing progress note dated 1/4/2016 at 5:31 A.M. documented a nurse entered the resident's room at 4:20 A.M. and found the resident lying on the floor beside his/her bed. The resident laid on his/her left side with his/her face down. The resident's pajama pants were soiled and he/she wore socks. Staff asked the resident what happened and the resident said he/she heard dogs barking and woke up. Staff observed swelling and a hematoma to the resident's right eye, abrasion to the corner of the right eye and left cheek, a laceration above the right eye, which measured 1.5 cm (centimeters) x 1.5 cm, and a bite to the top of the right lip. Staff provided first aide, administered Tylenol for complaints of face and neck pain, and notified the physician. Staff received orders for an X-ray of the cervical spine and face. Staff informed the resident's family member of the fall in the A.M. Review of a physician progress notes [REDACTED]. Staff obtained a CT (computerize tomography) scan of the head, which revealed a subdural hematoma and a cervical 2 fracture (broken bone in the neck). Review of a fall investigation dated 1/4/2016 documented the resident's call light was activated by movement towards the edge of his/her bed. Staff responded to the resident and he/she was awake. At the same time, a neighboring room call light activated and staff informed the resident they would return in a few moments. Ten minutes later, staff returned and found the resident on the floor with his/her head near the foot of the bed. The Occurrence Summary Report for Caretracker dated 1/4/16 revealed the nurse found the resident on the floor at 4:20 A.M. The resident had soiled clothing. The Occurrence Statement Sheet dated 1/4/16 revealed staff last saw the resident asleep at 3:30 AM. The statement sheet further revealed staff last toiled the resident at 1:00 A.M. (3 hours and 20 minutes before the fall. This was 1 hour and 20 minutes longer than the time frame the care plan directed staff to toilet the resident). The resident discharged from the facility on 1/4/2016 and was not interviewed or observed. During an interview on 2/23/2016 at 11:45 A.M. direct care staff O said the resident was frequently restless, confused, and staff placed the resident in a recliner at the nurse's station to keep an eye on him/her. During an interview on 2/23/16 at 5:20 P.M. direct care staff S said the resident required total staff assistance with cares and staff checked on him/her a lot because the resident was restless. During an interview on 2/23/16 at 11:50 A.M. licensed nursing staff H said the resident required total staff assistance with cares and if restless would be placed in a recliner at the nurse's station to be watched closely. During an interview on 2/23/16 at 5:25 P.M. licensed nursing staff J said the resident was confused, required total staff assistance with cares, and staff watched him/her closely. Staff J said sometimes staff brought the resident to the recliner when he/she did not sleep and staff watched him/her closely. During an interview on 3/2/2016 at 1:48 P.M. administrative nursing staff D said he/she completed an investigation for a fall the resident had on 1/4/16. Staff D said the resident had a flat call light placed at the edge of the bed, hip level, to alert staff when the resident moved towards the edge of the bed. Staff D said this resident and another resident were high risk for falls and both needed help at the same time. Staff D said the nurse had to prioritize and asked this resident if he/she could wait so staff could care for another resident. Staff D was not aware if the nurse asked the resident what he/she needed before he/she left the room. Staff D stated looking back now, it was not safe to leave the resident unattended. Review of the facility's Fall policy dated 1/2016 documented residents identified at risk for falls had implemented interventions to reduce fall risk. The facility failed to adequately supervise and provide services to meet the needs of this cognitively impaired resident, including toileting as planned, who required staff assistance, fell , sustained a subdural hematoma and a neck fracture.

The facility reported a census of 54 and 5 residents were sampled. Based on observation, interview, and record review the facility failed to develop and implement timely interventions to prevent and promote healing of one unstageable pressure ulcer (full thickness tissue loss in with the base of the ulcer covered by slough (dead tissue) and one suspected deep tissue pressure ulcer (underlying deep tissue damage caused by pressure) for 1 of 3 resident's sampled for pressure ulcers. (#4) Both pressure ulcers increased in size. Findings included: - Review of a physician order [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; he/she did not walk; was dependent on one staff with bathing; required supervision of one staff with locomotion on and off the unit; and supervision with set up assistance for eating. He/she did not reject cares and used a wheelchair for mobility. The resident was at risk for the development of pressure ulcers and had no pressure ulcers. Staff provided the resident a pressure reducing device for his/her bed and chair. The resident was not on a turning/repositioning program. Review of the Cognitive Loss CAA (Care Area Assessment) dated 2/9/2016 documented the resident had sequencing problems, was sometimes confused, and needed cueing. Review of the ADL (Activities of Daily Living) CAA dated 2/9/2016 documented the resident had a history of [REDACTED]. Review of the Pressure Ulcer CAA dated 2/9/2016 documented the resident was at risk for skin breakdown due to impaired bed mobility and left and right sided weakness. His/her skin was intact. Review of a Braden Skin Risk assessment documented the resident scored a 15, which indicated a low risk for pressure ulcers. Review of the care plan dated 2/10/16 documented the resident had cognitive loss, required assistance with ADLs, and was at risk for the development of pressure ulcers. The care plan directed staff to provide extensive assistance of 1-2 staff with ADLs to include repositioning every two hours and as needed, and to use a wheelchair cushion. The medical record lacked an admission care plan. (There was no plan in place to direct care for the resident from admission on 1/29/16 until the development of the comprehensive care plan on 2/10/16) Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of the MAR (medication administration record) dated 2/2016 documented the resident did not receive CIB at noon on 2/21/2016, indicated by a blank box. Review of a nursing progress note dated 1/29/16 at 9:18 P.M. documented the resident's skin was pink and warm with no breakdown. Review of right heel pressure ulcer reports documented the following: On 2/11/16 staff first observed a right heel pressure ulcer. The wound had no odor or drainage. The wound measured 2.2 cm (centimeters) x (by) 2.5 cm x 0.1 cm and had slough (dead tissue). On 2/19/16 the wound measured 3.2 cm x 1.8 cm, had no odor, necrotic (dead tissue), and was unstageable. On 2/23/16 the wound measured 3.3 cm x 2.6 cm, had scant drainage, and necrotic tissue. Review of left heel pressure reports documented the following: On 2/11/2016 staff first observed a suspected deep tissue injury to the resident's left heel. The wound had no odor, had yellowish drainage, and slough. The wound measured 0.5 cm x 0.4 cm x 0.1 cm. Staff taught the resident to shift his/her weight every 15 minutes when up, provided prafo boots (special boots worn to prevent pressure on the heels) to be worn at all times, and updated the care plan to reflect the new interventions. On 2/19/2016 staff documented the wound as an intact necrotic left heel blister wound with no odor or drainage, which measured 1.4 cm x 0.8 cm. On 2/23/16 the wound measured 4.0 cm x 3.6 cm, had no odor or drainage, and was necrotic. Review of a nursing progress noted dated 2/11/16 at 9:39 P.M. documented staff found a pressure sore to his/her right heel, which measured 2 cm x 3 cm x 0.1 cm and also a left heel pressure sore, which measured 2 cm x 3 cm x 0.1 cm caused from his/her shoes rubbing. During an observation on 2/23/2016 at 11:20 A.M. the resident propelled him/herself back and forth in his/her wheelchair. The resident used the heel of his/her boots to propel and as he/she propelled his/her feet slid in the boots. During an observation on 2/23/2016 at 12:40 P.M. the resident sat in his/her wheelchair at the dining room table and staff served him/her soup, milk, and water. He/she ate 100% of soup, drank 50% of milk, and a few sips of water. Staff did not offer the resident CIB as ordered. During an observation on 2/23/2016 at 4:57 P.M. licensed nursing staff I and direct care staff P assisted the resident from his/her wheelchair to bed using a mechanical sit to stand lift. Staff removed the dressing from the resident's left heel, cleansed with wound cleanser and applied skin prep (a protective barrier). Observation revealed necrotic tissue to the left heel, which measured 4.0 cm x 3.6 cm. Staff I removed the dressing to the right heel, cleansed with wound cleanser, applied [MEDICATION NAME], wrapped with kerlix, and secured with tape. Observation revealed necrotic tissue to the right heel and the wound measured 3.3 cm x 2.6 cm. Staff applied the Prafo boots, assisted the resident back to his/her wheelchair using the mechanical sit to stand lift, and the resident self propelled with his/her feet sliding back and forth. During an observation on 2/23/2016 at 5:30 P.M. staff served the resident carrot cake with cream frosting, soup, ice water, and milk. The resident ate 100% (percent). Staff did not offer CIB during observation as ordered. During an observation on 2/24/16 at 6:59 A.M. the resident laid in bed, eyes open and Prafo boots on both feet. The resident's heels rested on the boot and against the mattress. During an interview on 2/23/16 at 5:14 P.M. the resident said he/she did not know how long he/she had wounds on his/her feet and did not like wearing boots because they slid when he/she propelled in his/her wheelchair. During an interview on 2/23/2016 at 2:31 P.M. direct care staff Q said the resident propelled him/herself in a wheelchair, had pressure ulcers on his/her heels, and wore special boots on his/her feet. During an interview on 2/24/16 at 7:15 A.M. direct care staff R confirmed staff did not provide the resident CIB with lunch yesterday. During an interview on 2/24/2016 at 6:59 P.M. direct care staff R said the resident wore extra-large boots on both feet and was told the facility ordered him/her a different pair. During an interview on 2/23/2016 at 3:51 P.M. licensed nursing staff I said the resident needed assistance with ADLs and had wounds to both heels, which were not caused from pressure. Staff I said staff changed the resident's dressings to the wounds on the evening shift so he/she was not sure of the wounds. During an interview on 2/24/16 at 7:24 A.M. licensed nursing staff I said he/she did not give the resident CIB yesterday at lunch because staff tried to fill him/her up with foods and not drinks. Staff I said he/she documented on the MAR the resident received CIB at lunch on 2/23/2016 and should not have. During an interview on 2/24/16 at 9:15 A.M. therapy consultant Y said nursing asked him/her to assess the resident for Prafo boots because the boots he/she wore did not fit properly and the resident dragged his/her toes when he/she propelled in a wheelchair. Staff Y said he/she ordered different Prafo boots for the resident less than a week ago, which he/she currently wore. Staff Y said the resident already had heel wounds when staff ordered the extra-large Prafo boots, and the boots did not come with traction. Staff Y stated he/she ordered traction, which he/she expected to arrive in 2-3 days. Staff Y said traction helped keep the feet from sliding when propelling. On 2/24/2016 at 10:38 A.M. staff Y said he/she assessed the resident's Prafo boots and noted the bladder of the boot (portion of the boot that provided offloading) was 2 inches high on the left boot and a little less than 2 inches high on the right boot. Staff Y said he/she positioned the bladder correctly and was unaware who was responsible for ensuring correct position of the bladder for offloading pressure to the heels. During an interview on 2/24/2016 at 10:59 A.M. administrative nursing staff D said the resident had no pressure ulcers when he/she admitted to the facility and confirmed the resident developed one unstageable pressure ulcer and one suspected deep tissue injury to his/her heels. Staff D said the resident wore Prafo boots once staff observed the wounds and the Prafo boots were replaced within the past week due by therapy. Staff D said he/she expected therapy to educate the nursing staff on the correct positioning of the boot and he/she was not aware the boots needed repositioned. Staff D said the facility believed the resident developed the pressure ulcers due to his/her increased wheelchair mobility and the facility should have been more aware. Staff D said he/she was aware staff in (AL) Assisted Living elevated the resident's heels on pillows prior to his/her admission to long term care and was not aware the facility staff were not elevating the resident's heels since admission. Staff D said he/she expected staff to provide CIB as ordered by the physician. Staff D confirmed the medical record lacked an admission care plan and said he/she expected staff to initiate an initial care plan and include interventions to prevent pressure ulcers. During an interview on 2/24/2016 at 2:13 P.M. practitioner consultant V said the resident had no pressure ulcers when he/she admitted to the facility and currently had one suspected deep tissue injury and one unstageable pressure ulcer. Staff V said the wounds developed due to the resident's increased propelling in his/her wheelchair. Staff V said he/she knew the and resident's previous residence in AL used an offloading pillow and facility staff should offload the resident's heels at all times. Staff V said he/she expected staff to provide CIB as ordered by the physician. Review of the facility's Skin Integrity policy dated 7/2013 documented the facility implemented preventative measures to maintain intact skin. The facility failed to prevent the development of one unstageable pressure ulcer and one suspected deep tissue injury pressure ulcer for this cognitively impaired resident who was identified at risk for the development of pressure ulcers, required extensive assistance with mobility, and had intact skin on admission. The facility also failed to develop and implement interventions to promote healing and prevent worsening of the pressure ulcers once they developed. Both wounds increased in size.

The facility identified a census of 51 residents. The sample included 3 residents. Based on observation, interview and record review, the facility failed to provide and apply effective safety interventions and adequate supervision for 3 of 3 residents sampled with a history of falls. (#1, #2, #3) Findings included: - Resident #1 admitted from the hospital following a fall with serious injuries in the facility's assisted living unit. Review of resident #1's Physician order [REDACTED]. The significant change Minimum Data Set (MDS) 3.0 with an ARD date of [DATE] recorded the resident's BIMS score was 4, which indicated severe cognitive impairment. The MDS further recorded the resident required extensive assistance for bed mobility, transfer, locomotion on the unit, dressing, toilet use and personal hygiene, supervision for eating, and did not walk in his/her room or in the corridor. The falls Care Area Assessment (CAA) dated [DATE] recorded the resident was at risk for falls related to multiple falls with a right subdural hematoma (subarachnoid hemorrhage), was very confused and disoriented with impaired balance and used a wheelchair and staff assistance for stability. The falls care plan dated [DATE] directed staff to ensure the resident's bed was at the best height for transfers to help maintain balance, complete a fall risk screen quarterly and as needed, ensure the call light was within reach and remind the resident to use it to call for assistance, encourage activity participation for cognitive stimulation, use non-skid socks or shoes, make sure the resident wore his/her glasses, ensure the environment was hazard and clutter free and had adequate lighting, monitor vital signs, and the physician would review medications for any that increased the resident's fall risk. The care plan also included interventions with dates: [DATE], make sure wheelchair brakes were locked when the resident was on the toilet, [DATE] education of staff on toileting schedule, [DATE] do not leave the resident in the bathroom by himself/herself, [DATE] keep the door open at night, [DATE] bedside commode with bed level suitable for transfers, [DATE] re-educate resident to wheel forward and change call light to flat call light pad, [DATE] re-educate staff to not leave the resident unattended while sitting on the toilet, and [DATE] attach the call light to the resident while sleeping. The Fall Screening dated [DATE] recorded the resident's risk score was 14, (a score equal to or greater than 10 indicated a risk for falls.) Review of the resident's falls revealed the resident had 10 falls from [DATE] through [DATE]. The fall dated [DATE] at 2:30 P.M. recorded the resident fell in the bathroom when he/she attempted to self-transfer from the toilet to the wheelchair. The new intervention to prevent further falls was staff to lock the wheelchair brakes when the resident was on the toilet. The fall dated [DATE] at 4:15 A.M. recorded the resident fell going in to the bathroom and complained of right thigh pain after the fall. The new fall intervention was education of the staff on the resident's toileting schedule. The fall dated [DATE] at 12:15 A.M. recorded the resident fell in the bathroom and complained of pain in his/her buttocks. The new fall intervention was staff to stay with the resident while in the bathroom at night, and staff educated to monitor the resident closely every 30 minutes. The fall dated [DATE] at 3:00 A.M. recorded the resident fell outside the bathroom and complained of lower back pain and stated that he/she hit his/her head on the wall. Staff noted a bump at the back of the resident's head. The new intervention was to keep the bedroom door open to be able to monitor the resident at night. Staff sent the resident to the hospital emergency room (ER). The Resident Transfer Form from the facility to the hospital's ER dated [DATE] recorded, "Fall with head injury, (resident complains of) low back pain, has knob to base skull." The fall dated [DATE] at 2:05 A.M. recorded the resident fell when he/she self-transferred from the bed to the wheelchair, and the resident was unsure if he/she hit his/her head. Staff noted 2 abrasions to the resident's back and 1 abrasion to the resident's right knee. The new interventions were to place a bedside commode next to the bed at night and the bed at suitable level (for transfer), and staff to monitor the resident every 30 minutes. (This intervention had already been in place since [DATE].) The fall dated [DATE] at 12:00 P.M. recorded the resident fell when he/she attempted to go through his/her doorway backwards in the wheelchair. The new intervention was to change the call light to a flat call pad. The fall dated [DATE] at 10:15 A.M. recorded the resident fell when he/she left the bathroom, and did not know if he/she hit his/her head. The new intervention was staff education to not leave the resident unattended while sitting on toilet. (This intervention was already in place since [DATE].) The fall dated [DATE] at 3:45 P.M. recorded the resident fell when he/she walked to the bathroom, and staff noted redness to the resident's right upper and lower arm. The new intervention was staff to make sure the flat call light was in reach of the resident. (This is an expected standard of care for all residents.) The fall dated [DATE] at 2:30 A.M. recorded the resident fell when he/she tried to get to the bathroom. Staff noted the resident complained of pain on his/her forehead, and staff noted a lump 4 centimeters (cm.) wide by 2.5 cm. long on the resident's forehead and applied ice, and noted the resident had reddened areas on the right shoulder and shoulder blade. The new intervention was staff to ensure the call light was attached to the resident while sleeping. Review of the nurses note date [DATE] at 2:05 P.M. revealed the resident continued to have bruising to left eye brow area and the bruising moved down past his/her left eye, and the resident stated he/she did not remember the fall. The fall report dated [DATE] at 4:00 A.M. recorded the resident complained of severe pain in his/her left hip and left wrist, and the resident was able to move his/her upper extremities but had difficulty moving the left leg. The resident further stated that he/she fell but did not know when or how. Staff obtained an order for [REDACTED]. The x-ray report dated [DATE] found the resident had 2 fractured areas on the left hip. The hospital note dated [DATE] at 8:22 P.M. recorded the x-ray of the resident's wrist found 2 fractures on the left wrist. The hospital operative report dated [DATE] at 9:41 A.M. documented the resident had 2 surgeries, on his/her left hip and left wrist. The resident did not return to the facility. During an interview on [DATE] at 7:43 A.M., licensed staff C stated he/she remembered the resident was a fall risk, and staff checked the resident every hour. Other interventions included staff stayed with the resident in the bathroom when the resident was on the toilet and the resident had a fall mat next to his/her bed. Licensed staff C stated the resident was confused, and was only able to use the call light at times, but not regularly. During an interview on [DATE] at 2:11 P.M., administrative nursing staff A stated he/she expected licensed staff to implement an immediate intervention after a resident fell and then add the intervention to the resident's care plan and expected staff to read the resident's care plan interventions. Administrative nursing staff A and also stated the facility administrative and licensed staff monitored resident falls and interventions every week during a meeting, and acknowledged the fall interventions for the resident were not effective. During an interview on [DATE] at 8:49 A.M., the resident's family member stated the resident admitted to the hospital on [DATE], and hospital staff gave the resident antibiotics for a urinary tract infection and then performed surgery on the resident's left hip and left wrist on [DATE]. The resident developed pneumonia after surgery and admitted to a hospice facility on [DATE], and died 23 hours later on [DATE]. The facility provided the policy entitled Falls, dated [DATE] which directed residents would be identified for risk of falls and interventions implemented to reduce risk. Resident's high-risk status would be documented on the temporary and/or overall plan of care reflecting appropriate interventions to minimize falls. Nursing staff would implement a system to alert staff to resident's high-risk status. The facility failed to develop and implement effective interventions and failed to provide adequate supervision for this cognitively impaired, dependent resident with a history of falls. - Resident #2's Physician order [REDACTED]. The admission Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 9, which indicated the resident had moderate cognitive impairment and he/she required extensive staff assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene and required supervision for eating. The MDS recorded the resident had 2 or more falls since the prior assessment. The admission care plan dated [DATE] directed staff, the resident had a history of [REDACTED].M.), [DATE] keep walker and wheelchair out of reach and sight in his/her bedroom (non-injury fall at 8:00 P.M.) and [DATE] keep recliner control out of resident's reach (non-injury fall in his/her room witnessed). The falls care plan dated [DATE] directed staff to perform a fall risk screen quarterly and as needed, ensure the call light was within reach and remind the resident to use it, encourage activity participation for cognitive stimulation, ensure the resident wore his/her glasses, encourage and/or assist to toilet and/or for toileting needs (check and change) if the resident was restless and before and after meals and activities and as needed, ensure the environment was hazard and clutter free and had adequate lighting, the physician would review medications for any that increased fall risk, increase assistance during times of illness/fatigue (such as flu), the resident had gait problem ataxia, ambulate with the walker only with staff assistance, the walker could not be in the resident's room, exercise 2 times per day as needed, use a winged mattress on the bed, re-educate the resident to use the call light and ask for assistance with transfers, keep walker and wheelchair out of reach and sight in his/her bed room and additional interventions dated [DATE], keep recliner control out of resident's reach and [DATE] get resident a floor mat to put next to bed. Review of the falls screening scores revealed a score of 10 or more indicated the resident was at risk for falls. The fall screening dated [DATE] recorded a score of 17. The fall screening dated [DATE] recorded a score of 18 and the fall screening dated [DATE] recorded a score of 20. Review of the resident's record and fall reports revealed he/she lived in the facility's assisted living residence from [DATE] through [DATE], and had 31 falls during that time. Review of the physician's orders [REDACTED]." Review of the resident's fall reports revealed the resident had 4 falls from [DATE] through [DATE]. The fall report dated [DATE] at 11:55 A.M. recorded staff found the resident on the floor in front of the (electric lift) recliner. The new intervention to prevent further falls was staff re-educated the resident to use his/her call light and ask for help to transfer into the recliner or the wheelchair. (This intervention was already recorded on the resident's admission care plan dated [DATE].) The fall report dated [DATE] at 4:00 P.M. recorded staff found the resident on the floor in front of his/her electric lift recliner chair and the resident stated he/she was trying to reach his/her walker. The new fall intervention was staff to keep the resident's walker out of his/her room when resident was in his/her recliner. (The physician previously ordered this intervention on [DATE].) Review of the Physician's Progress Notes dated [DATE] recorded the resident had 2 falls over the weekend, and during the physician's interview with licensed and direct care staff learned the resident's "falls had to do with the fact that (his/her) walker was inside in (his/her) room and I had written an order on [DATE] that the walker cannot be in (his/her) room. (He/She) did see it and try to get up to it. The second fall was reportedly with (his/her) attempt to get up out of (his/her) recliner." The fall report dated [DATE] recorded the resident moved his/her electric lift recliner chair into the upward position and the resident slid from the chair. The new fall intervention was staff keep the resident's lift chair recliner controller out of the resident's reach. The fall report dated [DATE] at 3:45 A.M. recorded the resident fell on the floor next to his/her bed. The new intervention to prevent further falls was staff to place a mat next to his/her bed. The (electric) lift chair safety assessment dated [DATE] recorded, "The (direct care staff) use the chair for transfers but the control needs to be out of (the resident's) reach because (he/she) is not safe to use (the) control on (his/her) own." Observation of the resident [DATE] at 3:13 P.M. revealed the resident sat in his/her wheelchair in his/her room. The resident's glasses slid far down his/her nose, his/her left hand tightly grasped the left wheelchair brake lever, his/her right hand had a continuous tremor, and the resident's tongue thrust between words when he/she spoke. The electric lift recliner chair controller lay on the magazine rack next to the recliner in plain sight, and was not out of reach. Observation of the resident on [DATE] at 3:51 P.M. revealed the resident self-propelled his/her wheelchair into the hall. Observation on [DATE] at 4:34 P.M. revealed the resident in his/her wheelchair in the living room common area of the unit and bent over in the wheelchair with his/her feet on the floor and reached down and tried to place the television remote control on the wheelchair foot rest. At 4:37 P.M., staff in the area asked the resident to sit back in the wheelchair and the resident grabbed the staff's hands. At 4:49 P.M., the resident sat in his/her wheelchair, the left foot on the right footrest, and the right foot on the floor, and the resident self-propelled the wheelchair with his/her right hand. The resident continued to hold the remote control in his/her left hand. At 4:52 P.M., the resident had both feet on the floor to the right side of the footrests, and was sharply turned in the wheelchair and almost sat sideways in the chair. When staff attempted to place the resident's feet back on the footrests the resident refused and attempted to hit the staff with the remote control. Observation of the resident's room on [DATE] at 5:05 P.M. revealed the electric lift recliner chair controller lay on the magazine rack next to the chair and was not out of reach. Observation of the resident's room on [DATE] at 11:20 A.M. revealed the electric lift recliner chair controller lay on the magazine rack next to the chair and was not out of reach. Observation of the resident's room on [DATE] at 8:47 A.M. revealed the electric lift recliner chair controller lay on the magazine rack next to the chair and was not out of reach. Observation of the resident on [DATE] at 7:01 A.M. revealed the resident slept in bed, with the bed in a low position, and no fall mat in place on the floor next to the bed. A Broda chair (high back wheelchair) was directly next to the bed, placed in the middle of the length of the bed. The electric lift recliner chair controller lay on the magazine rack next to the chair and was not out of reach. During an interview [DATE] at 3:17 P.M. the resident stated he/she had Parkinson's disease, had many falls and he/she did not walk much anymore but thought he/she could walk. During an interview on [DATE] at 4:21 P.M., direct care staff E stated the resident was not too much at risk for falls and had a low bed and the resident used the call light. During an interview on [DATE] at 5:15 P.M. licensed staff F stated the resident was a fall risk and staff kept the resident s bed in the low position. Licensed staff F stated the resident fell 1 time from his/her recliner and thought staff should put something in the leather recliner to make it less slippery. During an interview on [DATE] at 4:38 P.M., the resident's family member stated the resident fell often and he/she used to walk but currently was too weak to walk, but the resident did not remember he/she was too weak to walk. During an interview on [DATE] at 9:46 A.M., licensed staff D stated the resident was a fall risk and staff tried to keep the resident in the common area so they could observe him/her unless the resident was in bed. Licensed staff D stated the resident had many falls on the assisted living unit and used the electric lift recliner chair control to stand up and fell , and did not fall out of bed. During an interview on [DATE] at 2:30 P.M., administrative nursing staff A stated he/she expected staff to place the resident's fall mat next to the bed when the resident was sleeping, and the Broda chair should not be placed as an intervention to keep the resident from falling out of bed. Administrative nursing staff A further stated the resident's electric lift recliner chair controller should be out of the resident's reach and sight. The facility provided the policy entitled Falls, dated [DATE] which directed residents would be identified for risk of falls and interventions implemented to reduce risk. Resident's high-risk status would be documented on the temporary and/or overall plan of care reflecting appropriate interventions to minimize falls. Nursing staff would implement a system to alert staff to resident's high-risk status. The facility failed to implement interventions as planned for this cognitively impaired, dependent resident with a history of falls. - Resident #3's Physician order [REDACTED]. The annual Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of [DATE] recorded the resident's Brief Interview for mental Status (BIMS) score was 14, which indicated intact cognition, the resident required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene, required limited assistance for locomotion on the unit, required supervision for locomotion off the unit and eating and had 1 fall since admission or prior assessment, with no injury. The falls Care Area Assessment (CAA) dated [DATE] recorded the resident had progressive multisystem post-polio neurodegenerative disorder, required extensive assistance of 2 staff with a Sara lift (standing lift) for transfers to electric wheelchair and to the toilet, wore braces bilaterally on the lower extremities and leaned to the left side, and had depression medication with potential side effects as cause for falls. The fall care plan dated [DATE] and updated [DATE] directed staff perform a fall risk screen quarterly and as needed, ensure call light is within reach and remind the resident to use it to call for assistance, ensure the bed rails were up as needed to facilitate his/her bed mobility, encourage activity participation for cognitive stimulation, encourage and assist the resident to wear non-skid socks or shoes, remind the resident to lock the wheelchair brakes, ensure the resident had his/her glasses, required total assistance of 2 staff for transfers, encourage and/or assist to toilet and/or for toileting needs (check and change) if the resident was restless and before and after meals/activities and as needed, ensure bed is in the lowest position, ensure environment is hazard and clutter free with adequate lighting, the physician will review medications for any that can increase fall risk, monitor vital signs, offer and encourage snacks and fluids, increase the assistance during times of illness/fatigue (such as flu), if the resident seemed sleepy encourage him/her to nap in bed, educate family and visitors on the assistance the resident needed if leaving the building or if they are going to be assisting the resident with Activities of Daily Living (ADLs), the resident's mattress had lips around the edge, remind the resident and his/her spouse to call for assistance instead of trying to do it themselves, remind the resident that spouse was not to assist with transfers, the resident agreed to use the call light when he/she needed assistance with transfers and not to ask his/her spouse, and the additional interventions, [DATE] make sure the electric wheelchair was charging up when not in use, remind the resident to ask for help by using the call light, and the evaluation note dated [DATE] recorded, the resident had a non-injury fall in the last 30 days, will continue to monitor , he/she repeatedly ask his/her spouse to assist him/her or does by himself/herself. Review of the falls screening scores revealed a score of 10 or more indicated the resident was at risk for falls. The fall screening dated [DATE] recorded a score of 11. Review of the resident's falls reports revealed the resident had 3 falls from [DATE] through [DATE] which occurred when the resident's spouse transferred the resident. Staff moved the resident's spouse to another unit in January, 2012. Review of the resident's falls reports revealed the resident had 3 falls from [DATE] through [DATE]. The fall report dated [DATE] at 6:00 P.M. recorded staff found the resident on the bathroom floor beside the wheelchair. The new intervention to prevent further falls was educating staff to monitor the resident every 10 minutes while on the toilet. The fall report dated [DATE] at 10:10 A.M. recorded staff found the resident on the bathroom floor, and the resident stated he/she hit his/her head. Staff noted an abrasion on the left side of the resident's head and on the resident's left arm just above the elbow area. The new intervention was staff reminded the resident to ask for help and not do things on his/her own. (This intervention was already in place on the [DATE] care plan.) The fall report dated [DATE] at 5:45 A.M. recorded staff found the resident on the floor next to the bed. The new intervention was to provide a lower bed. Observation on [DATE] at 9:29 A.M. revealed the resident in bed asleep and did not have a perimeter mattress on the bed. Observation on [DATE] at 11:59 A.M. revealed direct care staff F assisted the resident with personal hygiene care while the resident sat on the toilet. At 12:04 P.M. direct care staff F assisted the resident to stand and used the standing lift to transfer the resident from the toilet to the wheelchair, and did not call other staff to assist during the transfer. Observation on [DATE] at 9:14 A.M., revealed direct care staff F and direct care staff G assisted the resident to transfer from the wheelchair to the toilet. The transfer was completed at 9:18 A.M. and both direct care staff left the resident on the toilet with the standing lift directly in front of him/her on the toilet, and reminded the resident to use the call light for assistance when he/she finished on the toilet, and closed the resident's room door. At 9:24 A.M., observation revealed the resident leaned over to the sink to get a glass of water while sitting on the toilet. Observation at 9:31 A.M., 9:40 A.M., 9:43 A.M., 9:50 A.M., and 9:56 A.M. revealed no staff went into the resident's room from 9:18 A.M. until 9:56 A.M. Staff did not check the resident every 10 minutes as planned. During an interview on [DATE] at 12:26 P.M., licensed staff H stated the resident was a fall risk, and the fall interventions included the resident was supposed to ask for help, Sara lift (standing lift) because when the resident tried to transfer himself/herself he/she usually fell , when the resident was in bed, used the mobility bar to sit up, keep the bed at a lower position and level with hips and the wheelchair next to his/her bed and place the flat pad call light on the resident's abdomen when in bed. During an interview on [DATE] at 5:09 P.M., licensed staff F stated the resident was a fall risk and staff did not leave the resident on the toilet unattended, his/her bed was in the lowest position and staff kept an eye on the resident. During an interview on [DATE] at 5:17 P.M., direct care staff E stated the resident was a fall risk, and staff had to watch him/her constantly, had to be with the resident in the bathroom and could not leave him/her with the lift in front of him/her because the resident could still fall off the toilet, the resident had a fall from the bed and staff put the bed in the lowest position. During an interview on [DATE] at 9:24 A.M., the resident stated he/she thought he/she could stand by himself/herself without falling. During an interview on [DATE] at 9:34 A.M., licensed staff D stated the resident was a fall risk and he/she was physically capable to transfer but not safely, staff transferred the resident and frequently reminded the resident to use the call light but the resident refused, and staff toileted the resident right after meals. Licensed staff D stated the resident was safe alone on the toilet, as long as the standing lift was in front on him/her and staff licked the lift brakes. During an interview on [DATE] at 2:42 P.M., administrative nursing staff A acknowledged staff did not follow the fall care plan interventions, and stated it was policy to require 2 staff to assist during a resident transfer with any lift, and the resident required a 2 person lift transfer assist because of the resident's history of falls, and most of the resident's falls occurred in the bathroom or from the toilet. Nursing staff A stated the resident had a couple of beds and staff possibly removed the perimeter mattress. The facility provided the policy entitled Falls, dated [DATE] which directed residents would be identified for risk of falls and interventions implemented to reduce risk. Resident's high-risk status would be documented on the temporary and/or overall plan of care reflecting appropriate interventions to minimize falls. Nursing staff would implement a system to alert staff to resident's high-risk status. The facility failed to provide supervision and implement fall interventions for this dependent resident with a history of falls as planned.