Every finding on record at Lakeview Village

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. Finding included:- During the initial tour of the main kitchen on 04/20/26 at 08:00 AM, observation revealed the kitchen did not have foot activated trash cans by the hand-washing station, and four of the trash cans did not have lids. The kitchen refrigerator had two bags of diced onions without a date, and one bag was open to air. In the freezer, one bag of hash browns was left open, and in the dry storage one can of prunes had a dent.On 04/20/26 at 08:20 AM, observation of the rehabilitation on the second floor's refrigerator revealed one box of hamburger patties left open to air, food particles in the cabinet drawers and dust or dirt in the grooves of the cabinet's doors.On 04/20/26 at 08:30 AM, observation of the third rehabilitation kitchen revealed one bag of biscuits in the freezer, which had a brown substance in the bottom of the freezer, also observed dried food particles in the crevices of the cabinet and dust. On 04/20/26 at 08:35 AM, observation of the second-floor satellite kitchen on long term care unit revealed a white food substance behind the soda machine which also had soda syrup on the sides of the machine.04/20/26 at 08:35 AM Dietary Director BB stated his staff needed to step up their game.The facility's policy Maintaining a Sanitary and Safe Food Preparation Area revised 06/25/24. The purpose of this policy is to ensure that the facility will maintain a clean, sanitary and safe food preparation area. All machines and equipment that require cleaning shall be cleaned after use. The regular cleaning of all floors, walls, ceilings, and storerooms will be completed according to a specific and routine cleaning schedule.The facility's policy Food Storage revised 6/25/24. Food storage areas will be maintained in a clean, safe, and sanitary manner. Food services staff will always maintain clean food storage areas. Storage of prepared food stored in the refrigerator until services shall be dated and labeled. Such food will be tightly sealed with plastic wrap, foil or a lid.

Based on observation, record review, and interviews, the facility failed to provide activity of daily living (ADL) assistance for Resident (R) 3 when staff failed to ensure she received fingernail hygiene care. Findings included:- R3's Electronic Health Record (EHR) documented the following diagnoses: 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) with hemiparesis/hemiplegia (weakness and paralysis on one side of the body).R3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R3 required assistance with all ADLs.R3's Care Plan dated 10/08/25 recorded she had an impaired ability to care for herself and directed staff she needed help performing ADLsOn 04/20/26 at 09:10 AM, observation of R3's right hand revealed a black substance under two of the five fingernails.04/21/26 at 2:00 PM observation of R3's right hand revealed a black substance under two of her five fingernails.04/22/26 at 8:00 AM observation of Certified Nurse Aide (CNA) O prepares R3 for her shower. She receives a shower from hospice on Wednesdays and Fridays.04/22/26 at 10:50 AM observation R3's fingernails on her right hand, the dark substance had been removed, a brown stain remained under two of the five fingernails.On 04/22/26 at 08:20 AM, Interview with Certified Nurse Aide (CNA) N revealed the nail care the staff are to clean her nails every shift. R3 tends to ding in her brief, which causes her to have stuff under her fingernails.On 04/22/26 at 08:26 AM, Interview with Licensed Nurse (LN) F revealed R3's fingernails are to be cleaned every shift. She expects the staff to clean her nails anytime her nails have a dirty substance under them.The facility's policy dated 12/1/28 Nail and Foot Care Nail care can be provided by licensed nurses, caregivers, and volunteers. Nail care may be provided as part of life enhancement.

Based on record review and interview, the facility failed to ensure Resident (R) 143 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed. Findings included:- R143's Electronic Medical Record (EMR) documented R143 admitted the facility on 01/27/26. A Notice of Transfer form in the EMR dated 02/02/26 documented R143 was sent out to the hospital. The Notice of Transfer form, documented the form was provided to R143 and their representative.R143's EMR lacked evidence the bed hold policy was provided to R143 and his representative. Upon request, the facility was unable to provide evidence the bed hold policy was provided to the resident at the time of transfer. On 04/22/26 at 09:19 AM, Administrative Staff A confirmed the bed hold policy was not provided to R142 because the resident was on skilled services. Administrative Staff A stated that the facility did not provide bed holds for their short stay residents per facility policy. The facility's Bed Holds and Return to Facility policy dated 09/06/18 documented the facility will inform residents or a representative before resident is transferred to a hospital, or therapeutic leave of the bed hold policy. In addition, the social worker will mail a notice and contact the resident by phone the resident and the resident representative the next business day.

Based on observation, record review, and interviews, the facility failed to update the plan of care for activity of daily living (ADL) assistance for Resident (R) 3. Findings included:- R3's Electronic Health Record (EHR) documented the following diagnosis: 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) with hemiparesis/hemiplegia (weakness and paralysis on one side of the body).R3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R3 required assistance with all ADLs.R3's Care Plan dated 10/08/25 recorded she had an impaired ability to care for herself and directed staff she needed help performing ADLs. The care plan lacked intervention to provide nail care.On 04/20/26 at 09:10 AM, observation of R3's right hand revealed a black substance under two of the five fingernails.On 04/23/26 at 10:18 AM, interview with Administrative Staff A revealed the facility will update the Kardex because the staff will pick up a new one each day at the start of their shift, and then staff will update the main care plans from there.The facility's policy revised 11/23/17 Resident Directed Care Plans-Comprehensive the car planning process for each resident will include the resident, the neighborhood interdisciplinary team will develop a plan of services to be provided by the neighborhood. The following will not be included in a resident's care plan, daily care needs and standard practices of the neighborhood unless there are specific resident issue that need to be addressed. The care plan will include when residents need assistance with one of the following types of care hygiene/ADL care.

Based on observation, interviews, and record reviews, the facility failed to ensure staff implemented the interventions to promote wound healing for Resident (R) 11 when staff failed to use the foot cradle and Prevalon boots. Findings included:-R11's Electronic Health Record (EHR) documented diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to the body) and peripheral vascular disease (PVD-slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel).R11's 03/18/26 Quarterly Minimum Data Set (MDS) documented R11 had one Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters) and one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below). R11's Care Plan documented R11 was at risk for a pressure ulcer or other related skin issues due to her peripheral artery disease with occlusion. The plan directed staff R11 preferred to use a foot cradle (a supportive medical device used in a bed to keep the sheets and blankets from touching or putting pressure on a patient's limbs) and directed staff to apply Prevalon boot (special pressure-reducing heel protectors) to bilateral lower extremities when in bed.R11's CNA Kardex documented R11 was to have a blanket cradle attached to her bed to tent her blankets and was to wear Prevalon boots when in bed.R11's 04/08/26 arterial doppler (ultrasonography used to evaluate the direction and pattern of blood flow) to both lower extremities documented occlusion (the blockage, closure, or plugging of a hollow organ, vessel, or passage in the body) documented a doppler was performed on both lower extremities and the findings suggested severe PVD.A wound assessment report dated 04/21/26 documented the right lateral (pertaining to the side, away from the middle) wound was an arterial ulcer, Stage 3.A re-evaluation skin evaluation form dated 04/07/26 documented the right outer foot wound as a full thickness wound and listed the wound type as arterial.Observation on 04/21/26 at 07:43 AM, R11 laid in bed. The blanket cradle was not in place at the end of the bed and was observed lying on the floor next to the bed. R11's Prevalon boots were not applied to either foot. The boots lay on the floor next to R11's dresser. Observation on 04/21/26 at 11:31 AM revealed that R11 lay in bed. The blanket cradle was in place though the blankets were sunk down in the middle of the frame and rested directly on R11's right and left foot.Interviewed on 04/21/26 at 08:38 AM, Administrative Nurse F stated R11's Prevalon boots were to be in place on her feet and said the blanket cradle should always be at the end of R11's bed when she was in bed.Interviewed on 04/21/26 at 11:23 AM, Certified Nurse Aide (CNA) P stated R11's blanket cradle and Prevalon boots should be on her when she was in bed.Interviewed on 04/22/26 at 10:19 AM, Administrative Nurse F stated R11's wound was classified as pressure prior to receiving the results of the arterial doppler on 04/08/26. Administrative Nurse F said R11 had an order for the foot cradle and Prevalon boots to be utilized when she is in bed. Administrative Nurse F said she expected the blanket cradle and the Prevalon boots to be in place when R11 was in bed.Interviewed on 04/22/26 at 10:35 AM, Administrative Nurse D stated she expected staff to follow interventions and orders for wounds that were currently in place. Administrative Nurse D said staff should have implemented R11's Prevalon boots and blanket cradle per order.The facility did not provide a policy for non-pressure related skin conditions.

Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards for Resident (R)37 who required supplemental oxygen continuously and had the oxygen concentrator (a medical device that filters surrounding air to deliver concentrated oxygen) set-up in his bathroom with approximately 30 feet of oxygen tubing strung throughout his room, and R146 who required staff assistance when ambulating and ambulated throughout his room without staff present. Findings included:- Review of the Electronic Medical Record (EHR) revealed the following: 1. The EMR for R37 documented diagnoses of acute on chronic Systolic (congestive) heart failure (when a patient with pre-existing systolic heart failure experiences a sudden, severe worsening of symptoms), chronic respiratory failure with hypoxia (a long-term condition where the respiratory system cannot adequately oxygenate the blood), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, lack of coordination, and abnormalities of gait and mobility. R37's admission Minimum Data Set (MDS), dated 04/10/26, documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment documented that he had impairment in both lower extremities and used a wheelchair for mobility. He was independent when eating, required substantial or maximum assistance for toileting hygiene and putting on footwear, required partial to moderate assistance for bathing and lower body dressing, supervision or touching assistance for upper body dressing and personal hygiene, and set-up and clean-up assistance for oral hygiene. The MDS also documented R37 had shortness of breath or trouble breathing with exertion and received oxygen therapy. R37's Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/10/26, documented he needed help with ADL functions and mobility R37's Urinary Incontinence and Indwelling Catheter CAA, dated 04/10/26, documented that he required assistance with toileting transfers, hygiene, and had urinary incontinence. R37's Care Plan dated 04/06/26, documented that he used a wheelchair and staff were to assist with transfers. Other interventions included that personal items were to be kept within his reach and that R37 was to receive oxygen as ordered by the provider. Observed on 04/20/26 at 10:03 AM, R37 wore humidified oxygen. The oxygen concentrator was positioned in the bathroom, and the tubing was laid on the floor and strung to his chair that was approximately 30 feet in another part of his room. The oxygen tubing was strung across the floor, and there were several coils of tubing on the floor next to R37's recliner, where he was sitting. On 04/21/26 at 08:58 AM, Certified Nurse Aide (CNA) M stated that the oxygen concentrator should have been placed as close to the resident as possible and the oxygen tubing should not have been strung across the room. On 04/21/26 at 09:05 AM, R37 stated that his oxygen concentrator had remained in the bathroom, it was never moved. On 04/21/26 at 11:40 AM, Licensed Nurse (LN) G stated that the oxygen concentrator should have been as close to the resident as possible and as short of oxygen tubing as possible used to prevent tripping hazards. On 04/22/26 at 10:45 AM, Administrative Nurse D stated that it was appropriate for oxygen tubing to have been strung throughout the room and that the concentrator could be placed in another room. She said that this was used as a method to help wean the resident off the supplemental oxygen. Administrative Nurse D said that she expected staff to use the shortest length of oxygen tubing possible, no more than approximately nine feet. 2. The EMR for R146 documented diagnoses of need for assistance with personal care and abnormalities of gait and mobility. R146's Admit MDS, dated 04/17/26, documented a BIMS six, which indicated severe cognitive impairment. The MDS documented that he used a walker and wheelchair for mobility and that R146 required partial to moderate staff assistance for toileting hygiene, bathing, lower body dressing and putting on footwear, he required supervision or touching assistance for upper body dressing, set-up and clean-up assistance for oral hygiene and was independent for eating. R146's Falls CAA, dated 04/17/26, documented that he had impaired balance and required assistance and support during transfers and gait, and he had potential for falls and injury. R146's Care Plan documented an intervention, dated 04/15/26, that he required one person for transfers. Another intervention, dated 04/17/26, documented that R146 was walk to dine. R146's EMR had active Physician Orders, dated 04/13/26, for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat. R146's CNA Kardex for Wednesday 04/22/26 All Shifts documented that he was a one person assist with transfers, and one person assist with wheelchair mobility or 4-wheeled walker (4WW). R146's Initial Plan of Treatment for Physical Therapy Rehabilitation, dated 04/14/26, documented that R146 was a fall precaution, had decreased safety awareness, required contact-guard assistance with sitting to standing and required assistance when ambulatory. Observed on 04/20/26 at 11:09 AM, R146 was sitting alone in his room with gait belt around his mid-section, he then stood up and began ambulating with his 4WW that had a bath blanket draped loose over the front of it. Observed on 04/21/26 at 11:20 AM, R146 stood up from his recliner and ambulated with his 4WW from the recliner to the bathroom without staff present. Several staff walked by his room as he ambulated alone. Observed on 04/22/26 at 11:07 AM, R146 ambulated across his room with his 4WW. Staff were present in the hall outside the room. On 04/21/26 at 08:23 AM, CNA M said that she was unsure if R146 required ambulation assistance. On 04/21/26 at 11:40 AM, LN G stated that R146 had a walk to dine intervention on his care-plan and that indicated that he required stand-by assistance. LN G also said that if he walked to the bathroom or anywhere staff were to be present. On 04/21/26 at 12:15 PM, Consultant GG stated that R146 required contact guard assistance with all ambulation and the Kardex had him listed as assist x1 and that he was impulsive. On 04/22/26 at 10:45 AM, Administrative Nurse D stated that resident ambulation instructions should have been communicated between all staff on a unit and that the ambulation restrictions were listed on the CNA Kardex and were to have been communicated from shift to shift and staff to staff. The facility policy Fall Prevention and Management Protocol, dated 06/28/23, documented that staff would ensure the resident was oriented to their bedroom, which would include how to operate the resident call system at the bedside and in the bathroom. The policy also documented that furniture would be arranged to ensure a clear path and direct access to the bathroom. Also documented was that the nurse would add to the resident's Kardex the activities or habits that made the resident high risk for falls, along with known interventions.

Based on observation, interviews, and record review, the facility failed to provide Resident (R)148's physician ordered medications due to lack of availability. Findings included:- R148's Electronic Medical Records (EMR) documented diagnoses, which included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and aftercare following joint replacement surgery. R148's 04/22/26 admission Minimum Data Set (MDS) was not completed. R148's ADL functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/12/26, documented R148 required assistance with care including toileting. R148's admission Care Plan dated 04/18/26, documented staff were to assess R148 for pain and give pain medications as ordered.R148's admission Care Plan dated 04/18/26, directed staff to give medications as ordered and monitor behavior concerns or anxiety.R148's Physician Orders documented an order for clonazepam (an antianxiety medication) one milligram (mg) at bedtime for anxiety, started on 04/18/26.R148's Physician Orders documented an order for Soma (a muscle relaxant that is used to treat pain) 350 mg at bedtime for muscle pain. The order was changed to as needed on 04/20/26. R148's electronic Medication Administration Record (MAR) documented R148 did not get her ordered clonazepam on 04/18/26, 04/19/26, and 04/20/26. R148's MAR documented R148 did not get her ordered Soma on 04/18/26 and 04/19/26. R148's Progress Notes for 04/18/26 through 04/20/26 documented the clonazepam and Soma were not available. The note lacked documentation that the provider was notified of the missed medication or that the pharmacy was called in an attempt to get the medications.R148's Weekly IDT Meeting dated 04/22/26, documented the nursing barriers were chronic pain and anxiety.R148's vital sign tab documented the following pain ratings using a 0-10 scale (rating system where zero equals no pain and 10 equals the worst pain imaginable):04/18/26 at 07:30 PM R148's pain was rated 10. 04/18/26 at 11:56 PM R148's pain was rated 7.04/19/26 at 4:05 PM R148's pain was rated 9. 04/19/26 at 10:20 PM R148's pain was rated 10.On 04/20/26 at 02:03 PM, R148 was anxious and fidgeting in her bed. She reported her pain was not controlled. R148 reported that staff was not correctly giving her pain medication as ordered. She stated, They say they are giving it, but they are not.On 04/21/26 at 03:05 PM, Certified Medication Aide (CMA) R stated if a medication was unavailable, she would check the Cubex (a box that medications are kept) and if it was not in there, she would notify the nurse.On 04/22/26 at 10:57 AM, Administrative Nurse II stated that medications should be in the available in the facility within 24 hours of admission or orders. Administrative Nurse II said the facility received the orders prior to admission and got them in the computer and ordered, so when the residents arrive, the medication would be there or arrive shortly. The facility also had a Cubex where the nurse could get medications if the medication did not arrive. Administrative Nurse II said if the medication did not arrive, the nurse should follow up with the pharmacy to inquire why the medication did not arrive.On 04/22/26 at 11:25 AM, Administrative Nurse D stated she expected the nurses to get the medications for the residents as ordered.The Provider Pharmacy Requirements documented the pharmacy agreed to provide routine and timely pharmacy services as contracted and emergency pharmacy services 24 hours a day. The emergency medications are available within four hours. All other medications ordered will be provided as soon as possible or the next routine delivery unless otherwise directed by the facility staff.The Cubex Station Policies and Procedures effective 12/21/16 documented the nursing staff will use the Cubex for first dose and other situations where medications are not readily available.

Based on observation, interview, and record review, the facility failed to display accurate and identifiable posted nurse staffing information. Findings included:- On 04/21/2026 at 08:55 AM, observation revealed a daily staffing sheet hanging on the wall near the nursing station on the first floor of the facility.Review of the Daily Nursing Staffing Information sheets from 07/04/25, 12/02/26, 03/05/26, and 04/21/26 revealed the sheets lacked the scheduled hours. The resident census was missing from the daily nursing staffing information sheets on 12/02/26 & 03/05/26.On 04/22/26 at 01:30 PM, Administrative Nurse D reported that the floor nurse assigned to each unit would fill out the posted staffing sheet for that unit and would then post it prior to the upcoming shift. She then stated that the posted staffing sheet required the facility name, date, current census and the staffing sheet listed the actual hours worked for the nurses, Certified Nurse Aides (CNA), and Certified Medication Aides (CMA), but was unsure about the total hours being listed.The facility posting daily nurse staffing policy listed their procedure number 01.01.10 with date approved 07/07 and supersedes 05/27/09 for CFR 483.30(e). The policy documented the Director of Nursing Services or designee will ensure that the number of registered nurses, licensed practical nurses and certified nurse aides (caregivers and medication aides) scheduled for each day is posted at the entrance to each household.

The facility identified a census of 128 residents. The sample included three residents, with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observations, record review, and interviews, the facility failed to ensure staff provided adequate supervision to prevent an elopement for Resident (R) 1 and further failed to provide a thorough search in response to a WanderGuard (sensors that monitor doors and a technology platform that sends safety alerts in real-time) alert. On 04/13/25 at 07:15 PM, R1 who was severely cognitively impaired and at high risk for elopement, set off the WanderGuard alert system. Staff responded to the alarm 36 seconds later but did not see R1. Staff started searching for R1 but did not immediately open the staircase door and search the staircase where the WanderGuard alert system sounded. By the time the staff searched the staircase, R1 had exited the building through the staircase and walked around the sidewalk in the back of the facility. The facility located R1 approximately five to six minutes later near the parking lot on the ground. She had visible injuries including an abrasion to her forehead and right ankle swelling. The facility called an ambulance and R1 was transported to the hospital for evaluation and treatment. She returned later that evening with no fractures. The facility's failure to provide adequate supervision and implement a thorough search in response to the WanderGuard alert placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), abnormalities of gait and mobility, dementia (a progressive mental disorder characterized by failing memory and confusion), need for assistance with personal care, and restlessness and agitation. R1's Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being rarely or never understood. R1 had no behaviors and used a wander alarm daily. R1 was independent with bed mobility, transfers, and walking and had no falls since the last assessment. R1's Quarterly MDS dated [DATE], documented R1's BIMS score was 99, which indicated severe cognitive impairment. R1 had rejection of care and wandering behaviors for one to three days in the assessment period. R1 was independent with bed mobility, transfers, and walking and had no falls since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/19/24, documented R1 had short-term and long-term memory deficits and moderately impaired cognitive skills for daily decision-making. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 09/24/24, documented R1 required assistance with ADLs and mobility. R1 ambulated independently and used no devices for locomotion. The Falls CAA dated 09/24/24, documented R1's balance was sometimes slightly impaired, and she had wandering behaviors reported almost daily. R1 had two falls since her last MDS. R1's Care Plan dated 12/22/22, documented R1 had problems with remaining safe in her environment due to dementia and a history of wandering. R1's Care Plan documented R1 had a WanderGuard bracelet (a bracelet that helps monitor residents who are at risk of wandering) on her left ankle and staff redirected R1 when she was exit seeking or took a walk. R1's Care Plan dated 03/26/25, documented R1 had an impaired ability to take care of herself and needed help performing ADLs. The plan directed R1 was independent with transfers and ambulation with no devices. R1's Fall Risk assessment, dated 02/26/25 but created on 03/26/25, documented a high fall risk score of 17. R1's Elopement Risk assessment dated [DATE] but created on 03/26/25, documented R1 was at risk for elopement with a score of 10 and wore a WanderGuard bracelet. The facility's Investigation dated 04/18/25, documented on 04/13/25 at 07:31 PM, Administrative Nurse E notified Administrative Staff A and Administrative Nurse D of an incident that occurred. Administrative Nurse E reported that R1 got out of the doors and staff found her in the parking lot; R1 had apparently fallen after losing her balance on the rocks next to the sidewalk. Administrative Nurse E initially reported R1 got out of the facility doors around 07:15 PM and staff responded to the door where her WanderGuard alert sounded. Staff started searching for R1 and when they were unable to find R1, they reported her missing. Staff notified Administrative Nurse E at 07:19 PM and she notified security at 07:20 PM to drive the campus while staff continued to search inside the facility. At approximately 07:21 PM, a staff member stated they saw R1 in the parking lot on the ground and staff headed to her. At about the same time, security noticed R1 and pulled up next to her. It appeared R1 walked around the backside of the building on the sidewalk towards the Independent Living entrance but lost her balance on the rocks near the sidewalk and fell . Upon nursing assessment, the staff called for an ambulance due to possible injuries to R1's ankle. R1 returned a few hours later with no fractures. R1's EMR revealed the following notes: A Nursing Notes dated 04/13/25 at 11:33 PM, documented around 07:10 PM, R1 eloped through the Heritage door. The WanderGuard alarm went off and staff started looking for her. Staff found R1 sitting on the ground, and it appeared R1 fell in the parking area. R1's ankle was swollen. Staff called an ambulance and kept R1 on the ground until the paramedics arrived. The facility notified R1's representative, provider, and hospice. A Nursing Notes dated 04/14/25 at 12:20 AM documented R1 returned to the facility at 11:45 PM, accompanied by R1's representative. R1's representative stated the hospital completed a computed tomography (CT scan - a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan with no abnormal findings. R1 had a forehead contusion (an injury where blood and tissue damage occur beneath the skin without breaking the skin's surface), multiple bruises, and right ankle swelling. On 04/22/25 at 01:42 PM, R1 laid in bed with her eyes closed. Observation revealed an abrasion on her left forehead. Additionally, there was a high back wheelchair in R1's room. On 04/22/25 at 01:48 PM, Administrative Staff A walked the surveyor down the route that R1 took during her elopement on 04/13/25. Per Administrative Staff A, R1 exited through the Heritage stairwell doors that opened after 15 seconds of pushing on them. Observation revealed the Heritage stairwell double doors opened up into a hard-floor staircase with two flights of stairs descended to get to the first level with outside door access. The outside door opened up to the back of the building where generators and Independent Living parking were. The sidewalk from the door turned right towards an Independent Living entrance and there was a staircase to the right side of the sidewalk as one walked towards the entrance. Once past the Independent Living entrance, the sidewalk continued to the left. There were rocks on the right side of the sidewalk and sometimes on the left side as well. A dog park was located near the area R1 was found on the ground. The area where staff located R1 was all parking for the facility with no public streets per Administrative Staff A. On 04/22/25 at 01:58 PM, review of the camera footage provided from R1's elopement on 04/13/25 revealed at 07:14:05 PM, R1 was seen on camera wearing a long-sleeved shirt, pants, and shoes while she walked down the hallway. At 07:14:35 PM, R1 walked around the corner to the Heritage stairwell door and was out of camera view. Certified Nurse Aide (CNA) M exited the kitchen at 07:15:00 PM in response to a door alarm and she went to the elevator door. CNA M and CNA N realized it was the Heritage stairwell door and walked to that door at 07:15:36 PM. It was not seen whether or not the door was opened for staff to check the stairwell for R1. CNA M and CNA N started walking away from the Heritage stairwell door when the nurse walked down the hall asking where R1 was. On the camera, R1 was seen turning the corner of the stairwell at 07:16:17 PM while staff started searching for her. Staff went down the Heritage stairwell door to check for R1 who had already exited the stairwell and was off camera at 07:19:00 PM. There was no camera footage of the area where R1 was found. On 04/22/25 at 01:22 PM, CNA M stated on 04/13/25, she heard the door alarm go off and she called another aide to help assist her as she did not know how to reset the alarm. She stated CNA N typed in the code, but the alarm did not turn off. CNA M stated they looked out of the first door because it had a window but the second door they responded to did not have a window. She stated the door had an alarm code on it, but she did not know what it meant. CNA M stated she did not open the second door to check the stairwell and that was the door R1 exited from. She stated as soon as staff found out R1 was missing, staff immediately started looking. CNA M stated she saw R1 standing outside when she was upstairs and ran outside to find her but went out the wrong door. She stated she last saw R1 about two minutes prior to the alarm going off. CNA M stated R1 walked up and down the halls all the time but she had not seen R1 trying to go out of any doors. On 04/22/25 at 02:18 PM, Administrative Nurse D stated on 04/13/25, she received a call saying there was a fall and an elopement. She stated she arrived at the facility and started trying to figure out what happened while obtaining witness statements. She stated she believed the staff did everything correctly in response to the alarm but there was some confusion on where staff needed to look. She stated she expected staff to open the door and check the stairwell immediately. Administrative Nurse D stated she expected staff to check the back of the Kardex (nursing tool that gives a brief overview of the care needs of each resident) with the alarm code to see which resident could set the alarm off and if they did not locate that resident, staff were not able to clear the alarm until the resident was found. On 04/22/25 at 02:42 PM, Licensed Nurse (LN) G stated if a WanderGuard alarm went off, the code would show up on the screen with the location of the alarm and staff responded to that location. She stated once at the location, there was a number that staff identified the resident with, and they went through the doors to make sure a resident did not go through those doors. LN G stated once staff found the resident and knew they were safe, they cleared the WanderGuard alarm. She stated if a stairwell door alarm went off and the resident was not immediately seen, the staff were to go through the doors to search for the resident. On 04/22/25 at 04:15 PM, Administrative Staff A stated on 04/13/25, he received a call from Administrative Nurse E about R1 and drove to the facility. Administrative Staff A stated he was not sure what had happened when he arrived, but he started reviewing door codes and cameras. Administrative Staff A stated he expected staff to always check the immediate area and if staff had walked through the door, they could have seen her down the stairs. He stated he expected staff to open the door and search for the resident. The facility's Missing Resident policy, dated 05/18/18, directed the facility staff to act promptly and thoroughly to investigate and determine the whereabouts of any resident who was unable to be located. On 04/22/25 at 04:25 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the failure to provide adequate supervision to prevent an elopement for R1 placed R1 in immediate jeopardy. The facility put the following interventions into place prior to the onsite visit: The facility sent R1 to the hospital for evaluation and treatment on 04/13/25. The facility completed a post-incident review with immediate education with staff working on 04/13/25. The facility sent out an email and an alert to all staff with education on the elopement on 04/14/25. The facility started ongoing elopement education with all staff on 04/14/25. The facility updated R1's Care Plan on 04/15/25. The facility reviewed the WanderGuard list on 04/15/25. Due to the facility having completed all corrective actions by 04/15/25, prior to the onsite survey event, this deficient practice was cited as past noncompliance at the scope and severity of a J.

The facility identified a census of 116 residents. The facility had one main kitchen and two kitchenettes with dining areas. Based on observation, record review, and interview, the facility failed to ensure that staff stored and prepared food items in accordance with the professional standards for food service safety. This deficient practice placed the residents at risk for foodborne illnesses. Findings included: - On [DATE] at 07:17 AM, the initial tour of the kitchen revealed the following: Freezer number 12 had opened bags of frozen carrots, hash browns, sweet potato fries, French toast sticks, chicken wings, breaded okra, and curly fries that were not closed, labeled, or dated. Walk-in freezer number two had unlabeled and undated blueberries. Walk-in refrigerator number one had a rolling cart with a tray of macaroni and cheese and a tray of dried rice with butter that was not covered, labeled, or dated. Cooler number seven for leftover food had three containers of mashed potatoes, two containers of gravy, a tub of chicken base, and a container of chili that were not labeled or dated. Cooler number six had numerous plates of uncovered desserts that were dated [DATE]. Cooler number five had containers of cauliflower, blueberries, and tomatoes that were not dated. Observation on [DATE] at 07:34 AM revealed cooler number eight had six containers of unknown food not labeled or dated, a tray of small cups with lids that were not labeled or dated, and an opened half-gallon of milk that was not dated. Observation on [DATE] at 07:34 AM revealed the clean dish storage area had numerous bowls and ramekins in plastic containers that were not covered or all inverted. Observation on [DATE] at 07:38 AM revealed the walk-in refrigerator number three had a box of mandarin oranges that were leaking and a package of raspberries with mold visible. Observation on [DATE] at 07:41 AM revealed the dry storage had an opened back of pecans not dated or sealed. In the interview on [DATE] at 10:16 AM, Dietary CC stated all opened food items were to be wrapped closed, labeled, and dated before storing. She stated if she saw food that was not dated, then she threw it away unless somebody just started working on an item. Dietary CC stated dishes were stored underneath covers or upside down. In the interview on [DATE] at 10:20 AM, Dietary BB stated dishes were kept covered and pots and pans were kept inverted. He stated if staff took food out of the original packaging, the items were kept wrapped or in a closable plastic bag and then discarded after three days. Dietary BB stated he expected frozen food items to be stored in closable plastic bags. He stated he expected the kitchen supervisor to inspect all food areas daily for outdated items, items not dated or labeled, and expired food. The facility's Food Storage policy, last revised in [DATE], directed food stored in the refrigerator were dated and labeled and tightly sealed with plastic wrap, foil, or a lid. The policy directed all food not in its original container was labeled and was good for seven days past the open date. The facility's Maintaining a Sanitary and Safe Food Preparation Area policy, last revised [DATE], directed areas for cleaning dishes and utensils were located in a separate area from the food service line to ensure a sanitary environment was maintained. The policy did not address the proper storage of dishes to prevent contamination. The facility failed to ensure that staff stored food items in accordance with the professional standards for food service safety and failed to store dishes inverted or covered. This deficient practice placed the residents at risk for foodborne illnesses.

The facility identified a census of 116 residents. The sample included 24 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens, hand hygiene, placement of urinary dependent drainage bag, and the sanitary storage of respiratory equipment. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - During an observation on 06/03/24 at 10:17 AM, Resident (R)413's nasal cannula was laid directly on the floor next to R413's bed, and a pile of soiled linen was laid directly on the right side of his bed. During an observation on 06/03/24 at 11:17 AM, R89 sat in his recliner in his room. R89's catheter tubing and catheter drainage bag were touching the floor. During an observation on 06/04/24 at 11:42 AM, R89 sat in his recliner in his room. R89's catheter drainage bag was hung from the pocket of his recliner and the bottom of the catheter bag touched the floor. During an observation on 06/05/24 at 06:48 AM R415 laid on her bed. Licensed Nurse H washed her hands and donned her gloves, she opened the room door to exit the room, to obtain an isolation gown from the bin outside the room. LN H returned to R415's room, closed the door, and donned an isolation gown. LN H failed to doff her gloves and perform hand hygiene. LN H assisted R415 with raising the left-leg pajama pants. LN H obtained the urinary leg bag from the bathroom and laid the bag on the foot of R415's bed. LN H failed to perform hand hygiene and change gloves prior to cleaning the tip of the urinary leg bag. LN H disconnected the dependent drainage bag from R415's catheter and attached the leg bag to R415's catheter. LN H rinsed R415's dependent drainage bag and placed it in a plastic bag in the bathroom. LN H doffed her gloves and donned a new glove. LN H failed to perform hand hygiene between glove changes. During an observation on 06/05/24 at 02:12 PM, Certified Nurse Aide (CNA) O was in R33's room with her while she was on the toilet. CNA O donned (put on) gloves and removed R33's soiled pull-up then placed a clean pull-up on R33. CNA O doffed (removed) gloves but did not perform hand hygiene before donning new gloves. CNA O gave the resident toilet paper to wipe her mouth then adjusted her left hearing aid. CNA P pushed the sit-to-stand lift (mechanical lift used for transfers) into the bathroom and donned gloves. CNA O placed R33's feet onto the sit-to-stand lift's footrest and then doffed gloves. She did not perform hand hygiene before donning new gloves. CNA O pulled several wipes out of the wipe package located on the back of the toilet and held them in her right hand. She adjusted R33's pants to get her ready to stand up and the wipes touched the pants. CNA P lifted R33 up with the sit-to-stand and CNA O used one wipe to wipe R33's peri-area from behind one time. CNA O placed the other wipes on top of the wipe package and then doffed her gloves. She did not perform hand hygiene before donning new gloves. CNA O used one wipe to wipe R33's peri-area from behind, she used the same wipe for four swipes, then grabbed another wipe and used that same wipe for three swipes. CNA O grabbed a tube of barrier cream out of the drawer beside the sink and applied it with the same gloved hand she used to wipe R33 with. CNA O doffed gloves and then donned new gloves without performing hand hygiene. CNA P doffed gloves then pulled R33 out of the bathroom with the sit-to-stand lift and positioned her into her wheelchair with CNA O's assistance. After R33 was disconnected from the lift, CNA O doffed gloves and performed hand hygiene. CNA O gathered up the trash while CNA P put R33's foot pedals on and placed her at her table. CNA P then performed hand hygiene. The facility provided a policy related to Legionella testing but was unable to provide a plan, facility based risk assessment, or procedures and monitoring related to Legionella prevention. During an interview on 06/05/24 at 06:48 AM, Licensed Nurse (LN) H stated that R413's nasal cannula should never be placed on the floor and soiled linen should never be placed on the floor. LN H stated she should have performed hand hygiene between glove changes during R415's urinary leg bag change. During an interview on 06/05/24 at 11:37 AM, Administrative Nurse E, the facility infection preventionist, stated staff should perform hand hygiene between glove changes, going from dirty to clean or if visibly soiled. Administrative Nurse E stated the facility had frequent hand hygiene education when there was an increase in urinary tract infections noted. Administrative Nurse E stated the facility had a yearly skills fair for nursing staff to review the infection control procedures. During an interview on 06/05/24 at 01:47 PM Administrative Staff A stated there was not a facility specific risk assessment for identification for Legionella disease completed. Administrative Staff A stated he had downloaded the requirements from the Centers for Disease Control (CDC) website. During an interview on 06/05/24 at 02:28 PM, CNA O stated staff completed hand hygiene before and after care. She stated if gloves were removed during peri-care then hand hygiene should be completed before putting new gloves on. CNA O stated to prevent contamination during peri-care, staff used a different wipe with every swipe, and the wipes were pulled out one at a time. She stated she did not put wipes on top of the package. During an interview on 06/05/24 at 02:35 PM, Licensed Nurse (LN) J stated staff completed hand hygiene before starting peri-care and donned gloves. She stated after the dirty portion of peri-care was completed, staff removed gloves and washed hands before putting new gloves on to complete the clean portion of peri-care. LN J stated staff prevented contamination during peri-care by using one wipe per swipe, not using the same wipe, or folding the wipe over to continue to use. She stated wipes were pulled out one at a time. During an interview on 06/05/24 at 02:41 PM, Administrative Nurse D stated staff completed hand hygiene when entering resident rooms and got the resident ready before peri-care was started. She stated staff sanitized their hands again and then donned gloves. Administrative Nurse D stated staff wiped front-to-back for females then removed their gloves and sanitized their hands before putting new gloves on. She stated staff used one wipe per swipe and held the wipes in their clean hand or put them on a clean surface to prevent contamination of the wipes. During an interview on 06/05/24 at 03:00 PM, Administrative Nurse D stated staff completed hand hygiene when entering resident rooms and got the resident ready before catheter care was started. She stated staff sanitized their hands again and then donned gloves. Administrative Nurse D stated staff should perform hand hygiene between glove changes. During an interview on 06/05/24 at 02:41 PM, Administrative Nurse D stated staff completed hand hygiene when entering resident rooms and got the resident ready before peri-care was started. She stated staff sanitized their hands again and then donned gloves. Administrative Nurse D stated staff wiped front-to-back for females then removed their gloves and sanitized their hands before putting new gloves on. She stated staff used one wipe per swipe and held the wipes in their clean hand or put them on a clean surface to prevent contamination of the wipes. The facility's Caring for a Resident with a Urinary Catheter policy last revised 04/2011 documented that catheter care would be provided daily and when there was the possibility of fecal incontinence. The facility's Nebulizer & Oxygen Storage and Cleaning policy dated 11/2021 documented the facility would ensure that a resident received nebulizer & oxygen services and care that was consistent with professional standards of practice and meeting the resident's goals and preferences. Oxygen tubing would be stored in a bag when not in use by the resident. The facility's Infection Control Program policy dated 05/2024 documented hand hygiene had frequently been cited as the single most important practice to reduce the transmission of infectious agents in healthcare settings and was an essential element of standard precautions. The term Hand Hygiene includes both hand washing with either plain or antimicrobial soap and water and the use of alcohol-based products (gels, rinses, foams) containing an emollient that does not require water. The facility's Female Perineal Care policy, last revised 08/22/08, directed staff to perform the following for perineal procedure: collected equipment, washed their hands, explained the procedure to the resident, put on gloves, cleaned the anal area first by wiping with wet washcloth or perineal wipes from the vagina towards the anus with one stroke, discarded soiled washcloth or soiled wipe and repeated with clean washcloth or wipe until skin was clear of fecal material, discarded gloves into trash and washed hands, put on clean gloves, used a clean washcloth or perineal wipe to cleanse perineal area and used a clean washcloth or perineal wipe for each wipe until no fecal material was present on skin, then removed gloves and washed hands. The facility failed to ensure proper infection control standards were followed related to the implantation of a procedure or plan to monitor and prevent Legionella disease or other opportunistic waterborne pathogens, hand hygiene during catheter care, and peri care, storage of oxygen equipment, proper placement of soiled linen, and catheter bags resting on the floor. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 116 residents. The sample includes 24 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and had the potential to affect all residents. Findings Included: - An inspection of the facility revealed a suggestion box, located inside a walkway area that required a door code to access. The facility inspection revealed the facility had no labeled grievance boxes in place. On 06/04/24 at 10:19 AM, the Resident Council (RC) members reported they were not aware of how to file a grievance, or if the facility provided a way to file an anonymous grievance. The RC members reported they turned their complaints into Social Services or would have a member of their family contact Social Services to file a complaint on their behalf. The RC members stated they were not aware of any grievance form drop box. On 06/04/24 at 11:17 AM Administrative Staff A stated the facility did not have a grievance box, and that the box in question was a suggestion box. Administrative Staff A stated their policy was that grievances are filed via email, phone calls, or through social services. Administrative Staff A further stated he believed the residents knew how to file grievances as the facility did receive grievances from the residents. On 06/05/24 at 12:42 PM Activity Staff Z stated she had not been in the facility long but was trained to have residents go to social services if the resident had a complaint. She reported that she did not know where the grievance box was or if the facility had one. Activity Staff Z further stated she was unaware if there was a way to file an anonymous grievance and did not know about the suggestion box in an area that required a code to access. Activity Staff Z stated she spoke with a member of the nursing staff, and she reported nursing staff told her they believed the grievance box was on the assisted living side of the facility and residents would have gone there to file a grievance. The facility provided the Supporting the Right of Residents to Voices Grievances policy revised on 08/21/18, which documented a resident or their representative has the right to file grievances anonymously. A concern or complaint may be received in verbal or written form from any resident, responsible party, or family member. Residents and their families may also report a complaint or grievance in writing to any team member in the household or community using the Resident/Family Concern form located accessible to each neighborhood. The facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed all residents at risk for decreased psychosocial well-being.

The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for cognitively impaired Resident (R) 96. This placed R96 at risk for additional falls and or injuries. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses sequelae of cerebrovascular accident (CVA-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), vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (kidneys are damaged and can't filter blood the way they should), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot responded to the insulin), and aphasia (condition with disordered or absent language function). The Quarterly 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 R96 had two or more falls in the review period. The MDS documented R96 was independent with eating. The MDS documented R96 dependent on staff for hygiene and toileting. The Cognitive Loss/Dementia Care Assessment (CAA) dated 07/25/23 documented R96 had a BIMS of three and instances of refusing care during the observation period. R96 had a diagnosis of CBA, cognitive communication deficit, and a recent dramatic change in independence. R96 had moderate to severe impairment in decision which may result in unsafe behavior and potential for injury, or difficulty with performance of activities of daily living (ADLs). The Falls CAA dated 07/25/23 documented R96's balance was impaired. R96 had a CVA, cognitive communication deficit, recent dramatic change in independence, difficulty walking, and the need for assistance with personal care. R96 was at risk of falls due to balance problems and needed assistance for support during transfers and gait. R96 received staff support. Nursing staff were to provide safety cues, monitoring, a hi-low bed, perimeter mattress, gait belt, pendent call light, use of pancake call light at the bedside, and a pull string style call light in the bathroom. R96's Care Plan dated 08/07/23 documented R96 was at risk for falls, due to her diagnosis. The plan of care documented on 08/05/23 staff were to encourage R96 to always wear nonskid footwear. The plan of care dated 08/07/23 documented nursing was to involve R96 in a restorative nursing program as needed, place her bed against the wall, place a perimeter mattress to orient R96 to the edge of the bed, place personal items within R96's reach, and orientate R96 to her surroundings every time staff left the room. The plan of care noted R96 might attempt to self-transfer and staff were to help. R96 used a bed cane for positioning. R96's plan of care dated 12/05/23 documented anti-rollback and anti-tip mechanisms on the wheelchair for safety. The plan of care dated 12/19/23 documented that in R96's culture, it was custom to kneel to pray on the floor next to the bed with hands clutched. R96 does not always explain to nursing staff. The plan of care dated 02/25/24 documented that staff were to provide a double stacked call light with one call light on the wheelchair and one on R96's bed. R96's cupholder should be placed on the wheelchair for the fluid of choice. The Nursing Note dated 01/12/24 documented a witnessed fall without injury. R96 was holding onto the counter and went to the floor slowly. A new intervention for R96's fall documented staff was to ensure the foot pedals were removed when R96 sat in her wheelchair. Staff to use foot pedals if staff are pushing R96. A Nursing Note dated 01/13/24 documented an unwitnessed fall without injury. R96 was found seated on the floor by her bed. New interventions for R96's fall documented staff to continue with the care plan. Staff were to allow R96 space when she was resistant to care and return shortly. The Nursing Note dated 01/22/24 documented an unwitnessed, non-injury fall. R96 was found on the floor seated next to her bed with her knees bent and her arms folded around them. The new fall intervention documented that staff were to continue to follow the care plan. Staff were to allow space when the resident was resistant and encourage her to allow staff to assist and check on her frequently. The Nursing Note dated 02/02/24 documented R96 was observed on her hands and knees in the Den, her wheelchair was behind her, and no injury was noted. A new intervention for the fall documented that if R96 was observed closing a door behind her, staff were to encourage her to participate in an activity. The Nursing Note dated 02/04/24 documented R96 had a witness fall without injury, she was trying to put snacks away and fell on her right side. New interventions documented staff to encourage and assist R96 to a quiet area or to her room to relax when not ready for bed. The Nursing Note dated 02/09/24 documented R96 was found in the sunroom on her hands and knees with her wheelchair behind her, the fall was unwitnessed without injury. New intervention for fall included staff to adjust the toileting schedule. The Nursing Note dated 02/25/24 documented R96 had an unwitnessed fall. R96 lay on her right side, in her room by the TV. R96's wheelchair was on her left side, and no injuries were noted. New interventions for fall included a double pancake light was ordered, and staff were to place one on the wheelchair and one on R96's bed. The Nursing Note dated 03/25/24 documented that R96 was found on the floor near her bed. R96 was seated on her bottom with knees to her chest and her wheelchair was behind her in a locked position. There was no injury noted. The new intervention included staff checking on R96 often and offering to assist her with her night clothing around 07:00 PM. The Nursing Note dated 03/31/24 documented R96 had an unwitnessed fall in the hallway. R96 was kneeling holding onto the wheelchair with her hands. R96 had no injury. A new intervention was to place a cup holder on the wheelchair for fluid choices. The Nursing Note dated 04/04/23 documented R96 had a witnessed fall in her room, with no injury. The new intervention included assisting R96 to the bathroom prior to changing her clothing. The Nursing Note dated 04/21/24 documented R96 had an unwitnessed fall with no injury. The nursing note documented R96 was seated on her bottom in front of the nurse's station with her wheelchair directly behind her. The new intervention included a medication review, and if R96 was in a crowded space and getting agitated with other residents, staff were to assist R96 to a more open space and allow others to pass by. The Nursing Note dated 05/15/24 documented R96 had an unwitnessed without injury. The nursing note documented R96 lying on her right side on the floor next to her bed with the wheelchair within her reach. The new intervention for R96 fall was to give printed paper which included basic math addition worksheets and place worksheets in R96's room. A Nursing Note dated 05/20/24 documented R96 had a witnessed fall without injury. New intervention for R96's fall included staff continuing to provide observation and safety when the resident was observed standing without assistance. On 06/02/24 at 10:14 AM R96 was in the commons area. She sat behind the couch in her wheelchair looking at her peers. On 06/04/24 at 07:18 AM R96 laid in bed on her right side. R96 wore a purple stocking hat, with blankets pulled up around her. During an interview on 06/05/24 at 01:05 PM Certified Nurse Aide (CNA)R stated he knew the interventions for falls by looking at the Kardex. During an interview on 06/05/24 at 01:34 PM Licensed Nurse (LN) I stated R96 had several falls in the last six months. LN I stated all nursing staff have tried to come up with interventions. LN I said when residents fall a new intervention was placed in the resident's care plan. During an interview on 06/05/24 at 03:00 PM, Administrative Nurse D stated she had started a performance improvement plan (PIP) for all falls. Administrative Nurse D stated she did not feel the fall interventions were person-centered. The facility policy Fall Prevention and Management Protocol, last revised 06/28/23, documented: The interdisciplinary team (IDT) would develop a plan for care with interventions that would reduce the resident's risk for falls. The plan would include specific information about the resident's routine and personal habits that may place the resident at risk for falls. After a fall the plan of care would be reviewed, and a new intervention would be added if appropriate to help prevent future falls if appropriate. The IDT would review the fall in the risk meeting or skilled meeting making appropriate recommendations to the plan of care to help prevent falls. The neighborhood nurse and team would work on possible interventions that were individualized to each resident who was at high risk for falls and would communicate the new fall intervention in the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) (care plan) and the master care plan. The facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for R96, who was cognitively impaired. This placed R96 at risk for additional falls and or injuries.

The facility identified a census of 116 residents. The sample included 24 residents with two residents sampled for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, due to pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure staff followed the intervention in place for pressure-reducing boots for Resident (R) 14 to prevent the possible development of a pressure ulcer. This deficient practice placed R14 at risk for complications associated with skin breakdown. Findings included: - R14's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-elevated blood pressure), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) for R14 dated 03/06/24 recorded a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. The MDS recorded R14 as at risk for the development of pressure ulcers or injuries. The MDS documented that R14 needed a pressure-reducing device for the chair, a pressure pressure-reducing device for the bed, a turning or repositioning program, and ointments or medication. R14's Pressure Ulcer/Injury Care Assessment (CAA) dated 07/14/23 documented R14 required staff help with bed mobility. The MDS documented R14 had poor strength and endurance, muscle weakness, impaired mobility, and impaired balance and received medication with a Black Box Warning (BBW- the highest safety-related warning that medications can be assigned by the Food and Drug Administration. The CAA documented nursing staff were to provide incontinent care as needed, skin inspections, application of moisture barrier products, and the use of a specialty mattress with an air pump, heels up (a cushion to elevate the heels), turning and repositioning program, and a wheelchair cushion. R14's Care Plan dated 06/19/21 documented R14 as at risk for pressure ulcer development and other related skin issues due to mobility impairment. R14's skin would be checked each day. Nursing was to follow R14's toileting plan for repositioning. Nursing would provide a pressure-reducing cushion for R14's wheelchair. R14 would wear heel protector boots when in her bed and a heel-up cushion. On 06/05/24 at 07:23 AM R14 laid flat in her bed with her heels directly on the mattress. R14's boot was placed on the open bed. The resident did not have her heel-up cushion or boots in place and R14's heels laid directly on the mattress. On 06/05/24 at 07:36 AM Certified Nursing Aide (CNA) N stated all CNAs were to know what services R14 needed. CNA N stated when staff picked up hall assignments, each staff should also pick up a copy of the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated the Kardex was a brief description of the care required for each resident. Nurses would let any staff member know where the Kardex's were kept. On 06/05/24 at 01:32 PM Licensed Nurse (LN) I stated all nursing staff were responsible for ensuring residents needing special equipment or devices were put in place. LN H stated all nursing staff had access to the plan of care and Kardex. On 06/05/24 at 03:00 PM Administrative Nurse D, stated all nursing staff was responsible for resident care. Administrative Nurse D stated if a resident needed heels elevated or boots, they should have been in place. The facility policy Pressure Injury Prevention and Management Policy, last revised in January 2018, documented that all residents were considered to have some risk for the development of pressure ulcers. Select the appropriate interventions based on the needs and preferences of the resident in the resident's care plan. Some of the possible interventions to assist with reducing the risk included placing a pillow or HeelZup (a cushion device that elevates the heel off the bed surface) under the lower legs to raise the heels off the bed when the resident was lying on their back as indicated on the plan of care. The facility failed to implement pressure-reducing interventions for r14's heels. This deficient practice placed R14 at risk for complications associated with skin breakdown.

The facility identified a census of 116 residents. The sample included 24 residents with three residents reviewed for bowel and bladder. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services related to incontinence (lack of voluntary control over urination or defecation) care for Resident (R) 33, who had a history of urinary tract infections (UTI- infection of the urinary tract system) and failed to provide the necessary care and services related to indwelling catheters for R415. This deficient practice placed R33 and R415 at risk for UTIs and related complications. Findings included: - R33's Electronic Medical Record (EMR) documented diagnoses of overactive bladder (a bladder control problem that leads to the sudden urge to urinate), need for assistance with personal care, dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS) dated [DATE], documented R33 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R33 required substantial/maximal assistance with toileting hygiene, sit-to-standing transfers, chair/bed-to-chair transfers, and toilet transfers. R33 was frequently incontinent of urine and always continent of bowel movements. The Quarterly MDS dated [DATE], documented R33 had a BIMS score of eight which indicated moderate cognitive impairment. R33 required substantial/maximal assistance with toileting hygiene, sit-to-standing transfers, chair/bed-to-chair transfers, and toilet transfers. R33 was frequently incontinent of urine and bowel movements. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/02/24, documented R33 scored a 10 on her BIMS assessment and the cause of the problem was cognitive impairment related to Parkinson's disease. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 02/12/24, documented R33 needed help with ADLs and mobility. Nursing provided ADL, mobility, and transfer assistance as needed. The Urinary Incontinence and Indwelling Catheter CAA dated 02/12/24, documented R33 required assistance with toileting transfers and toileting hygiene. R33 was frequently incontinent and nursing provided toileting assistance, toilet transfers, skin cleansing and inspection, incontinence care as needed, and application of moisture-barrier product after each incontinent episode. R33's Care Plan dated 12/21/22, documented she had an impaired ability to take care of herself and needed help performing ADLs. The Care Plan directed R33 needed assistance with one staff member for bathing, ADLs, and dressing. R33's Care Plan dated 12/21/22, documented she was incontinent or had the potential to be incontinent of urine and directed that R33 required assistance with one staff for peri-care (cleaning the genital and anal areas of a patient). R33's Care Plan dated 03/06/23, documented she had the potential for bowel incontinence and directed staff to provide peri-care with each incontinent episode, applied protective barrier cream after each incontinent episode, and monitored R33 for signs and symptoms of infection. R33's EMR revealed an Elimination Assessment on 05/06/24 that documented she needed extensive assistance with toileting and was occasionally incontinent of urine and bowel movements. Upon request, the facility provided urinalysis (UA-lab analysis of urine) with Culture and Sensitivity (CS- a test used to identify the type of organism causing an infection and the compounds the organism was sensitive or resistant to) results for the last six months for R33. The results revealed the following: R33 had a UA completed on 12/20/23 with CS results on 12/22/23 that documented R33 had a UTI caused by Escherichia coli (E. coli- bacteria that can cause infection). R33 had a UA completed on 01/12/24 with CS results on 01/17/24 that documented R33 had a UTI caused by Enterococcus faecium (E. faecium- bacteria that can cause infection). R33 had a UA completed on 02/11/24 with CS results on 2/13/24 that documented R33 had a UTI caused by E. coli. R33 had a UA completed on 03/10/24 with CS results on 03/14/24 that documented R33 had a UTI caused by E. coli. On 06/05/24 at 02:12 PM, Certified Nurse Aide (CNA) O was in R33's room with her while she was on the toilet. CNA O donned (put on) gloves and removed R33's soiled pull-up then placed a clean pull-up on R33. CNA O doffed (removed) gloves but did not perform hand hygiene before donning new gloves. CNA O gave the resident toilet paper to wipe her mouth then adjusted her left hearing aid. CNA P pushed the sit-to-stand lift (mechanical lift used for transfers) into the bathroom and donned gloves. CNA O placed R33's feet onto the sit-to-stand lift's footrest and then doffed gloves. She did not perform hand hygiene before donning new gloves. CNA O pulled several wipes out of the wipe package located on the back of the toilet and held them in her right hand. She adjusted R33's pants to get her ready to stand up and the wipes touched the pants. CNA P lifted R33 up with the sit-to-stand and CNA O used one wipe to wipe R33's peri-area from behind one time. CNA O placed the other wipes on top of the wipe package and then doffed her gloves. She did not perform hand hygiene before donning new gloves. CNA O used one wipe to wipe R33's peri-area from behind, she used the same wipe for four swipes, then grabbed another wipe and used that same wipe for three swipes. CNA O grabbed a tube of barrier cream out of the drawer beside the sink and applied it with the same gloved hand she used to wipe R33 with. CNA O doffed gloves and then donned new gloves without performing hand hygiene. CNA P doffed gloves then pulled R33 out of the bathroom with the sit-to-stand lift and positioned her into her wheelchair with CNA O's assistance. After R33 was disconnected from the lift, CNA O doffed gloves and performed hand hygiene. CNA O gathered up the trash while CNA P put R33's foot pedals on and placed her at her table. CNA P then performed hand hygiene. During an interview on 06/05/24 at 02:28 PM, CNA O stated staff completed hand hygiene before and after providing care. She stated if gloves were removed during peri-care then hand hygiene should be completed before putting new gloves on. CNA O stated to prevent contamination during peri-care, staff used a different wipe with every swipe, and the wipes were pulled out one at a time. She stated she did not put wipes on top of the package. During an interview on 06/05/24 at 02:35 PM, Licensed Nurse (LN) J stated staff completed hand hygiene before starting peri-care and donned gloves. She stated after the dirty portion of peri-care was completed, staff removed gloves and washed hands before putting new gloves on to complete the clean portion of peri-care. LN J stated staff prevented contamination during peri-care by using one wipe per swipe, not using the same wipe, or folding the wipe over to continue to use. She stated wipes were pulled out one at a time. During an interview on 06/05/24 at 02:41 PM, Administrative Nurse D stated staff completed hand hygiene when entering resident rooms and got the resident ready before peri-care was started. She stated staff sanitized their hands again and then donned gloves. Administrative Nurse D stated staff wiped front-to-back for females then removed their gloves and sanitized their hands before putting new gloves on. She stated staff used one wipe per swipe and held the wipes in their clean hand or put them on a clean surface to prevent contamination of the wipes. The facility's Female Perineal Care policy, last revised 08/22/08, directed staff to perform the following for perineal procedure: collected equipment, washed their hands, explained the procedure to the resident, put on gloves, cleaned the anal area first by wiping with wet washcloth or perineal wipes from the vagina towards the anus with one stroke, discarded soiled washcloth or soiled wipe and repeated with clean washcloth or wipe until skin was clear of fecal material, discarded gloves into trash and washed hands, put on clean gloves, used a clean washcloth or perineal wipe to cleanse perineal area and used a clean washcloth or perineal wipe for each wipe until no fecal material was present on skin, then removed gloves and washed hands. The facility failed to provide the necessary care and services to R33, who had a history of UTIs. This deficient practice had the risk for UTIs and unwarranted physical complications for R33. 41037 - R415's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of overactive bladder, urinary retention (lack of ability to urinate and empty the bladder), dementia (a progressive mental disorder characterized by failing memory, confusion), and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] was in progress and not completed. R415's Care Area Assessment (CAA) had not been completed. R415's Baseline Care Plan dated 05/26/24 documented she had a Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and staff would monitor for signs or symptoms of urinary tract infections. The plan of care documented she used a dependent drainage bag at night and a urinary leg bag during the day. R415's EMR under the Orders tab revealed the following physician orders: Change Foley catheter monthly with French 15 due to urine retention dated 05/26/24. Replace Foley catheter monthly with French 15 as needed due to urine retention dated 05/26/24. Replace urinary leg bag and dependent drainage bag weekly dated 05/26/24. May change urinary dependent drainage bag to urinary leg bag during the day. Rinse bags after disconnection daily dated 05/26/24. Change urinary leg bag to dependent drainage bag at bedtime. Rinse bags after disconnection dated 05/26/24. Catheter care every shift twice daily dated 05/26/24. Empty the catheter drainage bag at the end of each shift and record results in the vital sign section in the EMR twice daily dated 05/26/24. Hiprex ( medication used to suppress UTI) one gram give one tablet by mouth twice daily with meals for urinary tract infection (UTI) dated 05/28/24. During an observation on 06/05/24 at 06:48 AM R415 laid on her bed. Licensed Nurse (LN) H washed her hands and donned gloves. She opened the room door to exit the room to obtain an isolation gown from the bin outside the room. LN H returned to R415's room, closed the door, and donned the isolation gown. LN H failed to doff her gloves and perform hand hygiene and apply clean gloves. LN H assisted R415 with raising the left-leg pajama pants. LN H obtained the urinary leg bag from the bathroom and laid the bag on the foot of R415's bed. LN H failed to perform hand hygiene and change gloves prior to cleaning the tip of the urinary leg bag. LN H disconnected the dependent drainage bag from R415's catheter and attached the leg bag to R415's catheter. LN H rinsed R415's dependent drainage bag and placed it in a plastic bag in the bathroom. LN H doffed her gloves and donned a new glove. LN H failed to perform hand hygiene between the glove change. During an interview on 06/05/24 at 06:48 AM, Licensed Nurse (LN) H stated she should have performed hand hygiene between glove changes during R415's urinary leg bag change. During an interview on 06/05/24 at 11:37 AM, Administrative Nurse E, the facility infection preventionist, stated staff should perform hand hygiene between glove changes, going from dirty to clean or if visibly soiled. Administrative Nurse E stated the facility had frequent hand hygiene education when there was an increase in urinary tract infections noted. Administrative Nurse E stated the facility had yearly skills fair for nursing staff to review the infection control procedures. During an interview on 06/05/24 at 02:41 PM, Administrative Nurse D stated staff completed hand hygiene when entering resident rooms and got the resident ready before catheter care was started. She stated staff sanitized their hands again and then donned gloves. Administrative Nurse D stated staff should perform hand hygiene between glove changes. The facility's Caring for a Resident with a Urinary Catheter policy last revised 04/2011 documented that catheter care would be provided daily and when there was the possibility of fecal incontinence. The facility failed to ensure the standard of care was provided during catheter care for R415 for a resident who was being treated for UTI. This deficient practice placed R1415 at risk of catheter-related complications and further UTIs.

The facility identified a census of 116 residents. The sample included 24 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)413. This deficient practice placed R413 at increased risk for respiratory infection and complications. Findings included: - R413's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of pulmonary fibrosis (lungs become scared and damaged), need for assistance with personal care, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Admission Minimum Data Set (MDS) dated [DATE] was in progress. R413's Care Area Assessment (CAA) was in progress. R413's Care Plan dated 05/29/24 documented staff would monitor for shortness of breath, assess his lung sounds, and give medications as ordered. R413's EMR under the Orders tab revealed the following physician orders: Oxygen at two liters per minute via nasal cannula. Oxygen sats every shift twice daily dated 05/30/24. During an observation on 06/03/24 at 10:17 AM, R413's nasal cannula lay directly on the floor next to R413's bed. During an interview on 06/05/24 at 06:48 AM, Licensed Nurse (LN) H stated R413's nasal cannula should never be placed on the floor. During an interview on 06/05/24 at 11:37 AM, Administrative Nurse E stated oxygen equipment should never be placed on the floor. During an interview on 06/05/24 at 03:00 PM, Administrative Nurse D stated oxygen nasal cannulas or oxygen masks should never be placed on the floor. Administrative Nurse D stated the nasal cannula or oxygen mask should be replaced to prevent respiratory infections. The facility's Nebulizer & Oxygen Storage and Cleaning policy dated 11/2021 documented the facility would ensure that a resident received nebulizer & oxygen services and care that was consistent with professional standards of practice and meeting the resident's goals and preferences. Oxygen tubing would be stored in a bag when not in use by the resident. The facility failed to ensure R413's oxygen tubing was stored in a sanitary manner to decrease exposure and contamination. This placed R413 at increased risk for respiratory infection and complications.

The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 60 had a documented risk assessment, a consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R60 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings included: - R60's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), abnormalities of gait, delirium (sudden severe confusion, disorientation, and restlessness), lack of coordination, cognitive-communication deficit, and hypertension (HTN-elevated blood pressure). The Annual 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 R60 had one non-injury fall since admission. The Quarterly MDS dated [DATE] documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented R60 was dependent on staff assistance for transfers and for the ability to move from a sitting to a standing position. R60's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/18/23 documented she had cognitive impairment, which placed her at risk for impaired decision-making. R60's Falls Care Area Assessment (CAA) dated 07/18/23 documented her balance was impaired related to her diagnosis of Alzheimer's disease. Contributing factors included a history of falls, poor safety awareness, poor decision-making skills, poor strength and endurance, muscle weakness, impaired balance, and impaired gait. R60's Care Plan dated 05/10/23 documented she had bilateral bed canes on her bed to assist with transfers and repositioning when in bed. A review of R60's EMR lacked evidence of a safety assessment for side rails, prior to the installation of side rails. The facility was unable to provide a risk assessment for side rails for R60. On 06/04/24 at 08:32 AM observation revealed R60 sat in her wheelchair next to her bed. The head of the bed was slightly elevated and there were bed canes in place on each side of her bed. During an observation on 06/05/24 at 06:15 AM R60 sat upright in her wheelchair with foot pedals on her wheelchair as nursing staff pushed her to her room. During an interview on 06/05/24 at 02:47 PM, Administrative Staff A stated he was unable to locate a safety assessment for R60. Administrative Staff A stated the facility was going to initiate a performance-improving plan (PIP) to address the at-risk assessment for a resident's use of side rails. The facility's Bed [NAME] Assessment policy last revised 03/2010 documented the facility would ensure that residents receive appropriate assessment for the use of bed canes for positioning purposes only. The facility did not use side rails. Upon admission, if a bed cane were added then the therapy department or a nurse would assess the purpose of the bed cane, including why they need it and what alternatives were or not an option. The bed cane use would be reviewed for appropriateness, during the annual assessment and with quarterly assessments. No physician orders are needed for bed canes since the facility used them for positioning only. Bed Canes would only be utilized for assisting in residents maintaining their bed mobility. The facility failed to ensure that R60 had a documented risk assessment, a consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the resident at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails.

The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 71 and R92, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed these residents at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R71's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (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 Annual 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 R71 had received antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), antidepressants (a class of medications used to treat mood disorders) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 99, and a staff interview indicated moderately impaired cognition. The MDS documented R71 had received antipsychotic medication, antianxiety medication, and antidepressant medication during the observation period. R71's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/06/23 documented she had received antidepressant, antianxiety, and antipsychotic medications and R71 was at risk for adverse side effects from the medications. R71's Care Plan dated 12/22/22 documented that staff would administer her medication as ordered and monitor for any side effects. R71's EMR under the Orders tab revealed the following Physician Orders: Trazodone (antidepressant) 50 milligram (mg) give half tablet (25 mg) by mouth twice a day for depression, dementia, and Alzheimer's disease, dated 05/30/24. Mirtazapine (antidepressant) 15mg tablet give half tablet (7.5 mg) by mouth at bedtime for insomnia (inability to sleep), dated 05/30/24. Sertraline (antidepressant) 100 mg tablet give one tablet by mouth daily in the morning for anxiety, dated 05/30/24. Lorazepam (antianxiety) 0.5 mg tablet give one tablet by mouth every eight hours as needed for increased anxiety, dated 05/30/24, and had a stop date of 06/13/24. Risperidone (antipsychotic) 1 mg tablet give one tablet by mouth three times daily for Alzheimer's disease, dementia, dated 05/30/24. R71's clinical record lacked a physician-documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication for a resident with dementia. Upon request, the facility was unable to provide the physician's documentation. During observation on 06/05/24 at 06:33 AM, R71 slept on the couch in the common area. During an interview on 06/05/24 at 11:06 AM Administrative Nurse D stated the facility discussed residents taking antipsychotic medication during the daily meetings. Administrative Nurse D stated it was the goal of the facility for each resident taking antipsychotic medication to be on the lowest dose or be discontinued. Administrative Nurse D stated dementia was not an appropriate indication for the use of antipsychotic medication. The facility's Monitoring Residents on Psychotropic Drugs policy revised on 10/10/17, documented that each resident's psychotropic regimen would be managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Psychotropic medications would only be administered when necessary to treat a specific, diagnosed , and documented condition and when the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. The use of non-pharmacological approaches for behavioral intervention would be implemented, unless contraindicated, to minimize the need for medications. The facility failed to provide a physician-documented rationale which included the multiple unsuccessful attempts for nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication for R71. This deficient practice placed her at risk for unnecessary psychotropic medication and related complications. 49634 - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses sequelae of cerebrovascular accident (CVA-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), vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (kidneys are damaged and can't filter blood the way they should), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and aphasia (a condition with disordered or absent language function). The Quarterly 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 R96 had a diagnosis of dementia during the review. The Cognitive Loss/Dementia Care Assessment (CAA) dated 07/25/23 documented R96 had a BIMS score of three and had instances of refusing care during the observation period. R96 had a diagnosis of CVA, cognitive communication deficit, and a recent dramatic change in independence. R96 had a moderate to severe impairment in decision-making, which may result in unsafe behavior and potential for injury and/or difficulty with the performance of activities of daily living (ADLs). The Care Plan dated 01/09/24 documented R96 used psychotropic drugs, had depression, and vascular dementia with psychotic disturbances. Staff were to give R96's medication as ordered, monitor for signs and symptoms of depression and delusions, attempt non-pharmaceutical approaches prior to administering medications, and report any gait disturbances poor balance, dizziness, vertigo, or unsteady gait. The plan of care documented that staff should report any adverse symptoms, educate R96's family of adverse effects, approach R96 gently in a non-confrontational manner, and administer medication to assist with my depression and psychosis. The EMR under the Orders tab dated 04/29/24 documented staff to give Risperdal (a mood stabilizer or antipsychotic) give 0.5mg tab twice daily, for vascular dementia with psychotic disturbances. R96's clinical record lacked a physician-documented rationale which included nonpharmacological interventions and risk versus benefits for the continued use of the antipsychotic medication. Observation on 06/02/24 at 10:14 AM R96 sat in the commons area behind the couch in her wheelchair looking at her peers. On 06/05/24 at 11:06 AM Administrative Nurse D stated the facility discussed residents taking antipsychotic medication during the daily meetings. Administrative Nurse D stated it was the goal of the facility for each resident taking antipsychotic medication to be on the lowest dose possible or for the medication to be discontinued. Administrative Nurse D stated that dementia was not an appropriate indication for the use of antipsychotic medication. On 06/05/24 at 01:32 PM Licensed Nurse (LN) I stated she was unsure if dementia was an appropriate diagnosis for an antipsychotic drug. The facility's Monitoring Residents on Psychotropic Drugs policy revised on 10/10/17, documented that each resident's psychotropic regimen would be managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Psychotropic medications would only be administered when necessary to treat a specific, diagnosed , and documented condition and when the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. The use of non-pharmacological approaches for behavioral intervention would be implemented, unless contraindicated, to minimize the need for medications. The facility failed to ensure nonpharmacological interventions and risk versus benefits were attempted prior to the administration of antipsychotic medication for R96, who had a diagnosis of dementia. This placed the resident at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 116 residents. The sample included 24 residents with six residents sampled for hospice services. Based on observation, record review, and interview, the facility failed to ensure a consistent method of communication process, including how the communication would be documented between the facility and the hospice provider, to ensure the needs of the resident were addressed and met 24 hours per day for Resident (R) 5. This placed R5 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard, thick, and narrow due to the buildup of plaque (fatty deposits) inside the artery walls, kidney disease(your kidneys are damaged and cannot filter blood the way they should), dementia (a progressive mental disorder characterized by failing memory, confusion), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R5's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R5 needed partial to moderated assistance with bathing and dressing. The MDS R5 had received hospice services while in the facility. R5's Functional/Rehabilitation Potential CAA dated 05/15/24 documented R5 needed help with activities of daily living (ADL). R5 had a balance deficit during transfers and gait. The MDS documented that R5 had the potential for further decline in ADLs and mobility. The MDS revealed R5 had graduated from hospice service. Nursing was to provide ADLs, mobility, and transfer assistance. R5's Care Plan dated 11/28/23 documented that R5 had impaired mobility and needed help with performing ADLs. R5 needed the assistance of one staff for ADLs, dressing, grooming, and bathing. R5's Care Plan lacked direction to staff for the collaboration of care and services with the hospice provider which included the services, frequency of visits, medications, and equipment provided by hospice. A review of the communication EMR under the Assessments and Hospice tab lacked documentation of collaboration of care for R5 from January 2024 through May 2024. Observation on 06/03/24 at 10:12 AM revealed R5 was sitting in her room in her wheelchair watching TV. Observation on 06/04/24 at 10:02 AM revealed R5 was up in her wheelchair. R5 was out in the hall visiting with nursing staff. On 06/23/24 at 10:59 AM Licensed nurse (LN) I stated the hospice providers had access to the facility's EMR. LN I stated hospice providers scanned documentation into EMR after each visit. LN I stated all services and equipment provided by the hospice could be found in the facility's plan of care for R5. On 06/05/24 at 03:00 PM Administrative Nurse D stated R5's plan of care should include all the services and equipment provided by the hospice provider. Administrative Nurse D stated the files were scanned into the EMR under the hospice tag for each visit. Administrative Nurse D stated the facility had to call the hospice provided to obtain the visits from 01/24-05/24. She stated the information was not scanned consistently and should have been scanned into the EMR with each visit. Administrator Nurse D stated we do have the information for each visit now, and the facility was scanning the files into R5's EMR. The facility's Hospice Services policy, last revised 04/24/24, documented the written hospice agreement would include a communication process including how the communication would be documented between the facility and the hospice provider to ensure the needs of the resident was addressed and met 24 hours a day. A plan of care would be established in coordination with the interdisciplinary team members(s), the physician, the resident, and/or designee. The plan of care would include the diagnosis, a common focus (problem) list and interventions, and what services the facility and/or hospice was responsible to provide. The facility failed to ensure collaboration between the facility and the hospice provider and failed to develop a care plan by the facility that included a description of the services, medication, and equipment provided to R5 by the facility. This deficient practice placed R5 at risk for delayed services which could affect her mental, and psychosocial well-being.

The facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for immunizations. Based on record review, and interviews, the facility failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination or administration information for Residents (R) 53 and R71. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R53's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. A review of R71's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration. Upon request for R53's and R71's declination or administration of PCV20, the facility was unable to provide consent or declination. During an interview on 06/05/24 at 11:37 AM, Administrative Nurse E, the facility infection preventionist, stated that R53 and R71 had a history of refusing all pneumococcal vaccinations offered in the past. Administrative Nurse E stated she was unable to locate a declination or consent for R53 or R71. The facility's Administration of Pneumococcal Vaccine to Residents policy revised 12/2022 documented to minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal disease, the facility would ensure that all residents would be offered the pneumococcal vaccine injection as desired by the resident and approved by the primary care physician. The facility failed to obtain PCV20 consents, declinations, or administration information for R53 and R71 who were eligible to receive the vaccination. This placed R53 and R71 at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

The facility identified a census of 113 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, who was cognitively impaired and at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff), from exiting the facility without staff knowledge or supervision on 11/26/23 at 01:23 PM. R1 pushed on a door leading to the stairwell for 15 seconds and was able to open the door. The door alarm sounded but the roam alert system (system which alerts when a linked roam alert bracelet is near) did not alert even though R1 wore a roam alert bracelet. Staff reset the door alarm but did not check the stairwell. R1 then went down a flight of stairs and exited through an outside door in the stairwell. R1 walked along the sidewalk around the building, to the front of the building where he entered the front door at 01:39 PM and was intercepted by Dietary BB then escorted back to long term care. The facility failed to provide adequate supervision and appropriate response to door alarms to prevent an elopement. These failures placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. R1 had physical behaviors directed towards others and wandering behavior one to three days in the assessment period. R1 required substantial/maximal assistance with walking 10 feet. He had one noninjury and one injury fall since admission. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/26/23, documented R1 had a BIMS score of five, physical behaviors directed towards others, and wandering behavior. R1's factors that placed him at risk for a problem included modified independence, moderate impairment or severe impairment in decision making which may result in unsafe behavior and potential for injury, and difficulty with performance of activities of daily living (ADLs). The ADL Functional/Rehabilitation Potential CAA dated 10/26/23, documented R1 needed help with ADLs and mobility. The Falls CAA dated 10/26/23, documented R1 had a history of falls and he received staff support for transfer and safety needs. The Behavioral Symptoms CAA dated 10/26/23, documented R1 had rejection of care and wandering behavior. R1 became physically aggressive with staff while toileting and was observed wandering on the unit. R1's Care Plan, dated 11/01/23, documented R1 had problems with remaining safe in his environment due to history of wandering and a diagnosis of dementia. The care plan directed he wore a wandering bracelet on his right ankle and staff redirected him when exit seeking or took him for a walk. R1's Care Plan, dated 11/01/23, documented R1 was at risk for falling related to history of falls and muscle weakness. The care plan directed R1 may attempt to self-transfer and staff offered assistance. R1's Care Plan, dated 11/01/23, documented R1 had an impaired ability to take care of himself and needed help with performing ADL. The care plan directed staff to provide assistance with one staff for bathing, dressing/grooming, and transfers. R1's EMR revealed an Elopement Risk Assessment, dated 10/13/23, that documented R1 had an elopement risk score of six, which indicated he was not at risk for elopement. R1's EMR revealed a Behavioral Documentation note on 11/12/23 at 09:21 AM that documented R1 had been up wandering about both neighborhoods that morning and was easily redirected. R1's EMR revealed a Behavioral Documentation note on 11/26/23 at 01:07 PM that documented after lunch, R1 walked around carrying his house shoes without his walker. Staff attempted to remind him he needed to use his walker and he needed to leave his shoes in his room. R1 stated he was leaving town for two to three weeks and where he was going, he would not be able to use the walker. R1 walked away carrying his shoes and refused to take his walker. R1's EMR revealed a Nursing Notes note on 11/26/23 at 03:07 PM that documented staff reported R1 almost got out and the Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) needed to be checked for function. The nurse went to R1 in the living room and checked his Wanderguard, which was working. The staff notified the weekend supervisor and removed R1's Wanderguard to check it for function. The Wanderguard did not alarm when going out of the care center but did when staff brought the alarm back into the care center. Staff changed R1's Wanderguard tag and placed it on his right ankle. Administrative Staff A came to facility and reviewed the camera and saw that R1 had opened the door and exited. R1 refused to allow the nurse to complete vital signs, he was cool to the touch, but did not have any shivering or jaw shaking to alert staff to him being cold. R1 was dressed in a long-sleeved shirt with an undershirt, casual pants, tennis shoes, and socks. In a notarized witness statement on 11/26/23, CNA M stated she heard the door alarm and went to check the area. As she approached, she saw R2 turn from the door and walk back down the hall. CNA M stated she checked to ensure the door was closed/latched, which it was, and reset the door alarm with the impression it was R2 who triggered it as she had several times that day. She stated the alarm never sounded so she assumed no one had passed through the exit door. CNA M stated she had seen R1 wandering all over the halls off and on all day, including that afternoon but did not recall the last time she saw him. In a notarized witness statement on 11/28/23, Dietary BB stated R1 was walking toward the front doors when she saw him on 11/26/23 at about 01:30 PM. She stated R1 was one of her residents and had just moved to the second floor. She knew he was not to be out alone, so she asked him where he was headed. Dietary BB stated R1 said he was going to see his friend and needed to get to the elevators. She stated she showed him the elevators and took him to the second floor. Dietary BB stated he did not want to go back to his room. She notified staff about what happened. The facility's investigative report, dated 12/05/23, documented on 11/26/23 at approximately 01:23 PM, R1 was seen in the lobby by Dietary BB who escorted R1 back to the second floor of LTC and notified the charge nurse. The charge nurse reported the incident to the supervisor who informed Administrative Nurse D and Administrative Staff A. Administrative Staff A arrived at the facility to investigate the incident. Initially, staff reported they thought R1 possibly followed a family member off of the floor. The facility reviewed camera footage and identified that was not the case. R1 ambulated to the exit door, pushed the door for 15 seconds until the door/magnetic lock released, and walked down the stairs. The releasing of the door magnetic lock activated the door alarm. R1 ambulated to the lobby where Dietary BB recognized him and assisted him back to the second floor of LTC. The egress exit alarm activated when the door opened; however, the roam alert did not activate/alarm. Certified Nurse Aide (CNA) M immediately responded to the egress door alarm and reset the door alarm. Since the roam alert was not activated and another resident was standing by the door, CNA M indicated she believed that resident activated the door alarm. She reset the door alarm and directed the resident away from the door. Video footage showed the following: at approximately 01:23 PM, R1 pushed on the door until the door releases. CNA M walked to the door, as she was already headed towards the door prior to the door sounding because she saw R2 by the door, immediately when the alarm sounded. She was observed resetting the door alarm at 01:24 PM. CNA M redirected R2 away from the door. At approximately 01:29 PM, R1 ambulated independently in through the front doors from outside. He wore pants, shoes, and a long-sleeved shirt at that time. Investigation of the incident indicated the roam alert at that door did not alarm. R1's roam alert tag was functioning appropriately. It was identified that the door alarm did not activate until the magnetic lock released after 15 seconds. R1 ambulated independently. The temperature outside at the time of the incident was approximately 36 degrees and the sidewalks were shoveled and salted. When questioned about the incident, R1 stated he was headed to his villa/home, which was on campus. In closing, the investigation indicated the incident was related to failure of equipment. The equipment did not activate at the time of the incident. The circuit board had not and did not display a warning signal to alert staff and/or maintenance. R1 was away from the neighborhood for a total of six minutes. According to the Kansas State University Historical Weather website, the temperature on 11/26/23 at 01:00 PM was 32.2 degrees Fahrenheit (F). On 12/19/23 at 12:50 PM, the outside door R1 left out of exited onto a sidewalk. The sidewalk was in good repair and continued around the building to the front entrance. There was parking lots located to the side and in front of the facility with a street that ran in front of the facility with a posted speed limit of 25 miles per hour. On 12/19/23 at 02:25 PM, the second-floor door R1 exited led to a stairwell. The stairs were made of cement/concrete and R1 had to walk down one flight of stairs to leave through the outside exit door. On 12/19/23 at 12:45 PM, Administrative Staff A stated R1 was identified as a wanderer and he had a roam alert bracelet staff checked every shift for placement and checked weekly for functioning. He stated on 11/26/23, R1 pushed on the door and set the alarm off but the roam alert alarm did not go off. R2 was also there, and she wore a roam alert which triggered in the alarm window but did not sound. Administrative Staff A stated Dietary BB saw R1 in the front entrance and escorted him back inside. He stated R1 exited out a stairwell door then walked around the sidewalk to the main entrance where he was able to enter the front door. Administrative Staff A stated the circuit board for the roam alert was failing and intermittently sending signals. On 12/19/23 at 02:24 PM, Administrative Staff A stated the door alarm did sound after the magnetic lock released when pushed for 15 seconds and if it had alarmed immediately when the door was pushed then staff would have answered right away. He stated R1 did go down a flight of stairs to exit. On 12/19/23 at 02:32 PM, Administrative Nurse D stated on 11/26/23, she was notified around 01:30 PM that R1 was brought back in through the front doors. She stated it was not reported to her that he had any wandering behaviors that day. Administrative Nurse D stated when a door alarm sounded, staff were expected to go to the door alarm, open the door to check and find the person, verify the roam alert number that popped up in the alarm window with the number in Kardex (CNA care plan) before resetting the alarm. On 12/19/23 at 04:05 PM, Administrative Staff A stated he expected staff to always respond to door alarms immediately, open the door and check the area, then account for all the residents. He stated he expected this every single time the alarm went off. On 12/20/23 at 10:43 AM, CNA M stated she was not aware that R1 was a wanderer or exit seeker. She stated on 11/26/23, she was documenting at the computer when she saw R2 going towards the exit door at the end of that hallway. She stated she jumped up from charting but did not take her Kardex with her as she wanted to get to R2 before she got to the end of the hall. CNA M stated by time she got to the end of the hall, R2 had made a U-turn and she passed her. While she was at the end of the hall, CNA M checked the door and saw it was closed and latched. She stated she did not see anybody and the only resident she saw in that direction was R2. CNA M stated since the door was latched and R2 was safely inside, she checked the roam alert window to see what number was on the code display but because she did not have her Kardex on her, she memorized the last three digits to check against the papers at the desk. CNA M stated the last three numbers were the same as R2's roam alert. She stated the roam alert alarm did not go off and staff relied on the roam alert alarm to go off. CNA M stated besides checking the roam alert number, there was no roam alert alarm going off to indicate a reside had went through that exit. She stated the door alarms went off frequently throughout the day if someone pushed on a door or left it open too long. CNA M stated the roam alert alarm sounded through the computer as well and indicated a resident passed over a threshold. She stated if a roam alert alarm went off, everybody, no matter who it was, went to assist. She stated staff always carried the Kardex and pulled it out to check the roam alert number with the screen. CNA M stated she did not take the Kardex with her to get R2 because she thought it was more important to go to R2. She stated if she knew there was another resident in that area, she would have gone through the doors and down the stairs asking if anyone had seen him. CNA M stated the Kardex was updated every day and new ones were printed every shift and listed which residents were wanderers with their roam alert numbers on the back. She stated she had assigned residents that she received report on and R1 was not one of her assigned residents, so she did not receive report on him. On 12/20/23 at 12:50 PM, Licensed Nurse (LN) G stated on 11/26/23, R1 was restless, was walking without his walker, and kept saying he was leaving. She stated staff kept telling him he needed to stay at the facility and wait for his wife to come get him. LN G stated she talked to R1 about 10 to 15 minutes before he had got out of the door, and he stated he was going to leave but she told him to wait for his wife. She stated another resident had asked for her to step into their room and that was when another nurse told her R1 had got out then was brought back in. LN G stated when a door alarm went off, staff were supposed to respond and if there was a code in the Wanderguard box, they looked at the Kardex to find the number and make sure the resident was still in the building. She stated everyone carried a Kardex which were reprinted at least every day and were supposed to be updated every day. LN G stated she had not observed R1 trying to push on any doors, but he would go look out of the front door to the care center then would turn around and sit down in the lobby area then back up to wandering again. She stated R1 wore a Wanderguard at the time. She stated R1 was not easily redirected that day because he was very agitated and had started cussing at staff for telling him to wait for his wife. LN G stated staff offered him food, offered him rest, and offered to call his wife but none of that seemed to work for him that day. She stated she did not feel like he needed to be one-on-one or closer observation because he had not tried to actually push on any doors to go out, he just walked up to them to look out then walked away. The facility's Elopement Prevention policy, last revised 06/18/12, directed specific interventions were developed and implemented for residents at risk for elopement such as increased frequency of checks to ensure safety, wander bracelet may be placed on resident, and resident may be moved to the 2nd floor care center. The policy directed it was the responsibility of all personnel to report any resident attempting to leave the care center to the charge nurse as soon as practical. The facility's Wandering Resident policy, dated 02/17/08, directed every effort was made to prevent wandering episodes while maintaining the least restrictive environment for residents who were at risk for elopement. The policy directed if a resident repeatedly attempted to wander off the neighborhood, a monitoring schedule was implemented to ensure resident safety. The facility failed to provide adequate supervision to prevent R1 from eloping out of the facility on 11/26/23 at 01:23 PM when the temperature was near freezing. This deficient practice placed R1 in immediate jeopardy. The facility put the following corrective actions into place by 12/05/23: All elopement risk residents were placed on 15-minute checks until the roam alert system was fixed beginning 11/26/23. R1's Care Plan was updated on 11/27/23. The security system company replaced the circuit board and changed door alarm to sound when doors were pushed on 11/27/23. An elopement drill was completed 11/28/23 and two more were completed on 11/30/23. Staff were educated on responding to door alarms from 11/27/23 to 12/05/23. CNA M received a final written warning for responding to door alarms on 12/01/23. Due to the corrective measures implemented and completed prior to the onsite survey, this deficient practice was cited as past noncompliance. The scope and severity remain a J.

The facility identified a census of 93 residents. The sample included three residents reviewed for elopement (when cognitively impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopement for Resident (R) 1, who was independently mobile and cognitively impaired. R1 was at high risk for elopement, wore a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building), and had a recent history of agitation, exit seeking, and behaviors. On 03/26/22 at approximately 06:18 PM R1 exited the unit through an unattended door left slightly ajar from a visitor. R1's Wanderguard triggered the safety alarm as she exited. Staff responded to the alarm but canceled the alarm without assessing the presence of all residents at risk and without reviewing the display which notified staff which Wanderguard triggered the alarm. As a result, R1 exited the facility without staff knowledge or supervision and facility staff observed the resident outside 10 minutes later. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and [CONDITION(S)] disorder (major mood disorder). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R1 required supervision with set up help only for locomotion on and off the unit, and in the corridor. She walked independently in her room. The MDS recorded R1 wandered four to six days, but less than daily during the look back period. The ADL Functional Care Area Assessment (CAA) dated 01/20/22 documented R1 had impaired cognitive abilities with short term memory and poor safety awareness. The Behavioral Symptoms CAA dated 01/20/22 documented R1 refused care, wandered, and had both verbal and physical behaviors directed toward staff. The Falls/Safety Care Plan initiated 01/27/22 documented R1 had problems with remaining safe in her environment related to dementia, depression, anxiety, and exit seeking. It directed staff to redirect R1 when she was exit seeking or take R1 for a walk. The plan of care further documented R1 wore a Wanderguard. The Elopement assessment dated [DATE] documented R1 had a score of 18, which indicated at risk for elopement. The Progress Note dated 03/14/22 at 12:02 PM documented R1 continued to go to the doors and tried to exit out the doors. Staff redirected R1 and R1 was resistive to redirection. R1 asked to leave to go home and take care of her husband and staff told R1 she would not be able to leave, but her husband would come visit. The Progress Note dated 03/14/22 at 04:59 PM documented R1's Wanderguard was not on her person. A new Wanderguard was placed on R1's left wrist. The Progress Note dated 03/19/22 at 09:47 AM documented R1 lacked her Wanderguard that morning, and staff were unable to find the Wanderguard in R1's room. Staff applied a new Wanderguard to R1's right ankle. The Progress Note dated 03/19/22 at 09:48 AM documented R1 had her coat on and stated, I am leaving to go see my husband who is sick. Staff attempted to redirect R1 but were unsuccessful. The Progress Note dated 03/21/22 at 11:51 AM documented R1 attempted to get out all morning. Staff told R1 many times that R1's husband would be there to visit R1 at 01:00 PM. R1 responded to the redirection for a short time but continued her attempts to leave. Staff convinced R1 to go to the dining room for lunch. The Progress Notes dated 03/26/22 at 09:37 PM documented an unidentified staff member called over to the unit at 06:45 PM on Saturday 3/26/22. The unidentified nurse reported R1 went out of the door of the care center and was seen outside of the building, trying to get back in at the main doors. Staff notified Administrative Nurse D immediately and an investigation was started into what happened that allowed the resident to get out the doors. The Progress Note dated 03/26/22 at 09:50 PM LN G documented at 06:33 R1 entered the unit with CNA M. The CNA stated R1 was seen in front of the main door entrance to the facility and was trying to get in. CNA M happened to know R1, so CNA M brought R1 back up to the second floor, where R1 resided. LN G conducted a full skin assessment, no physical injuries were noted. R1 reported right hip pain. R1 denied falling while outside. R1's elopement interventions were reviewed, and LN G assessed the functioning of R1's Wanderguard and placed a second Wanderguard on R1. LN G further implemented visual identification of R1's location and activity every 15 minutes and performed a teachable moment on identifying which resident set off the door alarm before resetting the door code. In a Witness Statement dated 03/28/22, Certified Nurse Aide (CNA) M stated around 06:30 PM, when coming back from a lunch break, CNA M found R1 wandering at the main entrance door. CNA M documented R1 asked to be let into the facility. CNA M wrote that, because he knew R1, he opened the door to the building, and assisted R1 to the second floor. CNA M stated he reported the situation first to Licensed Nurse (LN) G. In a Witness Statement dated 03/28/22 LN G stated he observed R1 around 06:05 PM in the living area of the second floor. LN G documented he reset the door alarm around 06:18 PM with the thought that another resident set it off. LN G noted an unidentified staff member, unidentified resident, and unidentified family member around the door area. In a Witness Statement dated 03/28/22 CMA R stated she observed R1 walking around the unit at 05:10 PM. At 06:15 PM the door alarm went off. CMA R reported she cleared the alarm. CMA R stated she observed an unidentified resident and family member enter the unit. CMA R stated she did not observe any residents on the other side of the door when she looked through the window of the door leading onto the unit. On 03/29/22 at approximately 10:30 AM, observation revealed the location of the facility was off the main road and on the side of the building community campus. There was a road along the front of the doorway with a posted speed limit of 20 miles per hour (mph). The neighborhood around the facility grounds had posted speeds of 30 mph. The road in front of the facility door was parallel and across the street from the parking area. On 03/29/22 at 11:30 AM R1 laid on the top of the covers in her bed. R1 seemed confused but was pleasant and discussed her cat figurines. R1 had a Wanderguard present on her right ankle. On 03/29/22 at 11:33 AM LN H stated that staff were to ensure R1 had her Wanderguard on every shift. R1 was crafty and could remove her Wanderguard very quickly. LN H further stated that if a door alarm sounded, staff were to check the screen that showed what time the alarm triggered and what Wanderguard number triggered the alarm. LN H stated there was a list of Wanderguard numbers assigned to each resident at the nurse's desk. LN H further stated staff were to make sure the residents were visualized where they were supposed to be before canceling the alarm. On 3/29/22 at 11:38 AM Administrative Nurse D reported she expected the staff to look at which Wanderguard band triggered the alarm and then go look for the resident assigned to that Wanderguard. CMA R looked out the window and did not see anyone, the nurse then looked at the alarm screen, and then went over talked with CMA R. CMA R told LN G everything was good. LN G thought the alarm went off because another resident, who also wandered quite a bit, was near the door. Neither LN G nor CMA R looked to see which Wanderguard numbers triggered the alarm. Administrative Nurse D stated the facility alarm sounded when a Wanderguard was near and signaled the specific resident's Wanderguard that set off the alarm. She further stated families had a door key to get in to see residents and the keys were coded to indicate who entered the facility. Administrative Nurse D said she contacted the family member that keyed in when R1 exited and that person could not recall any residents near the door when the unidentified family member entered. Administrative Nurse D reviewed the video and noted R1 was right beside the door but stated R1 looked very put together and might not have appeared to be a resident. On 03/29/22 at 04:00 PM LN G and CMA R remained unavailable for interview. The facility's Electronic Monitoring System for Exit Doors policy revised 03/30/09 documented the electronic monitoring system for exit doors for all neighborhoods would be operational so that residents who wander do not leave the neighborhood without an appropriate escort. The facility failed to ensure R1's received the necessary supervision to prevent an elopement and failed to ensure staff responded to safety alarms appropriately when the staff canceled the alarm without assessing the presence of all residents at risk and without reviewing the display which notified staff which Wanderguard triggered the alarm. R1 was able to exit the facility without supervision which presented the likelihood of serious harm or impairment. On 03/28/22 the facility completed the following corrections: Education to all facility staff reiterating that anytime an alarm went off on the roam alert system, staff should always check to ensure the resident was safe prior to clearing the alarm. The education included direction to staff to never clear the alarm prior to identifying the resident's location. Elopement drill performed and completed within two minutes. LN G received written reprimand which indicated no roam alerts were to be cleared until LN G confirmed the resident was safe inside the facility. If unsure of the resident, LN G needed to view the photo in the book with pictures of all residents that have a Wanderguard. CMA M received written reprimand was suspended and received written reprimand. CMA R was educated with demonstrated understanding and return demonstration on how to look up roam alert numbers, review profile book with residents that have a Wanderguard and view resident names on roam alert computer. This deficient practice was cited as past non-compliance.

The facility ' s census totaled 118 residents with 3 residents sampled for falls. Based on observation, record review, and interviews, the facility failed to provide interventions as planned to prevent falls for 1 of 3 residents sampled for falls (#1). Resident #1 fell and sustained a hip fracture. Findings included: - Resident #1 ' s electronic [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) scored 11 which indicated the resident ' s cognitive status was moderately impaired. The MDS documented the resident required extensive assistance of 2 staff members with transfers, and toilet use, and extensive assistance of 1 staff member with bed mobility, dressing and personal hygiene. The MDS further documented the resident ' s balance was not steady and only able to stabilize with the staff ' s assistance. The resident had 1 fall during the look back period with no injuries. The significant change MDS dated [DATE] documented the resident had 1 fall with major injury since last MDS. The fall Care Area Assessment (CAA) dated 9/1/15 documented the resident with a balance problem and needed assistance for support during transfers and gait. He/she had 1 fall in last 90 days on 7/1/15. The resident received support for transfers and safety needs. Nursing provided safety cues and monitoring, a hi-low bed, a stand up lift for transfers, a fall mat, a perimeter mattress cover, use of a call light at the bedside and in the bathroom, and mobility and transfer assistance. The fall care plan revised on 8/13/15 documented the resident was at risk for falling (related to history of falls), [DIAGNOSES REDACTED]. The interventions included: to schedule a therapy evaluation as needed, please involve the resident in a restorative nursing program as needed, provide a reacher (an apparatus the resident can use to pick items up with), a hi/low bed, a fall mat placed on 8/11/15, the bed placed against the wall, a perimeter mattress cover, encourage the resident to attend group fun exercises, yellow tips placed on the wheelchair brakes, and non-skid footwear at all times. Fall assessment dated [DATE] scored 15 which documented if the total score was 10 or greater, the resident should be considered a high risk for potential falls. The notarized statement dated 8/29/15 from licensed nursing staff H documented the direct care staff O removed the fall mat, left the room to get incontinent brief, and when he/she returned, the resident was found on the floor. Licensed nursing staff H ' s notarized statement documented all interventions were in place except no fall mat and the resident ' s bed was at wheelchair height. The nurse ' s notes dated 8/29/15 at 3:40 P.M. documented at 7:50 A.M. direct care staff O told licensed nursing staff H the resident was on the floor. Licensed nursing staff H entered the resident ' s room and observed the resident lying on his/her left side, with the left arm was under his/her body with both knees flexed back. There was no fall mat and the bed was about the height of a wheelchair. Direct care staff O stated he/she had removed the fall mat, left the room to get incontinent briefs, came back, and found the resident lying on the floor. The resident denied pain, however, after positioning the resident on his/her back and maneuvering his/her left lower leg to an outer rotation the resident stated ouch . The doctor ordered a pelvic and left hip x-rays. The x-rays showed an acute left hip fracture (broken bone). The x-ray report dated 8/29/15 documented the resident with an acute left hip fracture. A teachable moment form (a written training) dated 8/29/15 documented staff covered the subject of safety. Licensed nursing staff H wrote: when a resident has an intervention of a fall mat, the fall mat should be in place while the resident was in bed, even when stepping out of the room for briefs. Also, if the resident had a fall mat, when the resident was in bed, the bed should be in the lowest position. Direct care staff signed the teachable moment form. On 9/25/15 at 8:35 A.M. observed the resident positioned on his/her in a low bed with pillows on a perimeter mattress. The bed was positioned next to the window and a fall mat was on the floor next to the bed. The call light was placed across the resident ' s chest. During an interview on 9/25/15 at 2:23 P.M., direct care staff O stated when he/she first entered the resident ' s room on 8/29/15; he/she had their legs off the bed. He/she placed their legs back in the bed and removed the fall mat at bedside. Direct care staff O stated there were no incontinent briefs in the room and he/she left the room and went down the hall to get the incontinent briefs. Direct care staff O stated he/she failed to replace the fall mat when he/she left the room. Direct care staff O stated when he/she returned to the room, the resident was laying on his/her left side on the floor. Direct care staff O then went and got the nurse. An interview on 9/25/15 at 2:40 P.M. with licensed nursing staff H stated when he/she went to the room, the resident was laying on his/her side on the floor next to his/her bed. The resident ' s bed was not in its lowest position and the fall mat was not at the bedside. Licensed nursing staff H stated he/she asked direct care staff O about the bed not being lowered and he/she stated he/she forgot to lower the bed. Licensed nursing staff H stated direct care staff O told him/her that he/she also removed the fall mat and did not replace the fall mat when he/she left the room. Licensed nursing staff H stated he/she gave direct care staff O teachable moment related to make sure the fall mat was in place and the resident ' s bed was in the lowest position whenever he/she left a resident ' s room. An interview on 9/25/15 at 3:15 P.M. with licensed nursing staff H stated direct care staff receive an updated Kardex daily that documents what each residents ' needs are. This resident was to have the bed in the lowest position with a fall mat beside the bed whenever he/she was in bed. The 12/20/13 revised facility policy Fall Prevention and Management Protocol documented the interdisciplinary team would develop a plan of care with interventions that would reduce the resident ' s risk for falls. The facility failed to ensure the nursing staff provided the interventions as planned to prevent for falls for this cognitively impaired, dependent resident who fell from his/her bed and received a fractured hip.

The facility documented a census of 145 residents. The sample included 3 residents. Based on record review and interviews, the facility failed to have a system in place to provide guidance to the staff related to the use of hot packs which resulted in a resident (#1) who received 2nd-3rd degree burns. Findings included: - On 11/30/12 at 12:55 P.M. observation revealed the Hydrocollator in a locked storage room with a padlock of the top of the Hydrocollator and the temperature recorded 156 degrees. There were no instructions and/or signs posted regarding the usage of the Hydrocollator housed in this storage area. The facility policy " Moist Hot Packs " instructions were located in the therapy department and not accessible to the nursing staff. On 11/30/12 at 1:30 P.M. therapy staff H revealed the policy for Moist Heat Packs was located in the therapy department , therapy staff were the only facility staff to utilize the hot packs. Resident #1 ' s history and physical dated 8/31/12 included the [DIAGNOSES REDACTED]. The significant change Minimum Data Set 3.0 assessment dated [DATE] documented the resident ' s Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognitive status. The resident required extensive assistance of 2 staff with bed mobility, transfers and toilet use, and extensive assistance of 1 staff with dressing and personal hygiene. The MDS further documented the resident was at risk of developing pressure ulcers and had burns of second or third degree (destruction of skin and damage to underlying tissues). The Care Area Assessment (CAA) dated 10/31/12 related to pressure ulcers documented the resident required help with bed mobility and was at risk for skin breakdown. The resident had a thermal (pertaining to heat) wound on his/her right mid back for which he/she received a daily dressing. The care plan dated 10/11/12 documented the resident had impaired skin integrity. The approaches included: consult the dietician as needed, monitor for pain as needed; medicate the resident prior to wound treatment to prevent back spasms, monitor for signs/symptoms of infection, wound care physician consultation as needed, a foam pad with a cut out used to offload the resident ' s back when in the recliner, after the resident received a shower, remove the dressing and apply new dressing, and the resident ' s reclining back wheelchair provided with a high back pad and foam cut out to offload the back wounds. Review of the physician ' s notes documented on 10/8/12 at 4:31 P.M. recorded the resident with chronic pai[DIAGNOSES REDACTED] and weakness due to [DIAGNOSES REDACTED] (inflammation of the spinal cord) and to continue the resident ' s current medications. The physician ' s notes further documented the resident was in and out of alertness. Consultant J documented on 10/9/12 at 5:39 P.M. the resident had a 20.5 centimeters (cm) by 20 cm area on the right mid back of [DIAGNOSES REDACTED] (redness) with 2 open areas within the [DIAGNOSES REDACTED] that appeared like a blister that opened and the tissue sheared to the side. The middle open area measured 6.3 cm by 2.5 cm with depth 0.1 cm with a red and purple wound bed. The open area to the side measured 4 cm by 3 cm by 0.1 cm with a red wound bed. The open areas drained a small amount of serosanguinous (bloody) drainage. Consultant J documented several scattered intact blisters throughout the area of [DIAGNOSES REDACTED]. The resident denied any pain which was unusual because he/she typically complained of hypersensitivity to the skin on his/her back. The resident ' s physician documented on 10/10/12 at 9:14 A.M. the red area on the resident ' s back with a ruptured fluid filled sack. The resident did not complain of pain. The patient received topical heat in this area. The physician documented " presumed 2nd degree burn involving most of the resident ' s right side of his/her back " . The nurses notes dated 10/11/12 at 2:21 P.M. revealed on 10/9/12 around 8:30 A.M. to 9:30 A.M. the therapy staff reported to the nursing staff that the resident had some noticeable drainage on his/her shirt. On examination licensed nursing staff K documented 2 shearing spots on his/her back measuring approximately 20 cm by 15 cm in a circular shape, one just below the right shoulder blade and another spot slightly below that area on the right mid back with blisters that had sheered opened. The surrounding skin area appeared red. The resident stated the nurse used a heating pad on his/her back the previous night and suspected he/she sustained the burns. The resident ' s chart lacked a physician orders [REDACTED]. Consultant J documented on 10/12/12 at 10:09 A.M. the resident stated he/she had discomfort in some areas of the burn and in other areas of the burn he/she could not feel a thing. Consultant J documented on 10/15/12 at 10:14 A.M. the blister on the medial (toward the middle) side of the right mid back was not fluid filled anymore and had no open areas. The tissue on top of the blister was intact and adhered (stuck) to the skin with red/dark tissue observed underneath. The wound beds of the middle and lateral (to the side) open wounds were red and dark red/purple with no redness or swelling surrounding the wound. The resident did not complain of any discomfort during treatment. The 11/14/12 hospital history and physical documented the resident recently had a third degree burn to his/her back approximately 4-5 weeks ago from a heating pad. A local wound doctor treated the burns and recently an infectious disease doctor saw the resident. Apparently, the resident developed an abscess (a localized collection of pus that results from invasion of bacteria) over the last couple of days. Additionally, the resident developed a new abscess in the last 24 hours, to the side of the burn. On 11/30/12 at 12:08 P.M. administrative nursing staff C revealed the resident received a hot pack during the night of 10/8/12 without a physician's order [REDACTED]. Administrative nursing staff C revealed that the nursing staff was not trained on the use of the hot packs. On 11/30/12 at 1:22 P.M. licensed nursing staff D revealed that he/she obtained the hot pack from the Hydrocollator and wrapped the hot pack in 1 special hot pack cover and no other towels or covers was used. Licensed nursing staff D applied the hot pack to the resident ' s back. Licensed nursing staff D revealed that he/she did not assess the resident ' s skin before or after application of the hot pack. Licensed nursing staff D revealed that he/she did not check for an order for [REDACTED]. On 12/4/12 at 7:45 A.M. resident #1 revealed he/she requested a heating pad during the night, just after midnight and the nurse returned with some kind of covered, heated square block that he/she had never seen before. The nurse placed the hot pack behind his/her back. The resident revealed that he/she wore a t-shirt to bed and that he/she slept in a recliner. The resident stated he/she woke up 4-5 hours later and the pad was all bunched up, so he/she took the pad out from behind his/her back and tossed the pad on the floor. He/she revealed that certain parts of his/her back were dead and he/she could not tell if the pad was hot or not. On 12/4/12 at 8:33 A.M. licensed nursing staff D revealed he/she had placed the hot pack with one covering behind the resident ' s back. Licensed nursing staff D revealed the Hydrocollator was located in a storage room that was accessible to the nursing staff. The storage room contained no instructions of how to use the hot packs. Licensed nursing staff D revealed the hot packs should be used for no more than 30 minutes, then removed and the resident ' s skin inspected for any irritations. Licensed nursing staff D was unsure how long he/she left the hot pack on this resident and he/she did not check the resident ' s skin for any irritations. Licensed nursing staff D revealed that he/she had used the hot packs in the past on other residents with no complaints voiced. Licensed nursing staff D revealed that other nurses on the night shift had been observed using the hot packs. An interview on 12/05/12 at 12:35 P.M. with licensed nursing staff K said that he/she knew where the hydro collator was located and have used hot packs on residents who had a physician order. He/she said he/she had not been instructed to not use it, he/she was not trained on how to use hot packs and was not aware of any facility policy regarding their use. An interview on 12/05/12 at 12:50 P.M. with licensed nursing staff L revealed that he/she had previously used K pads but not hot packs. He/she said the facility did not instruct or train him/her how to use the hot packs, was never told not to use them, and he/she was not aware of a facility policy regarding the use of hot packs. He/she said that the facility did not train him/her on the use of the K pad but he/she read the instructions and used it for a resident who had a physician order [REDACTED]. The 9/8/10 revised facility policy " Moist Hot Packs " revealed residents with desensitized areas should not use the moist hot packs. The 9/8/10 revised facility policy located only in the therapy room for " Moist Hot Packs " included the following: 1) Inspect the area to be treated. 2) Explain the procedure to the resident. a) The heat from the pack should be comfortably warm, but not hot. b) It may take several minutes to feel the warmth. 3) Check the skin sensation. Use hot packs with extreme caution if sensation is impaired. 4) Place the resident in a comfortable position so that the hot pack will be on top. (The resident may lay with hot packs under their neck or back; however, additional padding will be necessary). 5) Apply the hot packs to the resident, being sure there are at least 6-8 layers of toweling between the packs and the resident. 6) Cover the resident with a sheet or blanket to avoid chilling. 7) Set the timer for 20 minutes and give the resident a call bell. 8) Check on the resident frequently for skin irritation or burning. 9) At the end of the treatment time, remove the pack, dry the resident, and inspect the skin for any unusual redness. 10) Replace the hot pack in the Hydrocollator unit (machine that contains hot water with a temperature up to 165 degrees and the hot packs). a) Dispose of the towel used directly next to the resident. b) Hang or spread the other layers of padding to dry. On 12/4/12 the facility provided a 2/09 policy " T-pump Heat Therapy System (K-pad) " which documented this would be the only source of heat therapy that will be used by the nursing staff. The policy was revised on 11/30/12 to include " No hydrotherapy pads, or items heated in the microwave will be used by the nursing staff (rice packs or towels). The facility failed to have system in place to provide guidance to the nursing staff on the use of hot packs which ultimately caused this resident who had sensation impairments, with 2nd-3rd degree burns on his/her back that lead to abscesses and hospitalization s.

The facility recorded a census of 115 residents. The sample included 3 residents with pressure ulcers. Based on observations, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing of pressure ulcers and to prevent new ulcers from developing for 2 sampled residents (#1 and #2). Findings included: - Resident #2's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident at risk for pressure ulcer development. The MDS revealed the resident did not have pressure ulcers or other ulcers, wounds or skin problems. The significant change MDS dated [DATE] documented the resident had short and long term memory loss and required extensive assistance of 1 staff with all activities of daily living. The MDS further documented the resident was frequently incontinent of urine and bowel. The resident developed 3 stage 2 pressure ulcers of which 2 were not present or were at lesser stage on prior assessment. The pressure ulcer Care Area Assessment (CAA) dated 11/4/11 documented the facility would care plan the pressure ulcers in order to minimize worsening of the present ulcer and the development of new ulcers. The care plan dated 10/6/2011 documented the resident at risk for a pressure ulcer or other resulted skin issues due to being frequently incontinent of urine and bowels and unsteady gait and balance. The approaches included: help the resident to prevent further skin breakdown and prevent the resident from getting an infection, treatment as ordered by the doctor, monitor the three pressure ulcers and the one wound for signs and symptoms of infection, check the resident's skin each day when getting dressed, notify the nurse with changes, toilet the resident or change the resident, provide peri care using peri-wash and barrier after each incontinent episode, and float the resident's heels when in the bed. An addition made to the care plan on 11/10/11 documented the resident had 3 toes amputated related to pressure ulcers so when bathing and/or applying lotion make sure that the resident's feet/toes are in good condition. The resident had a chronic sacrum wound. The resident received new diabetic shoes to wear to assist with circulation to his/her feet. The care plan directed nursing staff to check and make sure that the shoes fit properly and were not causing any redness to the resident's feet. The nurses notes dated 8/23/11 documented that physical therapy (PT) notified nursing of some redness to resident's left heel. The heel was blanchable when palpated, unopened, dry, and intact. Staff should apply Sensacare (barrier cream) to the resident's bilateral heels daily. Nurse's note dated 9/1/11 documented the sacral fissure and both heels were intact. Nurse's note dated 9/29/11 revealed an open area to left of the gluteal fold which measured 0.5 centimeters (cm) by 1 cm with no drainage. Staff applied Sensacare to this area. Nurse's note dated 10/5/11 revealed that during a routine skin assessment and follow up wound measurement of the left gluteal fold, which measured, 1.5 cm by 1.5 cm with depth of 0.2 cm, staff found another wound on the left medical aspect of heel which measured 0.8 cm by 1.0 cm with depth of 0.1 cm. Nurse's note dated 10/6/11 licensed nursing staff B documented the resident continued at risk for wounds. The resident continued with a sacral fissure which remained unchanged from previous weeks. The resident had three new areas noted this week: the left gluteal fold and the left and the right heels. Nurse's note dated 10/7/11 revealed the resident had an open area on his/her left buttocks and staff treated per physician's orders [REDACTED]. Nurse's note dated 10/11/11 licensed nursing staff C documented the resident's sacral fissure opened and the resident had 2 open areas to left left gluteal fold and left heel. Nurse's note dated 10/13/11 the nurse documented the staff should apply a foam dressing to the resident's left heel and change daily. Sensacare cream applied to heels daily and if the right heel opened, then foam to right heel. Nurse's note dated 10/15/11 documented the nursing staff should float the resident's heels. Nurse's note dated 10/21/11 revealed the resident had one new open area to his/her right heel. Nurse's note dated 10/25/11 revealed the resident had three stage II pressure ulcers: left gluteal crease, bottom of left heel and lateral side of right heel. The physician felt the resident's intake and dementia were major barriers to wound healing. Nurse's note dated 11/1/11 revealed a new order for wound care dressing to bilateral heels and change every 5-7 days or as needed. The nursing staff may use heel protectors/boots while the resident was in bed and if needed in the wheelchair. Nurse's note dated 12/19/11 noted a new open area on the coccyx which measured 1.5 cm by 2 cm. Staff would cleanse and apply Sensacare barrier cream. The pressure ulcer flow sheet documented the resident continued with 4 pressure ulcers from 12/19/11 to 1/16/12. The pressure ulcers were on the gluteal fold, the sacrum, left inner heel and right outer heel. The sacral fissure opened since 10/13/11. On 1/18/12 at 10:30 A.M. observed the resident laid in his/her bed on his/her back. The resident's left heel and right outer foot were laying on the pillow. License nurse staff C provided the treatment to the left heel where he/she covered a pinpoint open area with [MEDICATION NAME] (topical antibiotic ointment), foam and tape. The right anterior heel was red, tender to touch and slight swelling noted. Staff covered the wound with [MEDICATION NAME], 4 x 4 and taped the dressing in place. Licensed nursing staff C applied a clean pair of socks to and then placed both feet directly on the pillow. The resident was not wearing heel protectors/bunny boots at this time. On 1/18/12 at 10:55 A.M. observed licensed nursing staff C and licensed nursing staff D returned to the resident's room to provided wound care to the resident's coccyx. Observation revealed 2 open stage 2 pressure ulcers on the right buttocks and an open fissure on the left buttocks. Licensed nursing staff C revealed that the resident had a new open area on the right upper buttocks. Licensed nursing staff C revealed that the resident did not have the open area on the right upper buttocks on Monday, January 16, 2012. Licensed nursing staff C and licensed nursing staff D then repositioned the resident on his/her back and laid the resident's heels in direct contact with the pillow. Review of the resident's January treatment record revealed that the resident could wear pressure relieving boots when in bed. The updated kardex instructed the nursing staff to encourage the resident to float his/her heels when in bed. The revised 8/25/08 facility policy, "Stage II Pressure Ulcer Protocol" instructed the nursing staff when the resident is laying on their back, to place a pillow under lower legs to elevate heels off the bed surface. The nursing staff instructed to use pillows, gel pads, foam wedges, elbow and heel protectors as indicated in care plan to protect bony prominence. On 1/18/12 at 10:30 A.M. licensed nursing staff C revealed that the nursing facility did not use heel protectors but the resident used to have the big boots. The resident was walking at that time and it caused him/her problems with walking. On 1/18/12 at 4:20 P.M. licensed nursing staff E revealed residents had kardexes that staff updated regularly that nursing followed for the residents' cares. On 1/18/12 at 4:35 P.M. direct care staff F revealed that the kardex and care tracker told the nursing staff what cares residents needed. On 1/19/12 at 7:45 A.M. administrative staff A revealed that staff updated the kardex daily and the nursing staff should follow the instructions on the kardex. The order for the bunny boots should not be on the treatment record, it should be in the care plan and on the kardex. The bunny boots should never be ordered as needed either. The facility failed to provide preventative measures to prevent the development of multiple pressure ulcers for this dependent resident. - Resident #1's closed record Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented Brief Interview for Mental Status (BIMS) with a score of 0 which documented the resident had severely impaired decision making skills. The MDS further documented the resident required extensive assist of 1 staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further documented the resident was at risk for the development of pressure ulcers. The pressure ulcer Care Area Assessment (CAA) dated 5/19/11 documented the resident at risk for impaired skin integrity due to multiple episodes of loose stools, poor strength/endurance, poor oral intake, and required assist with all aspects of care. The care plan dated 4/15/10 documented the resident at risk for a pressure ulcer or other related skin issues due to generalized weakness, immobility, increase in sleeping, infection of [MEDICAL CONDITION] and end of life. The approaches included: check the resident's skin each day when getting the resident dressed, notify the nurse of any changes of the resident's skin, staff should reposition the resident after toileting, keep the resident's heels heels off of the bed, staff should position the resident in bed with pillows between the resident's knees/feet, use elbow protectors and float heels with heel protectors. The care plan updated on 12/4/11 documented the resident with 5 stage one pressure ulcers, located on both heels, the right lateral (outer) ankle, the right hip, and the right buttocks. The approaches documented the staff would provide a low air loss mattress to the resident's bed, staff to position the resident with pillows between the his/her knees for comfort, apply elbow protectors, and to float the resident's heels with heel protectors. The 12/3/11 nurses notes documented the resident was in bed resting and his/her call light was within reach. His/her bed was in a low position and his/her feet elevated. The nurses notes revealed no skin issues. The nurses notes dated 12/4/11 at 3:31 P.M. documented the resident remained in bed today. The resident complained of increased pain to hip area with repositioning. Staff placed a pillow between the resident's legs due to slight reddening to the resident's left knee. The nurses notes dated 12/4/11 about 6 P.M. the staff repositioned the resident and found new reddened skin areas to both heels, the right lateral ankle, the right hip, and the right buttocks. Staff applied a skin protective barrier cream and floated the heels off the resident's bed. Staff called the hospice company and requested a low air loss mattress for the resident and also requested two heel protectors for the resident. The nurses notes dated 12/4/11 and timed 10:13 P.M. documented the resident had a new low air loss mattress placed on his/her bed. The wound measurements (all stage I = redness only) documented as follows (measurements in centimeters): right heel left heel right hip right lateral ankle right upper buttock 12/4/11 3 x 3 3 x 3 4 x 2 1.5 x 3 2x1.5 12/5/11 2 x 2 ----- 2.5 x 1.5 ------- ------- 12/9/11 2.2 x 2 ----- -------- ---------- ------- 12/16/11 2.2 x 2 ------- --------- ---------- ------- The revised 8/25/08 facility policy, "Pressure Ulcer Prevention and Management Policy" instructed the nursing staff that when a resident was bedfast to place a pressure relieving mattress. The revised 8/25/08 facility policy, "Stage One Pressure Ulcer Protocol" instructed the nursing staff when a resident is laying on his/her back, to place a pillow under lower legs to elevate heels off the bed surface. The nursing staff instructed to use pillows, gel pads, foam wedges, elbow and heel protectors to protect bony prominence. 1/18/12 at 11:21 A.M. administrative nursing staff A stated the facility did not use heel protectors until the end of life. We saw where on the care plan it said the 8/11/11 heel protectors provided by hospice but we received the low air loss mattress and heel protectors on 12/4/11. The care plan had standard approaches and the nurses should customize them for each resident. The staff did not remove the heel protectors from the original care plan. The nurse assessed the resident's wounds and put into place what was needed. The resident received a low air loss mattress and heel protectors the evening after staff noted the redness. The facility failed to provide interventions to prevent the development of multiple Stage I pressure ulcers for this dependent resident.