Every finding on record at Life Care Center of Kansas City

The facility identified a census of 57 residents. The facility had one kitchen. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to overflowing trash and food storage. This deficient practice placed the residents at risk for food-borne illness.Findings included:- During the initial tour on 08/18/25 at 07:33 AM, observation revealed the following:The kitchen floor was sticky. In the small one-door freezer, there was food wrapped in plastic wrap that appeared to be fish, unlabeled and undated. In the two-door freezer, there was a bottle of pink Minute Maid lemonade, a tub of ice cream, and a bag of cookie dough opened and undated.The green trash bins were overflowing with trash, next to the stove, uncovered. On 08/18/25 at 07:46 AM, Dietary Staff BB stated all foods should be dated and labeled. She stated the kitchen floor was sticky and would be cleaned. Dietary Staff BB stated that the trash should not be overflowing and should always be covered.The facility's Food Safety policy dated 05/01/25 documented that food was stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth.

The facility identified a census of 57 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from August 2024 through July 2025, lacked evidence of tracking and identification of possible infection outbreaks at the facility, lacked consistent identification of infection, and of antibiotic administration. The facility was unable to provide evidence of the documentation of continent documentation of the infection control surveillance from August 2024 through March 2025. On 08/19/25 at 03:23 PM, Administrative Nurse E, the facility's Infection Preventionist (IP), stated she had just started as the IP in April 2025. Administrative Nurse E stated she was unable to answer whether the previous IP had tracked the antibiotic administration, tracking, and trending of clusters of infections or organisms. The facility's Antibiotic Stewardship policy, last revised 07/22/25, documented the antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This meant that the antibiotic was prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program would be managed and overseen by the Infection Preventionist.

The facility had a census of 57 residents. The sample included 15 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 44 E pressurized medical oxygen tanks in a safe, locked area, and out of reach of the eight cognitively impaired, independently mobile residents. The facility further failed to ensure R2's fall interventions were in place. This deficient practice placed the residents at risk for preventable accidents and injuries.Findings Included:- On 08/18/25 at 07:56 AM, an inspection of the facility’s oxygen storage room revealed that the door was not secured. An inspection of the room revealed 44 full E-supplemental oxygen cylinders in the storage racks. The door had a keypad and did not lock when the door was shut. On 08/19/25 at 07:22 AM, an inspection of the facility’s oxygen storage room revealed that the door was not secured. An inspection of the room revealed 44 full E-supplement oxygen cylinders in the storage racks. The door had a keypad and did not lock when the door was shut. On 08/20/25 at 08:22 AM, the facility identified it had eight cognitively impaired, independently mobile residents. On 08/19/25 at 07:25 AM, Licensed Nurse (LN) H stated the oxygen room should be unlocked. On 08/20/25 at 11:17 AM, Certified Nurse’s Aide (CNA) M stated the room had been unlocked, and she was unsure if the room should be locked or unlocked. On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff were expected to ensure the door was locked upon entering and exiting the room. She stated the room should always be locked. The facility’s “Oxygen Administration (Safety, Storage, Maintenance) revised 10/11/24 documented it was the policy of the facility to ensure that oxygen was administered and stored safely within the healthcare centers or in an outside storage area. - The Medical Diagnosis section within R2’s Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and a history of falls. R2’s “Quarterly Minimum Data Set (MDS)” completed 06/27/25 revealed a Brief Interview for Mental Status Score of 14, indicating severe cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required supervision or touch assistance for bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and putting on footwear. The MDS noted she had a history of falls. R2’s “Falls Care Area Assessment (CAA)” completed 06/13/25 indicated she had a history of falls related to generalized weakness and her medical diagnoses. The CAA noted she used a wheelchair. The CAA indicated that a care plan was implemented to minimize her risks of falls. R2’s “Care Plan” initiated on 11/28/20 indicated she required assistance with her activities of daily living (ADL). The plan noted she had a history of falls related to her medical diagnoses. The plan indicated signage was placed in her room to “call for help”. The plan instructed staff to ensure she wore non-skid footwear before transferring. The plan indicated her room was to have non-skid traction tape placed on her bedroom and bathroom floors to prevent falls. A review of R2’s EMR under “Census” revealed she was moved to a new room on 08/01/25. The EMR indicated she had no falls since being moved to her new room. On 08/18/25 at 07:34 AM, an inspection of R2’s room revealed no traction tape or signage posted in R2’s bedroom or bathroom. On 08/20/25 at 11:17 AM, Certified Nurse’s Aide (CNA) M stated R2 recently moved room and her fall interventions should have been transferred to her new room. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated staff were expected to ensure the interventions were in place each shift and transfer the implemented fall interventions when a resident was moved to a new room. On 08/20/25 at 11:24 AM, Administrative Nurse D stated R2 was recently moved to a different room, and her fall interventions should have been transferred to her new room. She stated staff were expected to inspect her room and ensure the fall interventions were implemented. The facility’s “Fall Management System,” revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility reported a census of 57 residents. The facility identified four medication carts. Based on observations, record review, and interviews, the facility failed to secure medication at the nurse's station. This deficient practice placed the residents at risk for unnecessary medication and administration errors.Findings included:On 08/18/25 at 07:45 AM, an inspection of the 200 Hall revealed a bottle of ocular vitamins dated 07/07/25 left unsecured on the counter at the nurse's station. The bottle contained the warning Keep out of reach of children, in case of accidental overdose, get medical help or contact poison control center right away.On 08/18/25 at 07:50 AM, Licensed Nurse (LN) G secured the vitamins and stated the medications were to be locked up in the nurse's carts and not left out at the station. On 08/20/25 at 11:24 AM, Administrative Nurse D stated medications were to be locked up at all times and out of reach of the residents. The facility's Medication Access and Storage policy, revised 09/2024, indicated the facility was to ensure all medications and biologicals remained locked and secured to prevent tampering or exposure to the environment.

The facility identified a census of 57 residents. The sample included 15 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)2's wheelchair foot pedals were utilized while being pushed. The facility additionally failed to ensure R43 had a way to communicate her needs due to her call lights being left out of reach. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings included:- The Medical Diagnosis section within R2's Electronic Medical Records (EMR) noted diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, and a history of falls. R2's Quarterly Minimum Data Set (MDS) completed 06/27/25 revealed a Brief Interview for Mental Status Score of 14, indicating severe cognitive impairment. The MDS noted she had no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required supervision or touch assistance for bed mobility, transfers, dressing, bathing, toileting, personal hygiene, and putting on footwear. The MDS noted she had a history of falls. R2's Falls Care Area Assessment (CAA) completed 06/13/25 indicated she had a history of falls related to generalized weakness and her medical diagnoses. The CAA noted she used a wheelchair. The CAA indicated that a care plan was implemented to minimize her risk of falls. R2's Care Plan initiated on 11/28/20 indicated she required assistance with her activities of daily living (ADLs). The plan noted she had a history of falls related to her medical diagnoses. The plan indicated signage was placed in her room to call for help. The plan instructed staff to ensure she wore non-skid footwear before transferring. The plan indicated that her room was to have non-skid traction tape placed on her bedroom and bathroom floors to prevent falls. The plan noted she used a wheelchair for mobility. On 08/20/25 at 11:17 AM, a Certified Nurse's Aide (CNA) stated staff were expected to use the foot pedals when pushing residents in their wheelchairs. On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff should not be pushing residents in their wheelchairs without using foot pedals to prevent their feet from dragging or being a fall risk. The facility's Fall Management System, revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred. - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle weakness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, fracture with routine healing, and hypoxia (inadequate supply of oxygen). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R43 was rarely or never understood. The MDS documented R43 was dependent on staff for all ADLs. R43 's Tube Feeding Care Area Assessment (CAA) dated 09/18/24 documented that R43 was nothing by mouth (NPO) and received tube feeding continuously. The CAA documented R43 receives hydration through tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube), and nursing administers the feeding and hydration per the physician's orders.R43's Care Plan dated 05/13/24 indicated R43 required staff assistance for her activities of daily living and was at risk for falls related to her medical diagnoses. The plan instructed staff to ensure her call light remained within reach and staff provided assistance as needed. On 08/18/25 at 08:34 AM, R43 lay in her bed on her back with her eyes shut. R43 had a thick yellow substance on her lips and in her mouth. On 08/19/25 at 02:12 PM, R43's call light lay between R43's bed and her roommate's bed on the floor. R43's call light was not within her reach.On 08/20/25 at 11:17 AM, the Certified Nurse Aide (CNA) M stated that call lights were to be placed within the resident's reach at all times.On 08/20/25 at 11:24 AM, Administrative Nurse D stated staff were expected to check the call light placement during each encounter to ensure the residents could communicate their needs. The facility's Fall Management System, revised 03/2025, indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility identified a census of 57 residents. The sample included 15 residents, with one reviewed for privacy. Based on observation, record review, and interviews, the facility failed to secure protected health information (PHI) for Resident (R) 31. This deficient practice placed R31 at risk for decreased psychosocial well-being due to a lack of privacy. Findings Included: - On 08/18/25 at 07:39 AM, a walkthrough of the 100 Hall revealed an unattended nursing cart across the hallway from the nurse's station. An inspection of the cart revealed R2's PHI displayed on the cart. At 08/18/25 at 07:40 AM, Licensed Nurse (LN) H exited a room in the 100 Hall and locked the computer screen. On 08/20/25 at 11:01 AM, LN G stated the computer was to be locked when not attended by staff to protect health information. On 08/20/25 at 11:40 AM, Administrative Nurse D stated staff were expected to lock the computer screens when they were not in use to protect the residents' PHI. A review of the facility's Resident Rights revised 09/2024 indicated the facility will ensure each resident's privacy and ensure all residents were educated and informed of their rights.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for the discharge process. Based on observation, record review, and interviews, the facility failed to provide a final summary of the resident's status at discharge for Resident (R) 64 and R1. This deficient practice placed R64 and R1 at risk of delayed care or uncommunicated care needs.Findings Included: - R64's “Electronic Medical Records” (EMR) documented diagnoses of malnutrition (consuming to few calories), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), cancer of the rectum, muscle weakness, unsteadiness on feet, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R64's Modification of Admissions Minimum Data Set (MDS) completed 05/13/25 noted a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented that he had an impairment of her lower extremity. The MDS documented R64 needed supervising or touching assistance with eating and oral hygiene, and partial/moderate assistance with toileting and bathing. R64’s “Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA), dated 05/13/25, documented generalized muscle weakness and was on skilled services, nursing assisted with activities of daily living (ADLs) function as needed, and staff to place R64’s call light within his reach. R64’s EMR recorded a “Discharge Assessment-Return Not Anticipated MDS” documenting R64's discharge date d 06/24/25. R64’s “Care Plan,” revised 07/07/25, documented the discharge plan was to go home after therapy services. The plan of care for R64 documented the facility would develop and follow a full discharge plan with a comprehensive plan. R64’s EMR under “Progress Notes” revealed a “Nursing Note” dated 06/24/25 that documented R64’s caregiver was at the facility to pick up R64 and take him home. R64 refused his medications; he stated he wasn't going to take them, and the caregiver agreed. R64’s belongings were packed and given to him. R64 left in a personal car. Paperwork was sent with R64. R64’s “Discharge Charge Summary” was undated and lacked documentation showing recompilation of his stay in the facility. On 08/20/25 at 11:01 PM, Licensed Nurse (LN) G stated it was the responsibility of the nurse who was on duty when a resident was discharged from the facility. He stated the nurse would document in the resident's nursing notes what the facility had done for the resident, where the resident was going, what he took with him, the medications he had, what the facility did with the medications, and what follow-up appointments the resident had scheduled. On 08/20/25 at 11:24 PM, Administrative Nurse D stated it was the nurse on duty’s responsibility to document a recompilation of the resident's stay in the facility, which included where his medication was sent, where the resident was going, and what the facility had done for the resident. The facility’s “Discharge Summary” dated 09/05/25 documented that the social services and nursing staff participate in developing a discharge summary when a resident is discharged to a private residence, another nursing facility, or another type of residential facility. The discharge summary provides a recapitulation of the resident’s stay and the resident’s status at the time of discharge to ensure continuity of care. Facilities will complete the discharge summary located in PointClick Care unless state policy requires the use of a state-mandated discharge summary form. - R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of respiratory failure with hypoxia (inadequate supply of oxygen), dyspnea (difficulty breathing), insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The “admission Minimum Data Set (MDS)” dated 03/13/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was independent with activities of daily living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R1 was independent with his ADLs. R1’s Cognitive Loss/Dementia Care Area Assessment (CAA)” dated 03/19/25 documented R1 had verbal behaviors directed toward other residents. R1's “Care Plan,” dated 07/16/25, documented nursing staff would discuss the history of hospitalization with him and family. The plan of care documented the staff would educate him and his family on his current health condition and self -manager. R1‘s EMR under the “Progress Notes” tab revealed the following “Health Status Note” on 05/30/25 at 06:36 PM: R1 was transferred to the hospital. On 08/19/25 at 11:41 AM, R1 sat outside the facility in his wheelchair during an activity. R1 visited with staff and other residents. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated he would have the resident sign the facility’s bed hold policy prior to the transfer to the hospital and give the resident a copy of the policy. LN G stated he called the resident’s family or their legal representative to notify them of the transfer. LN G stated he did not notify the family or representativity in writing. On 08/20/25 at 11:25 AM, Administrative Nurse D stated the written notification to the resident’s legal representative was provided by the social service department. Administrative Nurse D stated the bed hold policy was sent with the resident at the time of transfer. The facility’s “Bed-Hold Policy,” last revised 08/05/25, documented the bed-hold policy would be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility would provide written information to the resident or resident representative, the nursing facility's policy on bed-hold periods, and the resident's return to the facility to ensure that residents are made aware of a facility’s bed-hold and reserve bed payment policy before and upon transfer to ahospital or when taking a therapeutic leave of absence from the facility.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure that cleaning of her mouth was provided for Resident (R) 43, who required assistance from staff to complete the care. This deficient practice placed R43 at risk for complications, including discomfort related to poor personal hygiene.Findings included:- R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle weakness, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness, fracture with routine healing), and hypoxia (inadequate supply of oxygen).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R43 was rarely or never understood. The MDS documented R43 was dependent on staff for all ADLs. R43's Tube Feeding Care Area Assessment (CAA) dated 09/18/24 documented R43 was nothing by mouth (NPO) and received tube feeding continuously. The CAA documented R43 receives hydration through tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube), and nursing administers the feeding and hydration per the physician's orders.R43's Care Plan dated 05/13/24 documented R43 had oral/dental health problems (inflamed gums) related to poor oral hygiene and was NPO. R43's plan of care documented mouth care was to be provided at least daily. R43's plan of care directed staff to provide mouth care daily, and staff were to report any abnormalities to nursing. On 08/18/25 at 08:34 AM, R43 laid in her bed on her back with her eyes shut. R43 had a thick yellow substance on her lips and in her mouth. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated that the cleaning of a resident's mouth that had an internal feeding was not documented anywhere. He stated staff know residents with internal feedings need their mouths cleaned at least every shift. On 08/20/25 at 11:17 AM, the Certified Nurse Aide (CNA) M stated it was all the nursing staff's responsibility to ensure residents stay clean. CNA M stated normally, the LN was the person who cleaned residents' mouths when the resident had an internal feeding because they were in her room more often. She stated it was all the nursing staff's responsibility to ensure the residents are clean. On 08/20/25 at 11:24 AM, Administrative Nurse D stated residents should have their mouths cleaned when a staff member sees the resident's mouth is dirty. She stated that all residents should be clean and that it was every staff member's responsibility. The facility's Activities of Daily Living policy dated 09/25/25 documented the resident would receive assistance as needed to complete activities of daily living. The quality-of-care fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care by professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 58's bilateral lower extremities to prevent pressure ulcers. This placed R58 at increased risk for pressure ulcer development. Findings Included:- R58's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, communication deficit, need for assistance with person care, history of falling, disruption of wound, encephalopathy (a broad term for any brain disease that alters brain function or structure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following 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) affecting left dominant side. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R58 was never or rarely understood. The MDS documented R58 was at risk for pressure ulcers. The MDS documented R58 needed supervision or touching assistance to roll from right to left. The MDS documented R58 had a pressure-reducing mattress in her wheelchair and her bed. R58's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 05/29/24 documented R58 had a history of pressure injury. The CAA documented staff were to apply barrier cream to her buttocks for protection, and Skin-prep (liquid skin protectant) to bilateral heels.R58's Care Plan dated 05/21/25 documented R58 was at risk for skin integrity. The plan of care for R58 had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) on the left heel, which had healed. R58's plan of care documented to maintain intact skin with no breakdowns, R58 used a pressure-reducing mattress, and staff would perform weekly skin checks. R58's EMR under the Order tab documented the following physician orders:Bilateral boots were on even when she was in bed. Remove boots every shift to examine skin, related to disruption of wound, dated 03/14/25.Skin prep wipes were applied to the bilateral heel topically every shift related to the disruption of the wound, dated 03/14/25. The Braden Scale (a scale for predicting pressure sore risk) dated 07/25/25 documented a score of 12, which indicated a high risk for pressure wounds. On 08/19/25 at 02:14 PM, R58 laid on his bed on his back; R58's heels were directly on his mattress. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated that if a resident were to have boots applied to their heels, it would be a nursing duty and would be on the Treatment Administration Record (TAR). He stated it would be a nursing duty, and the nurse would ensure the boots were on the residents' feet. On 08/20/25 at 11:17 AM, Certified Nursing Aide (CNA) M stated that if a resident was to have their heels floated or boots applied to heels, it would show on the CNAs documentation and the charge nurses' documentation. She stated that all nursing staff would know that the residents' heels were to float, or boots needed to be applied to their heels. On 08/20/25 at 11:24 AM, Administrative Nurse D stated ensuring boots were applied to a resident's heels was ultimately the nursing duty and would be on the TAR. She stated the nurse could delegate the task to a CNA but would need to ensure the task was followed through. The facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management reviewed 03/31/23 documented the facility would provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds.

The facility identified a census of 57 residents. The sample included 15 residents, with two residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 54 was given (ROM- the full movement potential of a joint, usually its range of flexion and extension) exercises to prevent contractures (abnormal permanent fixation of a joint or muscle) and help with R54's flaccid left hand. This deficient practice left R54 at risk for further decline and decreased range of motion or mobility. Findings included:- R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following 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) affecting left non-dominant side, muscle weakness, need for assistance with personal care, dysphagia (swallowing difficulty), history of falling, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R54 was independent with eating, needed setup or cleanup for oral hygiene, and was partial/moderate assistance from staff for toileting, bathing, and dressing. R54's Functional Abilities Care Area Assessment (CAA) dated 05/09/24 documented R54 had a cerebral infarction with one-sided weakness and used his wheelchair for locomotion. R54's Care Plan dated 08/27/24 documented R54 had weakness and a decrease in physical mobility related to a cerebral accident. The plan of care documented R54 required extensive assistance from one staff member for locomotion using a wheelchair. The plan of care documented the staff were to observe and report any immobility, contractures forming or worsening. The plan of care for R54 documented the nursing and restorative aide were to perform active ROM to the bilateral lower extremities for 20 minutes. Review of R54's EMR documented no indication that ROM exercises were performed. R54's EMR documented no refusals of ROM exercises. On 08/20/25 at 11:01 AM, Licensed Nurse (LN) G stated the facility does have a restorative Certified Nurse's Aide (CNA). He stated the facility had been understaffed, and the restorative aide had been pulled to the floor to work as a CNA and was unable to do her restorative duties. On 08/20/25 at 11:17 AM, CNA M stated she was the restorative aide. She stated the facility was now fully staffed, and there was a plan in place for her to start doing exercises daily with the residents. On 08/20/25 at 11:24 AM, Administrative Nurse D stated the facility had been short-staffed, and the restorative aide was not able to work as a restorative aide. She stated the facility did have a plan in place to ensure the restorative program was in place. The facility's Restorative Nursing policy, reviewed on 09/20/24, documented that the restorative program was to promote the resident's optimum function. A restorative program may be developed by proactively identifying, care planning, and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities.

The facility identified a census of 57 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of monitoring antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 04/21/25 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R10 required substantial to maximum assistance with her activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R10 required substantial to maximum assistance with her ADLs. R10's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 04/24/25 documented she was alert and oriented and able to communicate her needs, but had cognitive impairment. R10's Care Plan, dated 04/15/25, documented staff would administer her medication as ordered by the physician. R10‘s EMR under the Orders tab revealed the following physician orders: Toprol XL (antihypertensive) oral tablet extended release 24-hour 25 milligram (mg) (metoprolol succinate), give three tablets by mouth at bedtime for chronic heart failure and high blood pressure dated 04/12/25. Review of R10's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 05/01/25 to 08/19/25 (111 days) lacked consistent heart monitoring for antihypertensive medication Toprol. Review of the Monthly Medication Review (MMR) from August 2024 to July 2025 lacked documented recommendations for heart monitoring for R10's antihypertensive medication orders for hold parameters and physician notification. On 08/19/25 at 11:41 AM, R10 laid asleep on her bed. R10 was covered with a blanket, call light was on the bed next to her. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated antihypertensive medication should be monitored. LN G stated that if an order lacked physician-ordered parameters, he would call and clarify the antihypertensive order. On 08/20/25 at 11:25 AM, Administrative Nurse D stated there should be monitoring for antihypertensive medication. Administrative Nurse D stated she would expect the CP to identify the lack of correct monitoring for medications.The facility's Pharmacy Services and Medication Regimen Review policy last reviewed 09/16/23 documented the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON).

The facility identified a census of 57 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow the pharmacist's recommendation for the monitoring of antihypertensive (a class of medication used to treat high blood pressure) medications for Resident R10. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications.Findings included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of adult failure to thrive, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and hypertension (HTN- elevated blood pressure). The admission Minimum Data Set (MDS) dated 04/21/25 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R10 required substantial to maximum assistance with her activities of daily living (ADL). The Quarterly MDS dated [DATE] documented a BIMS score of 14, which indicated intact cognition. The MDS documented that R10 required substantial to maximum assistance with her ADLs. R10's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 04/24/25, documented she was alert and oriented and able to communicate her needs, but had cognitive impairment. R10's Care Plan, dated 04/15/25, documented staff would administer her medication as ordered by the physician. R10‘s EMR under the Orders tab revealed the following physician orders:Toprol XL (antihypertensive) oral tablet extended release 24-hour 25 milligram (mg) (metoprolol succinate), give three tablets by mouth at bedtime for chronic heart failure and high blood pressure, dated 04/12/25. Review of R10's Medication Administration Record (MAR), Treatment Administration Record (TAR), and her EMR from 05/01/25 to 08/19/25 (111 days) lacked consistent heart monitoring for antihypertensive medication Toprol. On 08/19/25 at 11:41 AM, R10 laid asleep on her bed. R10 was covered with a blanket, call light was on the bed next to her. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated antihypertensive medication should be monitored. LN G stated if an order lacked physician-ordered parameters, he would call and clarify the antihypertensive order. On 08/20/25 at 11:25 AM, Administrative Nurse D stated there should be monitoring for antihypertensive medication. Administrative Nurse D stated she would expect the CP to identify the lack of correct monitoring for medications.The facility was unable to provide policy-related medication monitoring.

The facility identified a census of 57 residents. The sample included 14 residents, with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections), and pneumococcal (type of bacterial infection) vaccination for Resident (R) 1, R7, and R29. This placed the residents at increased risk for complications related to pneumonia. Findings included:- Review of R1's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 09/13/24. R2's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Review of R7's clinical record revealed the Pneumococcal Polysaccharide Vaccine (PPSV23) was offered and declined on 10/07/24. R7's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. On 08/20/25 at 11:02 AM, Licensed Nurse (LN) G stated a resident was offered vaccination at the time of admission. LN G stated if the resident consented for any vaccinations, the vaccination would be ordered from the pharmacy. LN G stated the order would be placed on the Medication Administration Record (MAR). LN G stated the vaccination would be given upon delivery from the pharmacy and then documented in the resident's electronic medical record (EMR) under the Immunization tab. On 08/20/25 at 11:25 AM, Administrative Nurse D stated the residents were offered immunizations at the time of admission. Administrative Nurse D stated Administrative Nurse E was responsible to track and ensure the vaccinations offered. The facility's Pneumococcal Vaccine Policy for Residents policy, last reviewed 07/08/25, documented each resident would be offered pneumococcal immunization, unless the immunization was medically contraindicated, or the resident has already been immunized. There would be documentation in the medical record if there is reason to believe that pneumococcal vaccine(s) was given previously, but the date cannot be verified, and this had an impact upon the decision regarding administration of the vaccine(s).

The facility reported a census of 66 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exited the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent R1 from exiting the facility. This placed R1 at risk for accidents or injuries. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), muscle weakness, abnormalities of gait and mobility, convulsions (involuntary series of contractions of a group of muscles), hypertension (elevated blood pressure), hypotension (low blood pressure), dizziness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required partial to moderate assistance from staff for transfers, and toileting. R1 required supervision or touch assistance with propelling in his wheelchair from staff. R1 had no behaviors and had not exhibited wandering. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] documented R1 admitted to the facility for therapy for strengthening related to weakness. R1 used a wheelchair for locomotion. The Falls CAA dated [DATE] documented R1 used a wheelchair for locomotion. Staff were to encourage R1 to participate in exercises to prevent falls. The Quarterly MDS dated [DATE] documented a BIMS score of six which indicated severely impaired cognition. R1 was independent with transfers and required supervision or touching assistance from staff with showering and propelling in his wheelchair. R1 exhibited no behaviors and did not exhibit wandering. R1's Care Plan initiated [DATE] documented R1 had a history of attempting to leave the facility unattended and R1 had impaired safety awareness. R1 was added to the elopement book. Staff were directed to provide R1 safe wandering as R1 was an elopement risk. R1 had a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) in place, and staff were directed to document the resident's wandering behavior and attempted diversional interventions in the behavior log. Staff were directed to observe R1 for behavior episodes and attempt to determine the underlying cause for the behavior; considering location, time of day, persons involved, and situations. Staff were directed to intervene as necessary to protect the rights and safety of others. Staff were to approach and or speak calmly, divert attention, remove R1 from the situation, and take R1 to an alternate location as needed. R1's locomotion intervention revised [DATE] documented that R1 was able to propel himself using his wheelchair. The Nursing: Elopement Risk Evaluation dated [DATE] documented that R1 was at risk for elopement, had a history of attempts to leave the facility unattended, and had impaired safety awareness. The Orders tab recorded a physician's order on [DATE] to check WanderGuard placement, and function, and to check for expiration date and notified Administrative Nurse D if the WanderGuard was expired every shift. R1's clinical record lacked any documentation of R1's elopement incident. The Notarized Witness Statement dated [DATE] by Licensed Nurse (LN) G documented that LN G was notified that R1 was outside in the courtyard with Certified Medication Aide (CMA) R and the door alarm was sounding. R1 was brought back into the building and taken to the side of the building R1 lived on. LN G stated she notified Administrative Nurse D. Administrative Nurse D requested LN G check R1's Wander Guard to see if it was on and working. LN G observed the Wander Guard on R1's ankle and LN G checked to verify it worked. LN G reported R1 had wandered in his wheelchair around the nurse's desk asking for cigarettes and was redirected. The Notarized Witness Statement dated [DATE] by CMA R documented CMA R heard the door alarm sounding for about a minute or two when CMA R went to check the doors. CMA R documented she went to the front door of the building before realizing it was not that door, but the door to the back patio. CMA R turned to go to the back patio door when R2 yelled that R1 was outside the gate, and R1 was opening the gate. CMA R proceeded to go out the back patio door to and retrieved R1 from the back parking lot. CMA R stated LN G came to assist with taking R1 back into the building. LN G asked CMA R if CMA R was outside with R1, to which CMA R stated no, she was responding to the alarm. On [DATE] at 04:55 PM the other gate in the courtyard, located roughly 18 steps from the back patio door, had no locking mechanism on the gate. When the gate was pushed from the inside of the courtyard the gate swung freely and revealed the back parking lot behind the building. The ground leading up to the gate was level concrete and the gate opened up to level pavement meeting up with the concrete. On [DATE] at 01:22 PM, R1 sat in his wheelchair facing the back patio door. R1 was dressed in clean clothes and had a nasal cannula on receiving oxygen. R1 had a WanderGuard on his right ankle. R1 responded when greeted and R1 stated it was a nice day but nothing further was said when questioned. R1 continued to look out the back patio door while speaking. On [DATE] at 01:53 PM LN G stated that she was called and told that R1 was in the courtyard. LN G stated that she was informed R1 had been outside the fence around the courtyard. LN G brought R1 back into the building and checked to make sure R1 was ok. LN G stated she told Administrative Nurse D that R1 was outside. Administrative Nurse D asked LN G to check if R1's Wander Guard worked. LN G called R1's family representative but did not call the physician related to LN G was waiting for further instructions from Administrative Nurse D. On [DATE] at 03:45 PM Certified Nurse Aide (CNA) M stated that she recalled R1 getting out to the courtyard and going through the gate but could not recall the day it occurred. CNA M stated that CMA R had responded to the door alarm before CNA M got there. CNA M revealed this was not the only time R1 had pushed through the back patio door without staff. CNA M further revealed he had done it another day, but CNA M was outside taking a smoke break, and met R1 at the door. On [DATE] at 04:35 PM Administrative Staff B stated that the door alarms go off all the time. Administrative Staff B stated R1 went out thru the door and R1 did go out to the parking lot. Administrative Staff B recalled CMA R going out to get R1 and the gate was open to the parking lot. On [DATE] at 04:44 PM, Housekeeper U stated that anyone could open the gate leading out of the courtyard to the parking lot. Housekeeper U revealed you just grabbed the silver thing, and it would open easily. On [DATE] at 04:55 PM the other gate in the courtyard, located roughly 18 steps from the back patio door, had no locking mechanism on the gate. When the gate was pushed from the inside of the courtyard the gate swung freely and revealed the back parking lot behind the building. The ground leading up to the gate was level concrete and the gate opened up to level pavement meeting up with the concrete. The facility Area of Focus: Elopement policy reviewed [DATE] documented an elopement occurred when the resident leaves the premises or a sage area without authorization and or any necessary supervision to do so. A resident who leaves a sage area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and or other medical complications, drowning, or being struck by a motor vehicle. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. When the resident is found, the charge nurse or designee will assess the resident's physical, mental, emotional, and cognitive state and notify the physician and responsible party. The resident will be monitored as deemed necessary by the interdisciplinary team. An incident (event) report will be completed by the charge nurse or designee to include witness statements. The facility failed to ensure R1 received adequate supervision and appropriate interventions to prevent R1 from exiting the building without staff. This placed R1 at risk for accidents or injuries.

The facility identified a census of 63 residents. The sample included four residents. Based on observation, interview, and record review, the facility failed to accurately and thoroughly complete Minimum Data Sets (MDS) for Resident (R) 1. This placed the resident at risk for unidentified care needs. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. R1 was independent with activities of daily living (ADL). R1's oral and dental status documented there were no dental concerns noted. The Dental Care Area Assessment (CAA) dated 05/17/23 did not trigger. The Quarterly MDS dated [DATE] lacked documentation of a BIMS performed by R1 or a staff assessment. R1's oral and dental status was not addressed on the MDS. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. R1's oral and dental status was not addressed on the MDS. The Quarterly MDS dated [DATE] documented R1 was rarely understood, and per staff interview, R1 had short- and long-term memory problems. R1 was independent of ADLs. R1's oral and dental status was not addressed on the MDS. R1's Oral Assessment completed by a dental vendor dated 04/03/23, under the Misc tab, recorded R1 had probable extensive decay, and moderate inflammation, and R1 stated all his top teeth hurt. Additional notes documented that two unidentified licensed nurses (LN) stated that R1 complained of tooth pain often and asked if the dental services could see him. The assessment documented R1 stated that all his upper teeth hurt. R1 appeared non-emergent at that time, but R1 was directed to let staff know if he started to have pain that kept R1 awake at night. R1 was to seek an appointment with an offsite dentist if the pain worsened. On 04/15/24 at 11:23 AM R1 lay in bed with his blankets pulled up to his chin. R1 appeared with a flat affect. R1 stated he told the nurses all the time that his teeth hurt. R1 then pointed at the front of his mouth and stated his front teeth hurt and the doctor was aware that his teeth hurt. R1 revealed his teeth were hurting at the time of the interview. On 04/15/24 at 12:00 PM Administrative Nurse E stated she usually went and asked the resident for the oral and dental status. Administrative Nurse E stated it could be tricky if a resident refused to open up his or her mouth. Administrative Nurse E stated she tried to talk with a resident if there was pain, trouble swallowing, or a concern with their teeth. Administrative Nurse E revealed she asked R1 about his oral and dental status, but R1 failed to answer and refused to open his mouth. Administrative Nurse E stated that she should have reviewed the Oral Assessment in R1's EMR under the Misc tab but failed to look for any documentation related to R1's teeth. Administrative Nurse E stated she should have marked R1's assessment as not assessed instead of leaving the area blank or documenting no issues. The facility stated they used the Resident Assessment Instrument (RAI) Manual for MDS direction and policy. The facility failed to develop an accurate and thorough MDS assessment related to R1's oral status. This placed the resident at risk for unidentified care needs.

The facility identified a census of 63 residents. The sample included three residents reviewed for dental services. Based on record review, interview, and observation, the facility failed to identify and respond to Resident (R)1's dental needs which resulted in tooth pain and untreated dental issues. This deficient practice placed R1 at risk for pain and other complications related to dental issues. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of traumatic subdural hemorrhage (a condition due to bleeding under the membrane covering the brain), respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), convulsions (involuntary series of contractions of a group of muscles), 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 for Mental Status (BIMS) score of 12 which indicated intact cognition. R1 was independent with activities of daily living (ADL). R1's oral and dental status documented there were no dental concerns noted. The Dental Care Area Assessment (CAA) dated 05/17/23 did not trigger. The Quarterly MDS dated [DATE] documented R1 was rarely understood, and per staff interview, R1 had short- and long-term memory problems. R1 was independent of ADLs. R1's oral and dental status was not addressed on the MDS. R1's Care Plan initiated 05/12/22 documented that R1 was independent with ADLs but may need stand-by assistance of supervision at times. R1's Care Plan lacked interventions related to dental care and dental monitoring. R1's Oral Assessment completed by the dental vendor dated 04/03/23, under the Misc tab, recorded R1 had probably extensive decay, and moderate inflammation, and R1 stated all his top teeth hurt. Additional notes documented that two unidentified licensed nurses (LN) stated that R1 complained of tooth pain often and asked if the dental services could see him. The assessment documented R1 stated that all his upper teeth hurt. R1 appeared non-emergent at that time, but R1 was directed to let staff know if he started to have pain that kept R1 awake at night. R1 was to seek an appointment with an offsite dentist if the pain worsened. A review of R1's assessments under the Assessments tab lacked oral assessments from 01/01/23 to 04/15/24. A review of R1's clinical record lacked evidence facility staff followed up on the dental concerns and needs identified on 04/03/23. R1's Plan of Care Progress Note dated 04/12/24 at 12:42 PM documented the social worker scheduled a dental visit with the dentist on 04/15/24 at 07:00 AM. R1 would have a Certified Nurse Aide (CNA) escort attending the appointment with him. On 04/15/24 at 11:23 AM R1 lay in bed with his blankets pulled up to his chin. R1 appeared with a flat affect. R1 stated he told the nurses all the time that his teeth hurt. R1 then pointed at the front of his mouth and stated his front teeth hurt and the doctor was aware that his teeth hurt. R1 revealed his teeth were hurting at the time of the interview. On 04/15/24 at 11:28 AM LN G stated that R1 had never complained of pain and ate his food with no issues. LN G stated that R1's appointment at the dentist was an emergency but LN G did not know what the emergency was. On 04/15/24 at 02:18 PM Administrative Nurse D stated she did not see R1's dental assessment done in April 2023 until recently. Administrative Nurse D stated that R1 had not reported any oral pain that she was aware of. Administrative Nurse D stated the dentist came to the facility for monthly cleaning for residents. The facility's Dental Services policy reviewed on 08/23/23 documented that the facility was responsible for assisting the resident in obtaining needed dental services, including routine dental services. The facility would provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. The facility failed to identify and respond to R1's oral needs which resulted in tooth pain and untreated dental issues. This deficient practice placed R1 at risk for pain and other complications related to dental issues.

The facility identified a census of 69 residents. The sample included three residents. Based on record review, interview, and observation the facility failed to accommodate Resident (R) 1's need and preference for a transfer pole This placed R1 at risk of decreased mobility and impaired autonomy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of hemiplegia (paralysis of one side of the body), 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), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), muscle weakness, need for assistance with personal care, and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R1's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required supervision, verbal cues, or touching to help steady R1 during any form of mobility. R1 was independent with wheelchair mobility of at least 50 feet and making two turns. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 11/02/23 documented R1 was alert and oriented and communicated needs. R1 used a wheelchair for locomotion and required minimal assistance with ADLs. R1's Care Plan initiated on 10/27/23 directed staff to encourage R1 to participate to the fullest extent possible with each interaction. R1's Care Plan lacked direction on how R1 transferred, or assistance required. R1's Physical Therapy Evaluation and Plan of Treatment dated 10/25/23 documented R1 reported he used a transfer pole at his prior facility and was independent at baseline with a transfer pole. This treatment plan note documented the information was communicated to nursing staff and therapy asked about ordering and installing a transfer pole for R1. The Progress Note dated 01/25/24 at 02:39 PM documented a transfer pole was properly installed into R1's room, secured at both the ceiling and the floor. The transfer pole was assessed by Consultant HH and determined to be unstable; specifically, the middle of the pole was not safe to use for transfers. R1's EMR lacked any other documentation about a transfer pole. On 02/22/24 at 12:30 PM, Consultant GG stated to order equipment for residents, she went to Administrative Staff A or Administrative Nurse D. Consultant GG stated that if equipment had to be installed, facility maintenance would take care of that. Consultant GG revealed she worked with R1 at his previous facility, and he utilized a transfer pole there. Consultant GG stated that the facility had access to transfer poles and if a resident wanted a transfer pole. Consultant GG said transfer poles could be ordered and put up for the resident to aid in maintaining independence. Consultant GG further stated that R1 was very vocal and would tell staff what he wanted, so Consultant GG did not understand why she had not heard that R1 wanted a transfer pole. On 02/22/24 at 12:33 PM, Consultant HH stated that R1 worked on becoming independent with transfers and used the bed cane to aid his transfers in and out of bed. Consultant HH stated that R1 originally asked about a transfer pole, but after he worked with therapy on transfers in and out of bed, he did not mention it again. Consultant HH revealed she never asked if R1 wanted the transfer pole after he mentioned it at the first assessment. Consultant HH stated that when the transfer pole was brought in for R1 from an outside service, it was put up by maintenance. Consultant HH said she evaluated if the transfer pole was safe to use for R1. Consultant HH stated that the transfer pole bent in the middle due to the connection and she felt that particular transfer pole was unsafe for R1 to use. On 02/22/24 at 12:40 PM, R1 sat in his wheelchair and appeared clean. R1 stated he talked to everyone about his desire for a transfer pole, but he never received one from the facility. R1 stated he spoke with Administrative Staff A about the transfer pole. R1 said Administrative Staff A told him that the facility could not provide a transfer pole. R1 stated that when the outside service brought a transfer pole to the building for R1, he had to wait for maintenance to put the pole up and then for someone from therapy to evaluate if the pole was safe to use. R1 revealed that Consultant HH came and assessed the transfer pole, determined the pole was unsafe, and removed the pole. R1 became visibly upset as he talked about the transfer pole being removed from his room. R1 revealed that no one asked him if he wanted another transfer pole put up. R1 stated that he used the bed cane to transfer out of bed but pulling on that to get up caused his bed to slide when he transferred. On 02/22/24 at 01:15 PM Administrative Staff A stated R1 had a bed cane as an aid to transfers in and out of bed. Administrative Staff A stated she never heard that R1 wanted a transfer pole and had no idea where the idea came from. Administrative Staff A stated R1 had not requested to have a transfer pole. Administrative Staff A revealed she had not asked R1 if he wanted a transfer pole, even after the outside service had provided a transfer pole that was deemed unsafe for use. On 02/22/24 at 01:20 PM, Consultant GG stated she reviewed her communication with Consultant HH and stated Consultant HH texted when R1 arrived asking about the process to request a transfer pole for R1. Consultant GG stated she must have missed that communication. Consultant GG stated she had not asked R1 if he wanted a transfer pole. On 02/22/24 at 01:22 PM Administrative Nurse D stated she had not asked R1 if he wanted a transfer pole. The facility's policy Resident Rights reviewed 09/25/23 documented the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to receive the services and/or items included in the plan of care. the facility failed to accommodate R1's need and preference for a transfer pole to assist with bed transfers. This placed R1 at risk of decreased mobility and impaired autonomy.

The facility identified a census of 67 residents. The sample included 17 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This placed the residents at risk for decreased quality of care. Findings included: - Review of the Payroll-Based Journal for Fiscal Year 2023 Quarters1 through 4 revealed the facility triggered for no RN hours on four or more weekend days during quarter one 10/15/22, 10/16/22, 10/22/22, 10/29/22, 10/30/22,11/05/22, 11/12/22, 11/13/22, 11/19/22, 11/26/22,12/03/22, 12/10/22, 12/11/22, and 12/24/22). Review of the Payroll-Based Journal for Fiscal Year 2023 Quarter2 revealed the facility triggered for no RN hours on four or more weekend days during the quarter (01/01/23, 01/15/23, 01/21/23, 02/04/23, 02/05/23, 02/12/23, 02/18/23, 02/19/23, 02/26/23, 03/12/23, 03/18/23, and 03/26/23). Upon request, the facility provided handwritten Time Clock Adjustment sheets for the dates listed above. The facility failed to provide proof of eight hours of consecutive RN coverage a day seven days a week as requested. The facility also provided an Earnings Statement for RNs for the dates requested, but the statements lacked proof of the actual punch times to verify the dates and consecutiveness that the staff members worked. On 01/04/24 at 11:30 AM Administrative Staff A stated the facility always had an RN on staff in the building every day. Administrative Nurse D stated on the weekends management staff covered the RN hours a lot of the time but she was unable to show verification or punch times for their hours worked since they were salaried employees and did not clock in/out like regular hourly staff. The facility lacked a policy regarding staffing hours. The facility failed to ensure there was RN coverage at least eight consecutive hours a day seven days a week. This placed all residents at risk of delayed care and the potential for physical or psychosocial harm.

The facility identified a census of 67 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns. Findings included: On 01/02/24 at 07:27 AM an observation in the main kitchen area revealed three plastic storage containers with cereal inside. The containers lacked labels and were undated. On 01/02/24 at 07:35 AM an observation in the kitchen's meat freezer revealed two resealable plastic bags. One plastic bag contained ham and the other contained chicken patties. The plastic bags were not labeled and were undated. On 01/02/24 at 07:36 AM, an observation in the kitchen's meat freezer revealed one opened box of frozen beef patties. The box was open to air and the patties were uncovered. On 01/02/24 at 07:38 AM, an observation in the kitchen's dry storage area revealed one bag of dry noodles. The bag was opened and was undated. On 01/02/24 at 07:39 AM, an observation in the kitchen's dry storage area revealed one opened box of graham cracker crumbs. The box was open and the crumbs were open to air. On 01/02/24 at 07:40 AM an observation in the kitchen's dry storage area revealed one bag of tortilla chips. The bag was opened and was undated. On 01/02/24 at 07:43 AM, an observation in the kitchen's A refrigerator revealed one package of cheese slices. The package was opened and was undated. On 01/02/24 at 07:45 AM, an observation in the kitchen's A refrigerator revealed one gallon of whole milk. The gallon of milk was opened and was undated. On 01/02/24 at 07:47 AM an observation in the kitchen's vegetable freezer revealed two bags of diced green peppers. The bags were opened and undated. On 01/02/24 at 07:48 AM an observation in the kitchen's vegetable freezer revealed one resealable bag of mixed peppers/onions. The bag was not labeled or dated. On 01/02/24 at 07:49 AM, an observation in the kitchen's baking freezer revealed one bag of breadsticks. The bag was open to air and undated. On 01/02/24 at 07:50 AM an observation in the kitchen's baking freezer revealed one resealable plastic bag of cookies. The bag did not have a label and was undated. On 01/02/24 at 07:50 AM an observation in the kitchen's baking freezer revealed one plastic bag of French fries. The bag was opened and undated. On 01/02/24 at 07:54 AM, an observation in the kitchen's main area revealed three bags of hot dog buns and one loaf of bread. The bags were opened and undated. On 01/03/24 at 12:09 PM, Dietary BB stated after items were opened, staff were expected to add a date to the packaging, and any items placed into a resealable plastic bag should have been labeled and dated. Dietary BB further stated food items that were placed in a resealable bag that lacked a label and/or date should have been discarded when found. The facility's Food Safety policy with a revised date of 04/26/23, documented that Pre-packaged food is placed in a leak-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and the date (when the item is transferred to the new container). Use by date is noted on the label or product when applicable. The policy further documented frozen, raw meat that is placed in a cooler in a pan and labeled with the pulled and use-by dates. The facility failed to maintain sanitary dietary standards related to the storage of food. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 67 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, failed to ensure sanitary storage of respiratory equipment, failed to ensure adequate laundry temperatures for laundry including laundry from residents with infectious disease and on transmission-based precautions and failed to ensure staff performed hand hygiene between resident car. The facility further failed to ensure appropriate disposal of filled red biohazard boxes and failed to ensure the Infection Preventionist tracked and trended infections within the facility. These deficient practices placed the residents at risk for complications related to infectious diseases. Findings included: - Observation on 01/02/24 at 07:05 AM a large bag of soiled linen rested on the floor in the 200 hallways. On 01/02/24 at 07:14 AM an unlocked soiled utility room on the 200 hallway revealed a small refrigerator, which the thermometer registered a temperature of 18 degrees. The refrigerator had ice along the back of the refrigerator. Two large red biohazard boxes sat on a cart with six small red biohazard sharps containers on top of the two large red biohazard boxes. Four of the six red sharps containers were filled past the fill line on the box. A can with cat litter and a cigarette butt sat on the counter next to the sink. On 01/02/24 at 07:21 AM the clean utility room on the 200 hall had an opened box of disposable gloves and a gait belt which partially rested on the floor. A blue hand splint rested directly on the floor as well. On 01/02/24 at 07:48 AM Resident (R) 44's oxygen tubing rested on the floor next to the bed, unbagged. On 01/02/23 at 11:35 AM R42's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask hung unbagged above his bed. On 01/04/24 at 06:43 AM Certified Medication Aide (CMA) S failed to perform hand hygiene between administration of medication to R21 and administered medication and inhaler to R10. The facility provided a policy related to Legionella testing but was unable to provide a plan, a risk assessment, or a procedure related to Legionella testing. A review of the temperature logs provided by the facility water temperature logs documented temperatures below the recommended 160 degrees. The facility was unable to provide washing machine specifications upon request. On 01/04/23 at 10:39 AM Administrative Nurse E, the facility Infection Preventionist stated she had a book that she did track the facility's infections some place. Administrative Nurse E stated she completed Mcgeer's criteria after a urine analysis was obtained. Administrative Nurse E stated respiratory equipment should never touch the floor, should be dated, and changed weekly, and placed in a clean bag when not in use. Administrative Nurse E stated she was not sure how frequently a resident's CPAP mask should be replaced. Administrative Nurse E stated hand hygiene should be performed in between each resident. On 01/04/24 at 12:08 PM Certified Nurse Aide (CNA) N stated soiled linen should never be placed on the floor. CNA N stated respiratory equipment should be stored in a clean bag when not in use. On 01/04/24 at 01:22 PM Administrative Nurse D stated hand hygiene should be performed between administration of medication and any other resident care. Administrative Nurse D stated respiratory equipment should be stored in a clean bag when not in use. CPAP masks should be cleaned daily after use. Administrative Nurse D stated the Infection Preventionist, administrator, and maintenance director oversee the plan and procedure for testing for Legionella disease. Administrative Nurse D stated the nurses were responsible for ensuring red biohazard sharps containers were changed and placed in the large red biohazard container in the soiled utility rooms. Administrative Nurse D stated night shift was responsible for monitoring the specimen refrigerator in the utility room to ensure it was defrosted and at the appropriate temperature. The facility's Hand Hygiene policy last revised 06/13/23 documented that the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's Laundry Services policy last reviewed on 06/04/23 documented that linens should be washed using the equipment manufacturer's recommendations for appropriate chemical mix and water temperature. A review of the facility's Oxygen Administration/Storage/Maintenance policy reviewed 09/2023 indicated oxygen will be administered in accordance with the physician's orders and current standards of practice. The policy indicated oxygen supplies will be changed weekly and when visibly soiled with dates indicating placement. The policy indicated oxygen tubing and masks were to be stored in provided bags to prevent environmental contamination or infections. The facility's Antibiotic Stewardship policy last reviewed on 05/19/23 documented that the antibiotic stewardship program promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This meant that the antibiotic was prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms and/or other adverse events. The program would be managed and overseen by the Infection Preventionist. The facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious diseases.

The facility identified a census of 53 residents. The sample included 16 residents with one resident sampled for stasis ulcers (a wound on the leg or ankle caused by abnormal or damaged veins). Based on observations, record reviews, and interviews, the facility failed to adequately assess and identify Resident (R)27's risk for skin injuries and place specialized interventions to prevent development of skin complications. The facility further failed to provide the physician ordered wound treatments for R27 when the facility consistently omitted the primary dressing component from R27's daily wound care order and omitted the topical agent as prescribed. Subsequently, R27's wound deteriorated, became infected, and required surgical repair. Findings included: - R27's Electronic Medical Record (EMR) recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) except eating and locomotion for which she was independent. R27 required assistance of two staff members for bathing. The MDS recorded R27 rejected cares daily during the lookback period. The MDS recorded R27 had one stasis ulcer and received a dressing to her foot. She had a pressure reducing device in her chair and bed but was not on a turning/repositioning program. R27 received an antipsychotic (medication used to treat [CONDITION(S)]), antidepressant (medication used to treat depression) and an antibiotic (medication used to treat bacterial infections) for all seven days of the look back period. The Quarterly MDS dated [DATE] recorded R27 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS recorded R27 required extensive assistance of one to staff members for all activities of daily living (ADLs) including locomotion and supervision of two staff for eating. R27 was totally dependent on one staff for bathing. R27 had verbal behavioral symptoms directed at other for one to three of the lookback days and rejected cares for four to six of the lookback days. The MDS recorded R27 was at risk for pressure injuries but had no pressure injuries. The MDS recorded R27 had no stasis ulcers, but did have an infection of the foot and diabetic foot ulcer and received a dressing to her foot. She had a pressure reducing device in her chair and bed, but was not on a turning/repositioning program. R27 received an antipsychotic, antibiotic, anticoagulant (medication used to thin blood), insulin, and received injections during the lookback period. The Activities of Daily Living [ADLs] Care Area Assessment recorded R27 was at risk for skin integrity impairment due to her medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27 received preventative treatments as ordered and/or as needed; staff provided daily skin checks with cares; weekly skin assessments by a licensed nurse and communications with the physician for any skin change noted. R27 had a pressure reducing mattress and wheelchair cushion to protect her skin. R27 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, prior to development of the ulcer directed staff to assist the resident with mobility and ADLs as needed (02/02/21); R27 required extensive assistance from staff to turn and reposition in bed as needed (01/27/21). The Care Plan directed staff to inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness and refer to podiatrist (foot doctor) as needed and provide weekly skin checks (05/02/21). A Braden Assessment (tool used to predict pressure injury risk and assess risk factors) dated 06/05/21 recorded R27 was at mild risk. The assessment recorded she was rarely moist and had only slightly limited mobility. The risk factors in section two of the assessment inaccurately documented she had no risk factors though the following were listed as a potential risk: decreased or impaired chair or bed mobility, urinary or bowel incontinence, use of antipsychotics, [CONDITION(S)], [CONDITION(S)] (swelling) and diabetes. A Braden assessment dated [DATE] recorded R27 was at mild risk. The assessment recorded she was rarely moist and had only slightly limited mobility. The risk factors in section two of the assessment inaccurately documented her only additional risk factor was diabetes. A Braden assessment dated [DATE] recorded R27 was at mild risk. The assessment recorded she was rarely moist and had only slightly limited mobility. The risk factors in section two of the assessment inaccurately documented her only additional risk factor was diabetes. A Braden assessment dated [DATE] recorded R27 was at mild risk. The assessment recorded she was rarely moist and had no limitations in mobility. The risk factors in section two of the assessment inaccurately documented her only additional risk factors were decreased or impaired bed/chair mobility and diabetes. The Weekly Skin Integrity Data Collection assessments, reviewed from 05/31/21 through 09/26/21 recorded R27 skin was intact with no issues. A Physician Note dated 09/21/22 recorded Consultant GG saw R27 for a chief complaint of left lower extremity [CONDITION(S)]. R27 had pitting [CONDITION(S)] of the left lower extremity (LLE). Consultant GG encouraged R27 to elevate her extremity when it was not use and ordered a compression stocking (TED- anti-embolism [blood clot]) to the left leg to be on in the morning and removed at night. The Orders tab revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Alert Note dated 09/27/21 at 11:25 AM documented the nurse was asked to look at R7's heel. Upon assessment, the nurse observed R27's left heel with a wound that was 4.5 inches wide, black, scabbed eschar (dead tissue), and dry flaky skin all around the perimeter of the wound. R27 stated it did not hurt unless it was touched. The note recorded R27 was diabetic as well. The nurse informed the director of nursing, executive director, the nurse practitioner and R27's representative at 11:20 AM. The nurse entered a skin assessment into the computer for R27. The note recorded the resident's information was sent to the wound care specialists for evaluation. R27's foot was cleansed, skin prep applied, and covered with a dry dressing. Review of the Orders tab revealed an order dated 09/27/21 to cleanse R27's left heel wound with wound cleanser, apply skin prep (liquid skin protectant) to the area and around the wound edges, cover with a dry dressing. Change daily and as needed (PRN) when soiled or missing. The Skin Integrity Data Collection assessment dated [DATE] recorded a new finding and documented an area on the left heel, which measured4.5-inches and was an eschar covered black ulcer with flaky skin noted around the entire perimeter of the wound and a dark red area above the back of the heel that was painful to the touch. The Care Plan reflected the following interventions added on 09/27/22: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. (resolved on 10/13/21). Observe for side effects of the antibiotics and over-the-counter pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . (resolved on 10/13/21). Encourage good nutrition and hydration in order to promote healthier skin (resoled on 10/13/21). Educate resident/family/caregivers of causative factors and measures to prevent skin injury (resolved on 10/13/21). Assess location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R27 was on antibiotic therapy for infection of the heel (resolved 11/23/21). The Heal360 wound progress note recorded a service date of 09/29/21. The note indicated the visit was the initial encounter for the wound evaluation. The Pressure versus Non-pressure Screening Questions sections recorded the ulcer was of mixed etiology (cause or reason), which included pressure. The note labeled the left heel wound as Wound 2 and described the wound as eschar covered. It measured 3.5 centimeters (cm) long(L) by (x) 4.2 cm width (w) x 0.2 cm depth (d). There was a small amount of sero-sanguineous (yellowish drainage with small amounts of blood) and had a mild odor. The wound bed was 51-75 percent (%) eschar with 1-25% slough (dead tissue which is yellow, tan, green or brown in color and may be moist, loose and stringy in appearance). The plan recorded orders to cleanse the area with hypochlorous acid (wound cleanser), apply [MEDICATION(S)] ( topical antibiotic ointment used to treat skin infections caused by bacteria), xeroform gauze ( primary wound dressing used to maintain a moist wound bed and decrease trauma to wound), and cover with a bordered gauze dressing. Change daily and PRN. Review of R27's EMR which included the Orders tab and the Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed the [MEDICATION(S)] and xeroform were not implemented as ordered. The order dated 09/27/22 (see above) was administered until 10/06/21. A Physicians Note dated 10/05/21 recorded Consultant II saw R27 for chronic medical conditions, and approval of monthly medications and orders for pharmacy. The note documented R's27 skin was warm and moist. The plan directed to continue medication and orders. The note lacked mention of the wound and /or infection. The Heal360 wound progress note, dated 10/06/21 recorded the left heel wound measured 4.2 cm L x 5.8 cm W x 0.1 cm D. The wound bed was 76-100 % eschar and had no slough. The periwound (skin immediately surrounding wound) presented with signs and symptoms of infection and indicated topical antibiotics were prescribed. The note recorded the quality of the wound tissue and wound measurements were deteriorated since the previous visit. The plan recorded orders to paint the eschar with skin-prep and ensure the edges and periwound were covered with skin-prep as well, then cover with bordered gauze. Review of the Orders and MAR/TAR for October 2021 revealed the following order dated 10/06/21 was administered daily 10/06/21 through 10/13/21: Apply skin prep to left heel every shift daily for wound care. The order lacked the instructions to ensure wound edges and surrounding skin were covered and lacked instruction to cover with bordered gauze. The Heal360 wound progress note dated 10/13/21, recorded the heel wound measured 3.5 cm L x 4.1cm W x 0.1 cm D. The wound bed was 76-100 % eschar with no slough. The periwound was normal in color, and had [CONDITION(S)], and maceration and signs of infection. The note indicated topical antibiotics were prescribed. The note indicated the quality of the tissue was unchanged, but the measurements were improved from the last visit. The plan recorded orders to cleanse the wound with wound cleanser and apply skin prep to periwound. Apply [MEDICATION(S)] to the affected area and apply calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp), and cover with bordered gauze. Change dressing daily and as needed. The note indicated it was ok to continue the current treatment orders until able to obtain supplies/medications for updated orders. The Wound Observation Tool dated 10/13/21 recorded R27 had a left heel diabetic ulcer, facility acquired on 10/06/21. It further recorded the wound specialists (WCP) followed the resident, a new treatment was ordered, the wound was debrided (removal of dead tissue) by WCP. R27 had nutritional supplements, heel protector, and an arterial doppler (test which checks circulation in arms or legs) and ankle brachial index (ABI-quick, noninvasive way to check for peripheral artery disease) would be ordered. R27's Care Plan was updated on 10/13/21 to include the following interventions: Administer medications as ordered. Administer oral supplementations to promote wound healing as ordered. Lab and/or diagnostic work as ordered and staff to report results to the physician and follow up as indicated. Provide elevating leg rests when up in wheelchair and a low air loss mattress. Staff to assist R27 with donning /doffing pressure reducing boot to left foot. A Skin/Wound Note dated 10/14/21 recorded R27 received a shower and treatment to her left heel. New observation revealed increased pitting [CONDITION(S)] (3 plus-system to describe severity of [CONDITION(S)] by the depth/return of pitting present) to the LLE. R27 had TED hose orders and a wheelchair leg rest/lift in place, but she was not always compliant. Skin-prep and ensure the edges and surrounding skin were covered with skin-prep as well, then cover with bordered gauze. The Orders tab documented an order dated 10/14/21 which directed a LAL mattress for wound prevention and maintenance, check every shift, to be set to resident comfort/preference. Review of the Orders tab and MAR/TAR for October 2021 revealed the following order dated 10/14/21 was administered daily until 10/20/21: Cleanse the left heel wound with wound cleanser, apply skin prep around the border edges of the wound, apply [MEDICATION(S)] ([MEDICATION(S)]) ointment, and apply a border gauze daily and prn when soiled. The order lacked instruction to apply the calcium alginate. An Infection Note dated 10/18/21 recorded the nurse finished R27's wound care treatment to her right [left] heel diabetic ulcer. The nurse noticed there was a significant amount of drainage. The ulcer was malodorous. The nurse cleansed the wound with wound cleanser and examined the wound. This nurse noted the wound had a significant amount of green exudate (drainage) that was moist and malodorous. R27 stated it was not sore to the touch. The nurse explained to R27 that the wound looked infected and explained the nurse would call the resident's doctor to try and get an antibiotic. No fever was noted at the time of treatment. The nurse contacted the resident's nurse practitioner and the reception was bad. The nurse then sent a text to the NP explaining the findings at 01:50 PM. The nurse informed Administrative Nurse D as well. convey the instructions. An Infection Note dated 10/18/21 recorded Consultant GG called at 02:06 PM with these directives: Start [MEDICATION(S)] (oral antibiotic) 100 milligrams (mg) two times daily for 10 days, get a wound culture, and lab work. The note recorded the nurse read the findings of the arterial doppler results obtained from on 10/14/21 and Consultant GG wanted a consultation for vascular surgery. The Heal360 wound progress note dated 10/20/21 recorded the left heel wound measured 4.4 cm L x3.6cm w x 0.1 cm d. There was moderate amount of sero-sanguineous drainage that had a mild odor. The wound bed was 51-75% slough and 1-25 % granulation (healthy) tissue. No eschar was present. The periwound had [CONDITION(S)] and maceration, was normal in color and exhibited signs of infection. The note documented the quality of tissue was improved, though drainage and measurements had deteriorated. The plan recorded orders to cleanse the wound with wound cleanser and apply skin prep to periwound. Apply [MEDICATION(S)] (broad spectrum topical antibiotic ointment) to the affected area, apply calcium alginate to wound base and cover with bordered gauze daily and PRN for soiling, saturation or unscheduled removal of dressing. The Wound Observation Tool dated 10/21/21 documented a left heel diabetic ulcer facility acquired on 10/06/121. The tool recorded the treatment was as follows: Cleanse left heel wound with wound cleanser, apply skin prep to border of wound, apply [MEDICATION(S)] 0.1 % ointment, apply silver alginate, then apply bordered gauze daily on dayshift and change when soiled, or missing prn. [MEDICATION(S)] 100 mg BID [twice daily] x 10 days ordered. The Orders tab recorded the following order dated 10/21/22: Cleanse the left heel wound with wound cleanser, apply skin prep around the border edges of the wound, apply [MEDICATION(S)] 0.1 % ointment, and apply a border gauze daily and PRN when soiled. The order lacked instruction to apply calcium alginate to the wound bed. Review of the Heal360 wound progress notes dated 11/03/21 through 11/24/21 revealed the plan recorded the following orders: Cleanse the wound with wound cleanser and apply skin prep to periwound. Apply [MEDICATION(S)] to the affected area, apply calcium alginate to wound base and cover with bordered gauze daily and PRN for soiling, saturation or unscheduled removal of dressing. Review of the Wound Observation Tool dated 10/28/21 through 12/02/21 revealed the tool recorded the following treatment on each tool: Cleanse left heel wound with wound cleanser, apply skin prep to border of wound, apply [MEDICATION(S)] 0.1 % ointment, apply silver alginate, then apply bordered gauze daily on dayshift and change when soiled, or missing prn. Review of the November 2021 MAR/TAR revealed the dressing order dated 10/21/21 which lacked instruction for the calcium alginate was administered daily 11/01/21 through 11/30/21 except on 11/21/21 and 11/22/21. An Order Administration Note dated 11/21/21 documented the treatment was not performed because R27 did not want to lay down. The note indicated it would be passed on to the evening shift. An Order Administration Note dated 11/22/21 documented the treatment was not performed because R27 was out of the facility at an appointment with vascular surgery. Review of the November 2021 MAR/TAR lacked evidence the dressing was administered on 11/21/22 and 11/22/21. A Health Status Note dated 11/22/21 recorded R27 left the facility for an angiogram at the hospital. Review of R27's paper chart revealed an Operative Report dated 11/22/21, which documented the results of the angiogram. The report recorded the surgeon's findings which confirmed occlusions of multiple arteries. The impression recorded R27 did have a patent anterior tibial artery (artery of the leg which carries blood to the foot), which would allow for healing of the heel ulcer and continued wound care was recommended. Pressure prophylaxis was of the utmost importance in the course of the wound care therapy. If the ulcer, which did not involve bone at that time, penetrated deeper, amputation would be most prudent, but amputation could be avoided if wound care, nutrition, and pressure prophylaxis was ongoing. The Heal360 wound progress note dated 12/05/21 recorded the left heel wound measured 3.5 cm L x3 cm w x 0.4 cm d. There was moderate amount of sero-sanguineous drainage that had a mild odor. The wound bed was 26-50% slough and 51-75 % granulation tissue. No eschar was present. The periwound had [CONDITION(S)] and maceration, was normal in color and exhibited signs of infection. The note documented the wound had deteriorated slightly, debridement was performed again, and Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) was added to daily treatment The plan recorded orders to cleanse the wound with wound cleanser and apply skin prep to periwound. Apply Santyl to entre wound bed, edge to edge, nickel thick. Apply [MEDICATION(S)] (broad spectrum topical antibiotic ointment) to the affected area, apply calcium alginate to wound base and cover with bordered gauze daily and PRN for soiling, saturation or unscheduled removal of dressing. Review of the Orders tab revealed the Santyl order was never entered. A Physicians Note dated 12/16/21 recorded Consultant II saw R27 for chronic medical conditions, and approval of monthly medications and orders for pharmacy. The note documented R27's skin was warm and moist. The plan directed to continue medication and orders. The note lacked mention of the wound and /or wound treatment. Review of the December 2021 MAR/TAR revealed the dressing order dated 10/21/21 which lacked instruction for the calcium alginate and lacked instructions to apply Santyl was administered daily 12/01/21 through 12/31/21. Review of the Wound Observation Tool dated 12/16/21 through 01/12/22 revealed the tool recorded the following treatment on each tool: Cleanse left heel wound with wound cleanser, apply skin prep to border of wound, apply [MEDICATION(S)] 0.1 % ointment, apply silver alginate, then apply bordered gauze daily on dayshift and change when soiled, or missing prn. A Physicians Note dated 01/06/22 recorded Consultant II saw R27 for chronic medical conditions, and approval of monthly medications and orders for pharmacy. The note documented R27's skin was warm and moist. The plan directed to continue medication and orders. The note lacked mention of the wound and/or wound treatment. A Health Status Note dated 01/16/22 recorded R27 was coughing, had a temperature of 99.7 degrees, an oxygen saturation of 85%. A Covid test was negative. Staff notified Consultant GG, administered medication to reduce temperature and applied oxygen at three liters per minute. A Health Status Note dated 01/16/22 at 04:42 AM recorded R27 continued to have decreased oxygen levels, difficulty arousing, and continued with elevated temperature. She had gurgling breath sounds and was unable to cough up anything. Staff called 9ll and the ambulance arrived and transported R27 to the hospital. Staff notified Administrative Nurse D and Consultant GG. Review of the hospital Infectious Disease Progress Note revealed R27 was admitted to the hospital for altered mental status, shortness of breath and cough. R27 was found to be septic (systemic infection) with several infectious sources. The note recorded R27 had a urinary tract infection and [CONDITION(S)] of the left posterior calcaneus (heel bone). The note recorded orthopedics (bone doctors) were consulted and recommended an amputation, but R27 declined the procedure. The note further documented a left partial calcenectomy (surgical procedure where the soft tissue is debrided then parts of the calcaneus are resected with a chisel). Observation on 04/05/22 at 12:46 PM R27 rested in bed with her eyes closed. The head of the bed was elevated. She wore a heel boot on her left foot and had a low air loss mattress on the bed. On 04/06/22 at 02:40 PM, Certified Nurse Aide (CNA) M stated the nurses let the CNA's know who was at risk for skin issues or pressure injuries. She said if the residents were in bed or the chair, staff should turn and/or reposition them every two hours. CNA M stated if she noted a sore or skin problem, she reported that to the nurses. CNA M stated staff used different ways to prevent skin injuries which included turning the residents and keeping them dry and clean. She further stated staff should evaluate or float the heels to prevent heel sores and if the resident had heel protectors in their room, she would place the heel protectors on the resident. She said she was unsure if heel protectors were included in the residents' care plans. On 04/06/22 at 03:35 PM Licensed Nurse (LN) G stated she was uncertain how the wound on R27's heel developed. LN G stated she had not observed the wound on R27's foot because it was always covered. She stated she was unaware of any special precautions or interventions related to R27's wound. LN G said R27 was always supposed to wear a heel boot on her foot and she was compliant with wearing the boot. LN G said the wound team made rounds in the facility every Thursday. She further reported if she had any questions regarding ordered treatments, she would contact the physician for a clarification. On 04/06/22 at 05:00 PM LN H stated she had no personal knowledge of R27's wound when it originally developed. She said she thought it started as a diabetic ulcer. She stated that R27's wound was followed outside the facility by a wound specialist. LN h said at one point, the facility and the facility's wound care team were following the wound until R27 had the surgical flap repair. LN H said R27 was set to have another surgery, but the surgery was cancelled because R27 was non-compliant. LN H stated R27 continued to use her left heel to push herself up in bed, so the surgeons decided not to do the surgery. LN H stated R27 was always supposed to wear a boot and had daily wound treatments. LN H said staff repositioned R27 and assisted R27 out of bed whenever R27 wanted to get up. LN H said, in order to prevent skin issues from occurring, she would have interventions such as a low air loss mattress. She also stated licensed nurses do weekly skin assessments. She said if staff identified new skin condition the nurses received notifications and interventions were implemented as soon as possible. LN H said the facility was able to get any dressing supplies necessary and the supplies were ordered by Administrative Nurse D. LN H stated there was never any issues getting the supplies that they needed, however, if there were an issue, she would notify the physician and obtain a temporary order to use until the dressing supplies came in. She stated any communication with the physician regarding dressing orders or concerns were documented in the resident's chart. She stated when the wound team, made round, they verbally informed staff what they wanted ordered. Then, typically the next day, LN H could print out a copy of the visit which listed the orders. LN H said if the primary care physician disagreed with the wound treatment, and gave alternate orders, it would be recorded in the orders and in the resident's chart. On 04/06/22 at 05:25 PM Administrative Nurse D stated R27 did not have specialized interventions in place to prevent skin /pressure injuries prior to the left heel wound because R27 was not considered high risk. Administrative Nurse D said the facility utilized the Braden scale to determine if a resident was high risk instead of basing it on medical conditions such as [CONDITION(S)] or diabetes. Administrative Nurse D said the licensed nurses performed weekly skin assessments and performed a skin assessment the day before the left heel wound was identified. On a routine visit on 9/27/22, the podiatrist identified the wound on R27's foot. Administrative Nurse D stated she was notified of the left heel wound by the nurse on duty. Administrative Nurse D stated a referral was made to the wound care team to follow up with R27's left heel. Administrative Nurse D stated she did not have a reason why interventions were not placed on 9/27/22 but confirmed that specialized interventions such as a heel boot and low air loss mattress were implemented on 10/13/22. Administrative Nurse D reviewed the wound progress notes and R27's MAR/TAR and noted the dressing orders lacked the xeroform, calcium alginate, and Santyl ordered by the wound care specialists. Administrative Nurse D said during that time frame, October 2021 through December 2021, the wound team would come in and make rounds and did not make their notes available to the facility staff, so the facility staff did not have access to the orders until, sometimes, more than a week later. Administrative Nurse D confirmed it was the facility responsibility to act on behalf of the resident and obtain the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D acknowledged the lack of the primary dressings, xeroform and calcium alginate, as well as the lack of Santyl negatively impacted the wound healing process and contributed to the wound deterioration. The facility policy Area of focus: Basic Skin Management recorded the facility must ensure that a resident received care consistent with professional standards of practice. All residents had preventative measures in place that include pressure redistribution mattresses on all beds, wheelchair cushions, heel boots or suspension if needed and frequent repositioning. If any skin alteration or wound were identified, it was the responsibility of the nurse to perform and document an assessment/observation, obtain treatment orders and notify the physician and personal responsible party. The policy recorded orders were required for skin and wound care. Nursing administration should monitor the wound care program daily. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to adequately assess and identify R27's risk for skin injuries and place specialized interventions to prevent development of skin complications. The facility further failed to provide the physician ordered wound treatments for R27 when the facility consistently omitted the primary dressing component from R27's daily wound care order and omitted the topical agent as prescribed. Subsequently, R27's wound deteriorated, became infected, and required surgical repair.

The facility had a census of 64 residents. The sample included 22 residents. Based on record review and interview, the facility failed to develop and implement effective interventions to prevent the development of pressure ulcers, and promote healing of current pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident #221) Findings included: - Resident #221's annual (MDS) Minimum Data Set assessment, dated 5/11/18, documented the resident required extensive assistance from staff for bed mobility, transfers, toileting, personal hygiene, bathing, and was always incontinent of bladder. The MDS documented the resident was at risk for developing pressure ulcers, used a pressure reducing device for his/her bed and chair, and was on a turning and repositioning program. The MDS documented he/she did not have any pressure ulcers, but had moisture associated skin damage. The 6/1/18, 30-day MDS, documented the resident was not at risk for developing pressure ulcers, and had no pressure ulcers, or moisture associated skin damage. The annual CAA (Care Area Assessment) for pressure ulcers, dated 5/11/18, documented the resident was incontinent of bladder and bowel, and required extensive assistance with toileting. The CAA documented staff toileted the resident every 2 hours, turned and repositioned him/her every 2 hours at night, used a pressure reducing device for his/her wheelchair and bed, and provided extensive assistance for bed mobility and transfers. The 5/11/18 care plan directed staff to assist the resident as needed, reposition/shift his/her weight, and avoid long periods of skin to skin contact. The care plan directed staff to complete a skin risk assessment quarterly, annually, and as needed, weekly skin assessments, minimize pressure over bony prominence, notify the nurse immediately of any new areas of skin breakdown, provide a pressure reducing device to the resident's chair and bed, apply heel protectors to both feet when in bed for preventive care, and provide the resident with diabetic shoes with inserts. The weekly skin assessments recorded the following; 5/5/18 through 6/9/18 skin intact 6/16/18: 2 open areas to coccyx-4.3(cm) centimeters by 3.0 cm by 0.25 cm, and 2.0 cm by 2.0 cm by 0.25 cm The 5/4/18 at 2:06 PM, nurse's note documented the resident was readmitted to the facility, from the hospital, he/she appeared weaker and required more assistance with transfers. The note documented the resident's skin was intact. The clinical record lacked evidence of further documentation of any skin issues until 6/13/18. The 6/13/18 at 12:07 AM, nurse's note documented the resident had 2 open wounds on his/her left and right buttocks, and a reddened area, with boggy skin (abnormal texture of skin characterized by sponginess, usually because of high fluid content). The note documented staff cleaned the area, patted it dry, applied a skin barrier ointment and covered the area with a padded foam dressing. The note lacked documentation staff notified the resident's physician or family representative. The 6/13/18 at 1:12 PM, nurse's note documented the resident requested to stay in bed, and refused to turn and reposition, even though staff educated and encouraged him/her to do so. The note documented the dressings to the open areas had been removed by the presence of urine. The clinical record lacked evidence of documentation staff had notified the physician or the resident's family representative. The 6/15/18 at 1:18 PM, nurse's note documented the resident was more sleepy, had a poor appetite, and continued on an antibiotic for a urinary tract infection. The note documented staff repositioned him/her, and notified the resident's family and physician of his/her change in condition. The physician ordered staff to start (IV) intravenous fluids, obtain a chest x-ray, and draw blood for laboratory testing. The 6/15/18 at 10:51 PM, nurse's note documented laboratory results were faxed to the facility, and results included an abnormal white blood cell count of 38 (normal range is 4.0-11.0). The note documented staff notified the resident's physician by telephone. The 6/16/18 at 9:02 PM, nurse's note documented at 2:30 PM, staff noted the resident to be grimacing and repositioning himself/herself in his/her wheelchair. The noted documented staff notified the resident's physician, and the resident was transported to the emergency room by ambulance at 3:15 PM. The 6/16/18 emergency room record documented assessment of the resident's skin revealed a Stage 2 sacral pressure ulcer (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The 6/20/18 operative report documented the resident had a sacral pressure ulcer of his/her right buttock, and a excision debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), of skin, subcutaneous (beneath the skin) fat, and superficial muscle. The report documented the specimen area measured 10 cm by 8 cm by 2 cm, and a [DEVICE] (device used to promote wound healing in acute or chronic wounds) was placed. The 6/26/18 Hospital Discharge summary documented the resident's final [DIAGNOSES REDACTED]. Severe cases [MEDICAL CONDITION] can lead to the medical emergency, septic shock) from the sacral wound, Stage 3 pressure ulcer (sore that extends into the tissue beneath the skin, forming a small crater), surgically debrided, and [MEDICATION NAME] resistant [MEDICATION NAME] infection (bacteria that are resistant to the antibiotic [MEDICATION NAME]) in the wound. The discharge summary documented the resident was transferred to another facility for wound care and administration of oral antibiotics. In a signed note, dated 6/19/18 (after the resident was admitted to the hospital), Nurse G documented the resident had a closed area on his/her right upper buttock that was dark in color, with no drainage. The note documented the left buttock had an open area along the edges, and the depth was measured at less than 0.5 cm, there were no signs or symptoms of infection, and minimal drainage. In a signed note, dated 6/19/18 (after the resident was admitted to the hospital), Nurse H documented he/she observed a possible old scar/wound, intact, to the resident's mid coccyx, with the outside edging open to both sides and the top. The note documented the wound had yellow/white slough (dead tissue, usually cream or yellow in color) with no drainage, and an open area on the resident's left buttock with yellow/white slough, and no drainage. On 7/10/18 at 8:10 AM, Nurse G stated the resident had 2 blisters on his/her bottom that popped (opened), and staff applied skin preparation to the areas. Nurse G stated the areas did not have any signs or symptoms of infection, and minimal drainage. Nurse G stated the resident did not have a history of pressure ulcers, but he/she was at risk for developing them. Nurse G stated staff encouraged the resident to reposition but he/she refused. On 7/11/18 at 10:45 AM, Direct Care Staff M stated the resident had open areas on his/her bottom, and he/she received treatment on the area by the nurses. Direct Care Staff M stated he/she thought the wounds had worsened before the resident was admitted to the hospital. On 7/11/18 at 2:15 PM, Consultant Staff GG verified the resident was admitted to the hospital on [DATE] with pressure ulcers on his/her buttocks. Consultant Staff GG verified he/she examined the resident on 6/11/8, and there were no pressure ulcers noted at that time. Consultant Staff GG stated on 6/13/18, his/her nurse practitioner gave an order to the facility staff to cleanse, dry, apply [MEDICATION NAME] (sterile dressing used to cover acute and chronic wounds that are excreting fluids) and cover with a foam dressing, every day for 4 days, and as needed, until the wounds were healed. Consultant Staff GG stated the pressure ulcers would have occurred sometime between 6/11/18 (when he/she examined the resident) and 6/16/18 (when the resident was admitted to the hospital). On 7/11/18 at 2:45 PM, Administrative Nurse D verified the resident was at risk for pressure ulcers, and according to documentation, staff noted 2 open areas on the resident's left and right buttocks, that were reddened and had no drainage. Administrative Nurse D stated he/she could not speak about the wounds that were found while the resident was in the hospital, except that the wounds were not facility acquired. The pressure ulcer prevention policy, dated 11/2017, documented all residents, upon admission, are considered at risk for pressure ulcer development due to medical issues requiring nursing care related to disease process illness, or need for rehabilitation services. The policy stated upon admission, at a minimum, pressure ulcer preventions are implemented to include at least a group 1 pressure re-distribution mattress, turning and repositioning with activities of daily living care/assistance, incontinence care if needed to include skin barrier applications as needed, preventative wheelchair cushion, heel suspension via pressure re-distribution surface or heel suspension with pillows, boots, devices, etc., and skin moisturizers with bathing and/or as needed. The facility failed to implement timely appropriate interventions to prevent pressure ulcers from developing, and promote healing of facility acquired pressure ulcers, for Resident #221, who was admitted to the hospital with [REDACTED].

The facility reported a census of 64 residents. Based on observation, record review, and interview, the facility failed to protect the residents in the facility from 1 of 3 residents sampled (#1) with documented wandering tendencies and history of inappropriate behaviors with other residents, this failure placed the residents in immediate jeopardy. Resident #3 reported that resident #1 had inappropriately touched him/her in June 2015. The facility failed to implement timely and appropriate interventions to prevent further instances. Then resident #1 was found in bed with resident #2 and providing a sexual act in December 2015. The facility also failed to complete a thorough investigation of the sexual abuse incidents. Findings included: - Resident #1's Physician order [REDACTED]. The annual Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score 9 which indicated moderately impaired cognitive status. The MDS further documented the resident wandered daily with no assistive devices. The cognition Care Area Assessment (CAA) dated 6/12/15 documented the resident had trouble following directions, wandered the facility to find his/her room, and had to be reminded several times a day where his/her room was. The behavior CAA dated 6/12/15 documented the resident tended to wander the building looking for his/her room. The quarterly MDS dated [DATE] documented the resident's BIMS remained at 9 and the resident continued to wander daily. The 12/10/15 updated psychosocial well-being care plan documented the resident wandered about the facility and went back and forth from one area to another area asking for direction. The resident would often ask How do I get to the basement? or Where is my room? The resident would at times ask to call his/her parent and did not remember that they had passed away. 6/6/15, staff added a goal to the care plan that the resident would not have an intimate encounter with another resident. Staff placed the resident on close observation following the resident to resident accusation (The close observation ended on 6/10/15). On 12/15/15 the resident initiated an intimate encounter with another resident. The approaches included: to provide diversional activities for the resident, to redirect wandering, i.e. TV (A&E), movies- drama, and music and group activities such as bingo, entertainment and group outings. Staff would assist the resident with finding the right location. Staff would observe the need for psychological psychiatric services. The social services director would be available to visit, allow the resident to express his/her feelings, and follow up for 2 weeks (after admission). The staff placed the resident on 15 minute checks for 24 hours, then hourly checks for 24 hours, then checks every 6 hours for 24 hours, and stopped the checks on 6/10/15. The staff would separate the resident from the other resident. The nursing staff was to consult with the medical doctor and the psychiatrist as needed. The physician's telephone orders revealed the nursing staff was to provide 15 minute checks from 6/6/15 at 10:00 P.M. until 6/8/15 at midnight then hourly until 6:00 P.M. and then every 6 hours until 6/9/15 at 6:00 P.M. The clinical record documented on 6/7/15 at 12:22 A.M. direct care staff heard a loud voice coming from resident #1's room on 6/6/15 at 7:00 P.M. Direct care staff reported he/she went to the resident's room and asked what was that, and the resident stated nothing. The direct care staff stated both of the residents were lying in their own beds. A short time later resident #3, whose BIMS was documented at 15 which indicated this resident was cognitively intact, hurried up the hall and reported that resident #1 had put his/her hands in resident #3's shorts. The nurse observed resident #3 with a strange bewildered look on his/her face and he/she appeared anxious. The nurse observed resident #3 enter the day room and sat down, and then resident #1 came into the day room and sat down. At this time, resident #3 left the south day room and walked to the north day room. Resident #1 left the south day room and returned to his/her room. Staff removed resident #3's bed and all personal items and placed in another semi-private room on a different unit. Two nurses went to resident #1's room and asked what had happened. Resident #1 stated nothing had happened, I was in bed and my roommate just went nutso . Resident #1 continued on close observation, and remained in his/her room since the reported event. The clinical record documented on 6/7/15 at 7:27 A.M. the resident rested quietly in his/her bed with no complaints voiced. The resident did not come out of his/her room all during the night. The nursing staff provided close observation of every 15 minute checks during the night and passed the check sheet on to day nurse. The clinical record documented on 6/7/15 at 3:38 P.M. the nursing staff continued the 15 minute checks per the facility policy. The resident was up ad lib and attended the meals as scheduled. The nursing staff recorded no inappropriate behaviors noted. The clinical record documented on 6/8/15 at 1:53 P.M. the nursing staff provided 4 hour checks on resident #1, no inappropriate behaviors noted, and the resident was up ad lib. Review of the census documentation revealed a new roommate was placed with resident #1 on 8/14/15, no documentation as to when and why this roommate was moved out. Next admission admitted to room with resident #1 was on 11/30/15. The clinical record documented on 12/13/15 at 11:38 A.M. direct care staff H at approximately 4:10 A.M. found resident #1 in resident #2's bed and massaging the roommate's genitalia. Licensed nursing staff H went immediately with direct care staff H to the residents' room and both residents were now lying in their own beds. Resident #1 stated I don't know when asked what he/she was doing. Resident #2 started to behave inappropriately as evident by holding on to his/her genitalia. Resident #2 was moved to another semi private room on the other unit on 12/13/15. The clinical record documented on 12/13/15 at 1:29 P.M. resident #1's family returned the call placed earlier, the nurse informed the family of the incident and family stated why was this happening again as the resident promised it would not happen again. The medical doctor gave an order for [REDACTED]. The psychiatrist documented on 12/15/15 resident #1 was found on 12/13/15 in resident #2's bed fondling him/her. Resident #2 was suffering with dementia (a progressive mental disorder characterized by failing memory and confusion) and incapable of mentally and physically resisting such behavior. The psychiatrist documented when he/she questioned resident #1 about his/her behavior, he/she calmly stated he/she did not recall any such behavior. It was quite believable that he/she did not remember such behaviors due to the [DIAGNOSES REDACTED]. The psychiatrist recommended the resident be placed in a facility with a younger population where those residents can resist such behaviors. The clinical record documented on 12/15/15 at 12:53 P.M. the nursing staff continued to monitor the resident every 15 minute after the reported incident. The notarized statement dated 12/16/15 documented by direct care staff O revealed he/she walked into resident #1's room during the last rounds of the night at 4:00 A.M. and caught him/her with the resident #2's genitalia in his/her hand. Direct care staff O asked resident #1 what he/she was doing, resident #1 stated he/she did not know, and then got out of resident #2's bed and jumped back into his/her own bed. The notarized statement dated 12/16/15 documented by licensed nursing staff H revealed direct care staff O observed resident #1 on resident #2's bed, massaging resident #2's genitalia. Licensed nursing staff H went to the residents' room and resident #1 was in his/her own bed. On 1/5/16 at 1:30 P.M. the resident sat on the couch in the TV room with 6 other wheelchair bound residents. Staff sat the nurses' station and walking down the hallway. Resident #1 walked by him/her to his/her room without any assistive devices. On 1/5/16 at 1:50 P.M. the resident sat on his/her bed in his/her room. On 1/5/16 at 2:45 P.M. licensed nursing staff J ambulated down the hallway to check on resident #1, returned to the nurses' desk, documented on the check sheet the resident was in his/her room and then proceeded to document in the computer. On 1/5/16 at 3:10 P.M. licensed nursing staff J ambulated down the hallway to check on the resident #1 and returned to the desk. On 1/5/16 at 3:35 P.M. observed the resident sitting on the edge of his/her bed in his/her room and noted a smell of burning odor coming from the heater in the resident's room. This surveyor told licensed nursing staff J, who was at the nurses' desk, of a burning odor coming from resident #1's room. Licensed nursing staff J called the maintenance staff to check the room related to odor. Nursing staff J still had not moved from the nurses' desk since the resident was last checked at 3:10 P.M. and did not ask other staff to check on this resident. Review of the check sheet revealed licensed nursing staff J had signed the he/she had checked the resident at 3:00 p.m., 3:15 P.M., and 3:30 P.M. however nursing staff J had not left the nurses' desk. Observation of the check sheet on 1/5/16 at 4:30 P.M. revealed the check sheet had not been signed for 4:00 P.M. and 4:15 P.M. On 1/5/16 at 3:25 P.M. interview with direct care staff P stated the staff had to tell the resident where his/her room was and assist him/her with daily cares. Direct care staff P acknowledges the December incident and stated there was another incident where this resident was caught trying to unzip another resident's pants during the summer and the facility moved that resident to the other side of the building. On 1/5/16 at 3:27 P.M. interview with licensed nursing staff J revealed staff were to check the resident every 15 minutes during the day and redirect him/her. The nurses were responsible to sign the 15 minute check sheet. The resident does wander about the building by him/herself and we had to redirect him/her all the time. On 1/6/16 at 8:45 A.M. observation revealed the resident walking independently with staff in attendance on a unit the resident did not reside on. The 15 minute check sheets since the incident on 12/13/15 lacked documentation on 12/17/15 from 6:15 A.M. until 8:00 A.M., 12/19/15 from 9:00 P.M. until 9:45 P.M., 12/22/15 from 6:15 A.M. until 7:45 A.M., 12/31/15 from 2:45 P.M. until 5:45 P.M., 1/1/16 from 3:45 P.M. until 4:45 P.M. , 1/4/16 from 4:15 A.M. until 5:15 A.M. , and 1/4/16 from 12:15 P.M. until 9:45 P.M. as to where the resident was. The 7/2011 revised facility policy Protection of Residents: Reducing the Threat of Abuse and Neglect documented each resident had the right to be free from mistreatment, neglect and misappropriation of property. This included the facility's identification of residents whose personal history render them at risk for abusing other residents and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. The facility failed to provide a policy related to the 15 minute check form. The facility failed to monitor this resident with a history of sexually inappropriate behavior with other residents. The resident had inappropriate sexual behavior toward another resident in June 2015 and repeated inappropriate sexual behavior toward a cognitively impaired resident on 12/13/15, which placed the residents in this facility in immediate jeopardy. The facility failed to accurately monitor and document the resident's whereabouts on the 15 minute check sheets for 6 different days from 12/13/15 until 1/4/16. This placed the residents in the facility in immediate jeopardy. The Immediate Jeopardy was abated on 1/7/16 after the facility in-serviced all staff on 1/6/16 related to the 15 minute checks, documentation of the 15 minute checks, and 1 on 1 initiated with resident #1. Resident #1 would not have a roommate while remained at the facility and would remain on 1 on 1 observation while resided in the facility. The director of nursing or designee would audit the 15 minute check sheets daily until the resident was deemed not to need the 15 minute checks. The deficiency remains at a scope and severity of a D .

The facility ' s census totaled 77 residents with 6 residents in the sample. Based on observation, interview, and record review, the facility failed to provide effective interventions to prevent elopement of 1 of 3 residents sampled (#1) at risk for elopement with cognitive deficits and this failure placed the resident in immediate jeopardy. Resident #1 was seen unattended by staff leaving a store 0.2 miles from the facility and staff found the resident 1 block away, across the street from the facility. This deficient practice placed the resident in immediate jeopardy. The facility also failed to provide adequate supervision and implement effective interventions as planned to prevent falls for 1 of 3 sampled residents (#5) reviewed for falls. Findings included: - Resident #1 ' s clinical record documented he/she had admitting [DIAGNOSES REDACTED]. The discharge 5-day Minimum (MDS) data set [DATE] documented the resident had a Brief Interview for Mental Status score of 4 (severe cognitive impairment), had delusions, wandered 1 to 3 days in the look back period, required supervision with setup only for transfers, walked independently, was steady at all times, and used a wheelchair . The undated Initial Data Collection Tool/nursing noted the resident admitted on [DATE] at 1:30 P.M. for skilled services and his/her mental function varied throughout the day. The interim care plan dated 6/16/15 documented the resident at risk for elopement, had wandering and/or exit seeking behavior, history of elopement on 6/15/15 when the resident left the facility. Staff educated the resident/family on wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), provided safe wandering, involved the resident in activities, and redirected the resident. On 6/15/15 at 7:00 P.M. staff initiated 15 minute checks for 24 hours, placed a wanderguard to the left ankle, encouraged family visits during peak exit-seeking times, and evaluate exit-seeking behaviors to determine causes/patterns. One-on-one Certified Nurse Aide (CNA) to be with the resident. The risk for elopement care plan dated 6/15/15 noted staff completed elopement assessments quarterly and with a significant change. The Risk of elopement/wandering Review dated 6/15/15 noted the resident was not cognitively impaired with poor decision- making skills (intermittent confusion, cognitive deficits or disoriented) had a [DIAGNOSES REDACTED]. Record review of the hospital notes revealed: The physician progress notes [REDACTED]. Note dated 6/9/15 at 3:02 A.M. noted the resident would not go to bed and was adamant he/she was not going to bed, he/she was waiting to board a plane. The behavior intervention response and plan note dated 6/12/15 at 7:49 A.M. noted the patient wandering the hallways looking for his/her family. Staff re-oriented the resident to place, time and situation. Nursing Note dated 6/15/15 at 3:41 P.M. documented the resident arrived at 1:30 P.M. without accompaniment per wheelchair, was alert times 1 with confusion, was able to make needs known, required moderate assistance of one staff with Activities of Daily Living (ADLs) and bed mobility. The resident required assistance from one staff with transfers for safety. The resident ambulated independently with use of assistive devices at this time, and received physical and occupational therapies for assistive devices related to unsteady gait. Resident is hard of hearing and wore eyeglasses secondary to visual impairments. The notarized witness statement dated 6/16/15 at 3:00 P.M. revealed social service staff GG documented during the admission meeting the family reported the resident was a wander risk and he/she would try to leave the last facility with family when they left. The notarized witness statement dated 6/15/15, at 8:00 P.M. dietary staff DD documented he/she served drinks to the resident around 5:00 P.M. The resident was gone when he/she returned to serve the meal to the resident. The notarized witness statement dated 7/15/15 from resident #7 documented he/she saw resident #1 follow a man carrying a box out the front door. He/she told direct care staff O that the resident walked out of the front door and his/her wheelchair was by the front door. Direct care staff O told him/her I don ' t know what you are talking about and pushed another resident down the hall. The notarized witness statement dated 6/15/15 at 7:58 P.M. direct care staff O documented resident #7 informed him/her that a resident followed a man with a box out the front door. Direct care staff did not know what the resident was talking about, saw an empty wheelchair by the front door, and went on his/her meal break. The notarized witness statement dated 6/17/15 documented a neighbor saw the resident in line at the Dollar Store at 5:30 P.M. on 6/15/15. At 6:30 P.M. he/she saw the resident sitting across the street at a house on the steps. The resident had shoes, a deck of cards, and a chair pad in his/her hands. A different neighbor went to the facility to inquire if the resident lived there while he/she called 911 at 6:44 P.M. The facility ' s nurse walked across the street to the resident, assisted the resident into the back of the police car in which both were driven back to the facility. The hand written nurse note dated 6/15/15 at 6:45 P.M. revealed during shift change a woman came to the nurses ' station and asked if an resident #1 ' s name was a resident at the facility. He/she informed the nurse the resident was sitting on a porch across the street. Staff found resident #1 sitting in a lawn chair on the front porch across the street at a duplex. The resident stated he/she had been out of the facility for a while. He/she did not know where he/she was, the day, the month or the year. The weather was 77 degrees, with cloudy skies. The resident clothing was dry except for his/her socks and his/her adult brief was wet. He/she did not have on shoes on but they were with him/her. The resident stated I ' m fine I am on a walk . Staff assisted the resident to stand, assisted back to the building with standby assistance. Staff placed a Wanderguard on the resident ' s left ankle. The length of time the resident was outside of facility unsupervised is unknown, approximately 1 hour and 15 minutes to 1 hour and 45 minutes. On 7/15/15 at 8:10 A.M. a tour by the surveyor of the path of elopement of the known places the resident was seen and staff found the resident sitting on the porch across the street of the duplex were as follows: From the front door of the facility there was a 50 foot ( ' ) sidewalk that lead to a 50 ' parking lot to a 2 way street with a steep incline/hill, could not see the road approximately ½ block to the north past the crest of the hill. There were no sidewalks on either side of the street. The speed limit on the street was 30 miles per hour. The duplex had a small uneven cement slab on east side of building, there were no chairs noted, there were 9 uneven cement steps to the south of the building with a steep embankment which led down to a 2 car cement driveway. The west side of the duplex had wood deck with 6 stairs. The Dollar Store was 0.2 miles from the facility ' s drive way. The street in front of the facility was 20 miles per hour (mph). The speed limit in front of the Dollar Store was 35 mph, with 2 lanes of traffic. According to AccuWeather.com the temperature on June 15, 2015 for zip code the low was 72 degrees and the high was 86 degrees. The hourly temperature was not available. Record review on notarized witness statements documented there were no alarms going off in the building on 6/15/15 between 5:00 P.M. and 6:45 P.M. The facility reported there were 15 residents at risk for elopement. On 7/15/15 at 3:13 P.M. direct care staff O stated resident #7 told him/her at about 6:15 P.M. a resident was walking out the front door with a man with a box. There was an empty wheelchair by the front door. I went to dinner break. Around 7:15 P.M. staff informed him/her that resident #1 escaped, and the resident wasn ' t back in the building yet. On 7/15/15 at 7:27 A.M. licensed staff I stated nursing staff completed an elopement risk assessment on the resident at the time of admission and as needed if wandering/exit-seeking and placed a wanderguard. If the resident was found at risk, the nurse updated the resident ' s care plan, updated the elopement book at each nurse station and the front desk with the resident ' s picture and place a wanderguard on the resident. When the facility doors opened an alarm sounded. Staff called a code green to which door opened and staff went out the doors to the right looking for residents. Staff completed a resident head count of all residents was completed. If a resident got out of the facility the administrator or the DON would report it to the state. On 7/15/15 at 5:03 P.M. licensed staff H said staff were to report if a resident was missing and we would look for them. Interview on 7/15/15 at 2:00 P.M. administrative staff A stated staff changed the facility door codes weekly. The receptionist left around 5:30 P.M. that day, prior to this elopement. He/she acknowledged direct care staff was told the resident went out of the front door unsupervised and did not tell any other staff members. On 7/16/15 at 11:43 consultant staff KK stated he/she did not have time to evaluate the resident due to the short time of him/her being in the facility. The facility ' s Elopement Policy undated noted elopement definition was an incident in which a resident leaves the facility grounds without staff knowledge: the resident had impaired decision making abilities and is unaware of his/her own safety needs. Staff assessed the resident at the time of admission for the potential of elopement based on the following indicators: history of wandering or elopement, history and/or assessment indicate an impaired decision making ability or impaired cognition with the ability to be mobile by walking or use of a wheelchair. The facility failed to provide a secure environment for this cognitively impaired, ambulatory resident who exited the facility without staff awareness and was witnessed in a store 0.3 miles away from the facility and was found by neighbors across the 2 lane street sitting in a lawn chair confused, in a wet adult brief and no shoes on his/her feet. This deficient practice placed the resident in immediate jeopardy. The facility completed educating the staff 6/19/15 on Elopement Policies and Procedures, Completion of Elopement Risk Assessment, Pre-admission meetings will now be held prior to the resident being admitted .Education was given on the use of the New Patient Information form and the use of the new code system and all the doors were inspected by RFI Technologies the volume was increased and the tone changed. The facility also reviewed all resident risk assessments for elopement and care plans were reviewed and updated as needed. The Elopement Book was updated and an Elopement Drill and education on Elopement was provided. The front desk hours have been extended, they were scheduled until 5 P.M. and now the hours have been extended to 7:30 P.M. The facility abated the immediate jeopardy on 6/19/15. This deficient practice remains at the scope and severity of D . - The closed record for resident #5 contained an admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident with moderate cognitive impairment. The MDS further documented the resident required extensive assistance of 1 staff member with bed mobility, transfers, toilet use, and personal hygiene, limited assistance of 1 staff member with dressing. The MDS documented the resident with no falls history. The activity of living Care Area Assessment (CAA) dated 7/3/15 documented the resident required limited assistance for activities of daily living. The CAA for falls was not triggered. The care plan documented the resident was at risk for physical injury from falls dated 6/18/15 included the following interventions: assist of 1 staff member with transfers and ambulating; provide assistant for bed mobility, transfers or ambulation; assistive devices included a wheelchair, a chair alarm when in the wheelchair or the chair and audible to the staff; a bed alarm when in bed and audible to staff; and fall mats to bilateral bedsides. On 6/30/15 added an x-ray of the right arm secondary to a fall. On 7/5/15 added to send to the emergency room due to a fall. On 7/6/15 added a perimeter mattress to the bed. The fall risk assessment dated [DATE] scored 18 which indicated the resident was at a high risk for falls. The clinical record documented on 6/29/15 at approximately 1:00 A.M. the resident went to the bathroom and slipped on his/her pillow that had fallen on the floor. His/her current interventions included fall mats, a chair alarm, the bed to the lowest setting and a bed alarm. The new intervention included to educate the resident and family to utilize the call light to get assistance when getting out of the bed and to utilize the emergency light in the bathroom before getting off the toilet. The clinical record documented on 7/5/15 at 2:35 A.M. the staff heard a bed alarm and found the resident leaning over the right side of his/her bed. The staff was unable to reach the resident in time before he/she fell over and hit his/her head on the bottom of the bedside table. Staff assisted the resident up after doing a head to toe assessment, applied pressure to the right side of the forehead, stopped the bleeding, and applied ice to the forehead. Staff cleaned the resident up and a bandage applied to the right side of the forehead and initiated one to one staff to stay with the resident. The staff notified the doctor, the nurse on call, and the family. The resident was sent to the emergency room and 5:35 A.M. when family arrived at the facility. The resident returned from the emergency room at 11:30 A.M. with no new orders. The clinical record documented on 7/6/15 at 11:45 P.M. the nurse heard a crash and the direct care staff went to the room and found the resident on the floor. The resident was found lying face down on the floor. The nursing staff turned the resident onto his/her back and noted a large hematoma (bruise) on the right side of his/her forehead. The nursing staff asked the resident if he/she was hurt and they did not respond. The nursing staff called the doctor and obtained an order to send the resident to the emergency room . The nursing staff called the family, then told of the fall and order to send to the emergency room . An interview with direct care staff R on 7/15/15 at 10:00 A.M. stated the resident was total care and we had to watch him/her closely because he/she would forget to call for help. His/her family was here a lot during the day, so that helped. He/she was a fall risk and we had a low bed, fall mats, and alarms on him. An interview with direct care staff S on 7/15/15 at 10:15 A.M. stated he/she was a fall risk and fell several times by not using his/her call light and not waiting for help. He/she did have alarms on for a while. An interview with administrative nursing staff D on 7/15/15 at 10:30 A.M. stated the resident did not have a mat placed on both sides of his/her bed as ordered and his/her table was on the side of the bed that he/she hit their head on. An interview with licensed nursing staff K on 7/15/15 at 6:01 P.M. stated on the 7/6/15 he/she came in at 6 P.M. and was told the facility had removed the bed alarm, so checked on him/her every 30-45 minutes, when the next shift of direct care staff came in, he/she told them the resident did not have the alarms anymore and to check on him/her more often. At 11:45 P.M. he/she heard a crash and we went and found his/her face down on the floor. The direct care staff had checked on him/her just 15 minutes before the fall. The direct care staff member and licensed nursing staff did not notice the fall mat was not in place during previous checks. The undated facility policy Falls Management documented an interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident ' s current safety needs and fall reduction interventions. The facility failed to develop and implement appropriate interventions to prevent falls and to ensure the nursing staff followed the care plan for this resident which documented fall mats to both sides of his/her bed. The resident fell out of bed, found on the floor lying face down, and the fall mat was not placed next to the bed. Staff failed to implement interventions as planned.

The facility identified a census of 74 residents. The sample size included 20 residents. Based on observation, record review, and interview the facility failed to have appropriate interventions in place to prevent falls for one (#3) resident of the 3 reviewed for falls. Findings included: - The Physician order [REDACTED]. by failing memory, confusion). The POS listed the resident received Occupational Therapy (OT) 3 times a week for 4 weeks for adaptive Activities of Daily Living (ADLs) for therapeutic exercise, functional mobility, wheelchair positioning and therapeutic activity. Noted on the POS, the resident was discharged from OT services due to meeting goals and reaching his/her maximum level of functioning. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident's Brief Interview for Mental Status score (BIMS) was 6 which indicated the resident had severely impaired cognition. The resident required extensive assistance with all ADLs except needed only supervision with eating and limited assistance with locomotion on the unit. He/she needed human assistance for balance with transfers, had no functional limitation of the upper or lower extremities, and had no falls. The resident received antidepressant, antipsychotics and diuretic medications daily. Care Area Assessment (CAA) dated 2/14/13 for falls noted the resident was at risk for falls secondary to impaired cognition, unsteadiness, and use of high risk medications. A Fall Risk assessment was done per facility protocol. The care plan for falls dated 8/13/13 listed for staff to invite and encourage the resident to attend activities and escort him/her to those of interest. Staff to provided environmental adaptions such as: the call light with in reach, adequate glare free lighting, and area free of clutter. Staff to provide the resident teaching to include safety measures to reduce fall risk and what to do if a fall occurred. Staff to provide and observe use of adaptive devices such as the wheel chair. Staff to refer for screens and treatment as needed with OT, and Physical Therapy (PT). Staff to remind the resident and reinforce safety awareness: lock the brakes on bed and the wheelchair before transferring, and educate and remind the resident to request assistance prior to ambulation. Staff to report falls to physician and the responsible party, report to physician any side effects associated with the resident's medication use. Intervention added on 11/7/13 noted for staff to remove the wheelchair from the resident's bedside at bedtime to prevent attempts to self ambulate. Provide resident with a call light and reorient as needed. An intervention dated 12/4/13 listed for the resident to use the call light and sit back completely in the wheelchair. The intervention dated 12/27/13 noted to apply anti-roll back device to the wheelchair. An intervention dated 1/7/14 listed for staff to educate the resident on the use of the call light, staff to assist the resident with transfers and lay the resident down after meals. The Fall Risk assessment dated [DATE] revealed the resident scored 18 and on 1/7/14 the resident scored 20. A score of 10 or higher noted residents were at a high risk for falls. Review of the interdisciplinary notes dated 12/04/13 at 9:28 P.M. noted staff found the resident on the floor next to his/her bed. He/she denied pain. The fall intervention was for the severely cognitively impaired resident to use the call light and sit back completely in the wheelchair. A fall dated 12/26/13 at 1:03 P.M. noted the resident was found by direct care staff on the floor in his/her room in a sitting position with his/her legs out straight in front of him/her wheelchair, the brakes were not locked. The resident had no injury and staff transferred him/her back to the wheelchair, toileted the resident, then brought him/her to the nurses' station. The resident said he/she was trying to get back into bed when he/she fell and forgot to use the call light. Observation on 1/7/14 at approximately 8:40 A.M. while checking resident call lights for proper functioning, the state surveyor knocked on a closed door, heard hollering and entered the resident's room. The resident's wheelchair was on the far side of his/her bed and the resident's buttocks (the back of a hip that forms one of the fleshy parts on which a person sits) sat partially on the right pedal of the wheelchair while the other part of her buttocks was on the floor. He/she hung onto the transfer bar with both hands. The wheelchair was not locked, no anti-roll device to the wheelchair and no alarms sounded. The resident said she did not attempt to use the call light. The surveyor alerted facility staff via use of the resident's call light. The resident's roommate then used the emergency call light in the bathroom to alert staff. After approximately a minute, the resident was assisted to sitting on the floor. He/she remained in the sitting position until staff arrived about 5 minutes after the call light was activated. Licensed nursing staff H assessed the resident, performed range of motion to the lower extremities, the resident denied pain or hitting his/her head. He/she asked the state surveyor if the resident's chair alarm sounded when the resident fell . A direct care staff person assisted licensed nursing staff H in transferring the resident to the wheelchair. The care plan intervention was for staff to educate the resident on the use of the call light, staff to assist the resident with transfers and lay the resident down after meals. Observation on 1/7/14 at 3:25 P.M. revealed the resident sat in the wheelchair, propelling him/herself using his/her feet, had non-skid slippers on, chair alarm to the wheelchair, and no anti-roll device noted. Observation on 1/8/14 at 6:45 A.M. the resident was in the wheelchair,propelling self using hands and feet down the hallway. Chair alarm to the wheelchair and the foot pedals were not on the wheelchair. Observation on 1/8/14 at 1:55 P.M. the resident sat in the wheelchair in the living room, watching TV. There was an alarm to the back of the wheelchair. On 1/9/14 at 6:45 A.M. the resident sat in the wheelchair in the TV room, eyes closed. No foot pedals noted to the wheelchair. There was an alarm to the back of the wheelchair. On 1/9/14 at 7:35 A.M. Administrative staff B applied an anti-roll back and anti-tip devices to the resident's wheelchair at this time. He/she said he/she was made aware the resident was to have them on the wheelchair yesterday. Observation on 1/9/14 at 8:45 A.M. the resident sat in his/her wheelchair watching TV. There was an alarm to the back of the wheelchair. The resident propelled self up and down the hallways on 1/9/14 at 9:40 A.M. There was an alarm to the back of the wheelchair. Observation on 1/9/14 from 10:20 A.M. to 11:00 A.M. revealed the resident remained in his/her wheelchair while listening to the guitar player and/or propelling self up and down the hallway. There was an alarm to the back of the wheelchair. On 1/9/14 at 1:25 P.M. revealed the resident sat in his/her wheelchair in the TV room. There was an alarm to the back of the wheelchair. The resident did not lay down after lunch on 1/8/14 or after breakfast and lunch on 1/9/14. Interview on 1/8/14 at 4:13 P.M. with direct care staff R said we try to keep the resident with us as much as possible to monitor his/her whereabouts. The resident did not remember to use the call light and did not remember that he/she could not transfer self anymore. He/she said the resident's wheelchair did not have anti-tip or anti-roll devices and the resident did not have an alarm to the wheelchair or to the bed. He said staff toileted the resident every 2 hours. Interview with direct care staff Q on 1/8/14 at 1:40 P.M. said the resident should not have foot pedals to his/her wheelchair anymore because he/she propelled self. He/she said the resident had a chair alarm but not a bed alarm. Interview with direct care staff O on 1/9/14 at 12:15 P.M. said the resident did not have any special equipment to the wheelchair except for a chair alarm and also had a bed alarm. He/she said staff needed to be with the resident when he/she attempted to transfer, said the resident did not use the call light or the brakes to the wheelchair when he/she attempted to self transfer. Direct care staff D said we toileted the resident every 2 hours. Interview on 1/9/14 at 1:17 P.M. with licensed nursing staff H said the fall intervention for the staff to remind the resident to use the call light was not appropriate because he/she did not remember well enough to use it and did not apply the brakes to the wheelchair to lock before transfer. He/she said the resident had a clip type alarm to the back of the wheelchair but he/she said he/she was not sure if staff unclipped it and used it on the bed or not. He/she said he/she was not aware the anti-roll device was not implemented until today. Licensed nursing staff H said staff toileted the resident every 2 hours but he/she was not aware if the staff laid him/her down after meals. The undated facility provided policy for Falls Management listed falls were a common source of serious injury in the elderly. If a resident received a score of 10 or greater on the Fall Risk Assessment, staff assess the resident for hip protection. An interdisciplinary care plan was developed as necessary to reflect each resident's current safety status, needs, and interventions. The care plan was reviewed thoroughout the course of treatment by the interdisciplinary team to assure the most recent, updated, and resident specific fall reduction interventions were incorporated as necessary into the plan of care. If a resident fell , the charge nurse reviewed and updated the care plan as needed to reflect the resident's present mobility, safety needs, and would communicate fall reduction interventions to the care givers on the unit and in shift report. The facility failed to implement appropriate and timely interventions and implement interventions as planned to prevent falls for this severely cognitively impaired resident who required extensive staff assistance with transfers.

The facility had a census of 66 residents. The sample included 6 residents. Based upon observation, record review and interviews the facility failed to timely implement interventions to prevent the development of a pressure ulcer for 1 (#5) of 3 residents sampled for pressure ulcers. Findings included: - Review of resident #5's annual Minimum Data Set (MDS) 3.0 dated 2/7/13 identified the resident had short and long term memory impairment, severely impaired cognition, totally dependent upon staff for bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use and personal hygiene. The MDS identified the resident did not walk in the corridor/room, utilized a wheelchair, and had range of motion impairment on both sides of his/her lower extremities. The MDS recorded the resident was at risk for the development of pressure ulcers, had (2) Stage 2 pressure ulcers not present upon admission/readmission, was on a turning/repositioning program, and utilized a pressure relieving device in the chair and wheelchair. The resident's pressure ulcer Care Area assessment dated [DATE] documented the resident had a history of [REDACTED]. had a stage 2 pressure ulcer. The resident scored 12 (at risk for the development of pressure ulcers) on the Braden Scale (scale used to predict the development of pressure ulcers) completed on 8/22/12 and 2/25/13. The resident's care plan (date unknown) addressed the resident at risk for pressure ulcers, staff turned and repositioned the resident every 2 hours and as needed, the pressure ulcer on the resident's right hip healed on 8/22/12 and staff did not position the resident on his/her right hip. The care plan included staff minimized the pressure over the resident's bony prominences and skin to skin contact. The care plan did not include how staff were to minimize skin to skin contact or minimize the pressure on the resident's bony prominences. An entry dated 1/24/13 included the resident's inner knees had open areas and the staff placed a pillow between the resident's knees at all times. The facility's weekly pressure sore tracking form dated 1/24/13 documented staff observed the resident had bilateral inner knee facility acquired stage 2 pressure ulcers. The form included the Stage 2 pressure ulcer on the inner aspect of the resident's left knee measured 0.3 centimeters (cm) by 0.5 cm, and the Stage 2 pressure ulcer on the inner aspect of the resident's right knee measured 0.3 cm by 0.3 cm. The facility's weekly pressure ulcer tracking report dated 2/20/13 documented the Stage 2 pressure ulcer on the inner aspect of the resident's left knee measured 0.5 cm by 0.3 cm and the Stage 2 pressure ulcer on the inner aspect of the resident's right knee measured 0.5 cm by 0.4 cm. On 2/27/13 at 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M. and 11:15 A.M. the resident sat in his/her wheelchair in the television room. Further observations revealed the resident had on pants, did not have a pillow between his/her knees and the resident's knees were in direct contact with each other. On 2/27/13 at 1:30 P.M., 2:00 P.M., 2:30 P.M., and 3:00 P.M. the resident laid in bed on his/her left side. Observation revealed the resident had a pillow between his/her knees and the resident's feet were not floated and without heel protectors. Observation revealed a pair of blue heel protectors on top of the resident's bedside cabinet. On 2/27/13 at approximately 3:15 P.M. licensed nurse I performed the treatment to the inner aspect of the resident's knees. Observation revealed the Stage 2 pressure ulcer on the inner aspect of the resident's left and right knees measured approximately 0.3 cm by 0.3 cm. During interview with licensed nurse I at that time, staff stated the pressure ulcers were facility acquired. On 2/28/13 the resident sat in the wheelchair with a pillow between his/her knees in the television area of the hall where he/she resided at 7:20 A.M. and 7:30 A.M. At 7:35 A.M. staff wheeled the resident to the assisted dining room. The resident sat in the wheelchair in the assisted dining room at 7:35 A.M., 7:45 A.M., 8:00 A.M., 8:15 A.M., and 8:30 A.M. At 8:30 A.M., 8:40 A.M., 8:45 A.M., 9:00 A.M., 9:15 A.M., 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M. the resident sat in his/her wheelchair in the television area. At 10:30 A.M. (2 hours and 55 minutes) the resident sat in his/her wheelchair in his/her room. During interview with licensed nurse I on 2/28/13 at 10:30 A.M. staff stated direct care staff just repositioned the resident. During interview with direct care staff Q on 2/28/13 at approximately 10:33 A.M. staff stated he/she repositioned the resident at approximately 10:30 A.M. Direct care staff Q stated he/she did not reposition the resident prior to 10:30 A.M. During interview with direct care staff P on 2/28/13 at approximately 10:35 A.M. he/she stated staff repositioned the resident at approximately 10:30 A.M. Direct care staff P stated he/she placed the resident in the wheelchair that A.M. around 7:10 A.M. and he/she did not reposition the resident since that time. On 3/1/13 at 7:20 A.M., and 7:30 A.M., the resident sat in his/her wheelchair without the pillow between his/her legs. Observation revealed the resident had on pants and the resident's knees in direct contact with each other. On 3/1/13 at 1:30 P.M. the resident laid in bed on his/her right side. During interview with direct care staff P at that time, he/she confirmed the resident was positioned on his/her right side. On 3/1/13 at approximately 1:30 P.M. direct care staff P stated the facility did not utilize assistive devices between the resident's knees until the resident developed the open areas. On 3/1/13 at approximately 1:35 P.M. licensed nurse I stated the resident did not utilize heel protectors and staff did not float the resident's heels. During interview with administrative nursing staff E on 3/1/13 at approximately 3:00 P.M. staff stated the resident's care plan did not specify how staff minimized the pressure over the resident's bony prominences or minimized skin to skin contact. Administrative nursing staff E stated he/she updated the resident's care plan on 1/24/13 (date the bilateral pressure ulcers were first observed) specifying staff to place a pillow between the resident's knees at all times. Administrative nursing staff E stated staff should float the resident's heels and the resident did not utilize heel protectors. On 3/1/13 at approximately 3:30 P.M. direct care staff R stated staff did not place pillows/devices between the resident's knees until the resident developed the open areas. Review of the facility's pressure ulcer policy and procedure revised 10/7/2010 included if the resident scored 14 or less on the Braden Scale, preventive measures were considered which may include use of arm and leg protectors, and special positioning with support pillows. The facility failed to ensure the resident's knees were relieved of skin to skin contact, failed to maintain a pillow between the resident's legs at all times as care planned, failed to reposition the resident every 2 hours as care planned and failed to float the resident's heels as planned for this severely cognitively impaired resident with a history of pressure ulcers who developed bilateral inner knee Stage 2 pressure ulcers.

The facility has a census of 65 residents of which 4 were sampled for nutrition. Based on observation, record review, and staff interview, the facility failed to provide consistent nutritional interventions for resident # 18 who had a significant weight loss and failed to provide the ordered therapeutic diet for one resident. Findings included: - The 30 day Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] for resident # 18 documented the resident was severely cognitively impaired and unable to make decisions for him/herself. The MDS also indicated the resident needed extensive assistance with eating. The Care Area Assessment (CAA) dated 1/11/12 for nutrition stated that the resident was on a mechanical soft diet and fed by staff and had a good appetite. It also stated that the [MEDICATION NAME] on admission was within normal limits. The cognitive status CAA stated that the resident had a [DIAGNOSES REDACTED]. His/her speech was often mumbled. The care plan dated 6/14/12 stated the resident had fluctuations in his/her weight pattern since admission. Staff documented a new order on 5/7/12 for mechanical soft with honey thick liquids. The resident was to be on Ensure pudding three times a day with meals, 2 cal supplement 60 ml (milliliters) three times a day and prostat 30 ml daily. Staff was to monitor labs as needed. Staff fed the resident all meals and staff to offer snacks between meals, encourage fluids between meals and with activities. The care plan also stated to offer substitutes to the resident if he/she did not like what was served. The diet order as stated on the Physician order [REDACTED]. Supplements ordered for the resident were 2 cal supplement 60 ml three times a day, prostat 30 ml daily and Ensure pudding three times a day. The resident was hospitalized for [REDACTED]. A nursing note dated on 4/20/12 (untimed) said staff were to give the resident Ensure pudding three times a day with meals. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED] The dietary assessment on 4/21/12 by a registered dietician documented the resident remained obese, and the [MEDICATION NAME] level was down. On 4/20/12 staff started the resident on a multivitamin, and Ensure pudding three times a day. In May, the MAR indicated [REDACTED]. 2 cal drink was ordered three times a day. A nurse practitioner visit on 6/11/12 documented skin turgor, the resident's appetite and fluid intake was good, and he/she fed self. The dietary assessment on 5/19/12 by the registered dietician documented the resident's weight was down 49 pounds in 3 months and the dietician reviewed weekly weights. Review of the resident's weight record revealed the following: 1/9/12 - 215 lbs.(pounds), 1/16/12 - 216 lbs., 2/12/12 - 210 lbs., 4/23/12 - 162 lbs., 5/1/12 - 161, 5/7/12 - 160 lbs., 5/15/12 - 161 lbs., 5/21/12 - 147 lbs., 5/28/12 - 148 lbs., 6/6/12 - 147 lbs., 6/12/12 - 145., 6/18/12 - 150 lbs. The resident had a 66 lb weight loss (30.5%) from 1/16/12 to 6/18/12. Review of the resident's labs on 1/20/12 revealed a [MEDICATION NAME] of 20 mg/dL milligrams per deciliter with a normal range of 17-34 mg/dl. On 4/6/12 the [MEDICATION NAME] was 8 mg/dL (17-34) and on 4/23/12 at 14 mg/dL (17-34). Observation on 6/19/12 at 4:30 P.M. revealed the resident sat in wheelchair at the dinner table, eyes open and held on to the table. At 4:45 P.M. the resident lifted a glass filled with thickened cranberry juice to his/her lips and drank it. He/she emptied the glass after 10 minutes all unassisted. At 4:45 P.M. staff assisted the resident with food of mechanical soft meat and potatoes, regular sized portions. With staff assistance he/she ate 100 % of the food offered. Staff did not offer Ensure pudding during or after this meal. Observation on 6/20/12 at 7:45 A.M. revealed staff served the resident small portions of ground ham, ground scrambled eggs and ground muffin. The resident ate 100% of the meal. Staff did not offer Ensure pudding to the resident. Observation on 6/21/12 at 9:15 A.M. revealed the resident was in the activity room with other residents. Staff delivered medication to the resident, and Ensure pudding was not offered. An interview on 6/20/12 at 4:30 P.M. with the resident's wife stated the resident had been losing weight for a while. The staff told him/her that he/she had ate well today. " I hope that is true." An interview on 6/21/12 2:45 P.M. with Direct Care Staff F stated he/she assisted the resident at meals all the time. The staff stated he/she never gave the resident pudding at any meal. He/she stated that if the resident was supposed to get pudding, the staff would know. An interview on 6/20/12 at 2:31 P.M. with Direct Care Staff T revealed staff go by what the care guide said and the staff updated it daily. He/she said staff let the charge nurse know if the residents did not eat. The care guide lacked evidence the resident was to receive supplements. An interview on 6/20/12 at 5:45 P.M. with Licensed Nurse Y stated that he/she assisted the resident with eating that evening and the resident ate well. He/she said sometimes the resident pushed away his/her food, then staff attempted other foods. An interview on 6/20/12 at 5:50 P. M. with Direct Care Staff U revealed the resident would sometimes indicate that he/she was still hungry by reaching and grabbing other peoples food. This staff said that he/she always gave the resident more food when the resident did that. An interview on 6/21/12 at 10:45 A.M. with acting Dietary Manager BB stated that he/she knew a resident did not eat well when the plate of food was untouched. An interview on 6/21/12 at 10:50 A.M. with Dietary Staff AA stated the dietary tickets for each resident had all their information on it. If there were changes, staff communicated it verbally or put it on the board. Observation of this resident's dietary ticket lacked information of the Ensure pudding. An interview on 6/21/12 at 11:35 A.M. with Administrative Licensed staff A stated this resident was to have supplements including Ensure pudding. He/she said he/she could not recall if we documented the pudding on the MAR. We have a program where we evaluate residents who are losing weight. We monitor those people more closely and give that list to the dietician. A phone interview on 6/21/12 at 1:35 P.M. with Licensed Dietary Staff P stated his/her usual protocol for dealing with weight loss in a resident was to take them off food restrictions, add supplements, follow up with the resident and continue to make recommendations to the staff as needed. Staff P also stated he/she had not seen this resident when at the facility on 6/13/12. The facility lacked evidence and documentation for interventions for this dependent resident with a significant weight loss. - The 5-31-12 physician orders [REDACTED]. The 6-7-12 Admission MDS (Minimum Data Set) assessment indicated resident #61 had moderately impaired cognition and needed a therapeutic diet. The 6-12-12 CAAS (Care Area Assessment Summary) indicated resident #61 had nutritional issues due to end stage [MEDICAL CONDITION] and needed a therapeutic diet. The 6-1-12 care plan indicated resident #61 had diet restrictions with food should have a renal/constant carbohydrate diet. According to the diet sheet that comes out of the kitchen with resident #61's meals, he/she received a regular diet. The sheet contained no other nutritional needs for the resident. The 5-31-12 admission diet orders indicated resident #61 needed a renal/ADA (diabetic) diet. According to the diet protocol for the facility, if the admission diet order indicated the resident should have a [MEDICAL TREATMENT]/renal diet, the diet order should then read: no added salt, no orange juice, no tomato, no potato, and limit milk to one per day. The 6-13-12 Nutrition Data Collection Assessment indicated resident #61 had a current diet order of renal ADA (diabetic) and the registered dietician calculated the resident's nutritional needs based on a height of 74 inches and a weight of 203 pounds. During an observation on 6-20-12 at 7:50 a.m., resident #61 ate a double portion regular diet that included orange juice, oatmeal, ham, scrambled eggs and blueberry muffins. Resident #61 ate 100% of his/her meal and drank 120 milliliters of orange juice. During an observation on 6-20-12 at 4:20 p.m., resident #61 ate a regular diet that included a tomato-covered Spanish omelet, fried potatoes a muffin, a cookie and vegetables. Resident #61 ate 100% of his/her meal and drank 300 milliliters of chocolate milk. During an interview on 6-20-12 at 5:15 p.m., direct care staff J stated resident #61 had a regular diet ordered. During an interview on 6-21-12 at 7:20 a.m., licensed nursing staff H stated resident #61 should have a renal diet but he/she ate whatever he/she wanted. During an interview on 6-21-12 at 9:00 a.m., administrative nursing staff A confirmed resident #61 had a recommendation from the dietician to change his/her diet from the renal ADA diet to the facility's no added salt, no orange juice, no tomato, no potato, limited milk diet, but the recommendation had not implemented. During an interview on 6-21-12 at 10:45 a.m., consultant staff P indicated the renal diet substitution included limiting potassium and sodium, no orange juice, no tomatoes, no potatoes, no bananas and limited milk intake. During an interview on 6-21-12 at 3:00 p.m., dietary staff O confirmed resident #61 had eaten a regular diet since admission to the facility. The facility failed to ensure resident #61 received a therapeutic diet as ordered related to his/her [DIAGNOSES REDACTED].

The facility identified a census of 70 residents. The sample included 19 residents. Based on observation, interview and record review the facility failed to provide treatments to prevent recurrence of a pressure ulcer for 1 of 2 sampled residents # 19. Findings included: - Resident # 19 ' s physician's order [REDACTED]. This pos ordered on [DATE] nursing staff to do a skin assessment weekly and document on the skin sheet. The pos had an order dated 10/14/10 to have the resident up in the wheelchair at least 2 hours the day. The POS ordered the resident to be fed through the peg tube with Glucerna 1.2 calories to run from 7:00 A.M. continuously until 7:00 P.M. Staff were to flush the peg tube with water every 6 hours and before and after giving medications and use water to flush between medications. The physician ordered nursing staff to give the resident a mechanical soft diet with low sweets and thin liquids. If the resident ate less than 50% of the lunch meal then nursing staff were ordered to give 1 can of glucerna. The resident also received Prostat, " a supplement of protein. " The annual Minimum Data Set (MDS) 3.0 dated 02/08/11 recorded the resident with short and long term memory problems, severely impaired cognitive skills for daily decision making and total assist with transfers and bed mobility. The resident was at risk of developing pressure ulcers and did not have any pressure ulcers. The resident had a pressure reduction mattress and device to the wheelchair. The Care Area Assessment (CAA) dated 2/22/11 for pressure ulcer recorded the resident at risk for pressure ulcers due to immobility, incontinence and cognitive impairment. The resident had an air mattress and was turned and repositioned. The resident ' s skin was monitored daily during routine cares and weekly during nursing skin assessments. Review of the Braden assessment (a numerical scale for determining pressure ulcer potential) dated 12/07/10 recorded a score of 13 indicating the resident at high risk for the development of pressure sores. A subsequent Braden assessment dated [DATE] recorded a score of 14 indicating the resident was at moderate risk for the development of pressure sores. Review of the Initial Data Collection Tool (a data collection tool used by the facility) dated 08/07/10 recorded the resident with 4 open pressure ulcer areas on the resident ' s sacral and buttocks areas as indicated by staff drawing circles on the resident diagram. 1) open area sacram 2.0centimeters (cm) x 2.0 cm, red no drainage 2) open area 0.8 cm x 0.5 cm, red no drainage 3) open 0.5 cm x 1.0 cm, red no drainage 4) open area 0.8 cm x 1.5 cm, red no drainage. Review of the Physician ' s phone order dated 03/01/11 ordered closed pulse irrigation 4 times weekly for 2 weeks to the sacral area pressure ulcer. Review of another Physician ' s phone order dated 03/01/11 ordered skilled physical therapy for electrical stimulation on the sacral wound. On 03/01/11 the physician ordered staff to stop the current treatment of [REDACTED]. " Review of the weekly skin integrity data collection assessment dated [DATE] recorded the resident with no wounds. Review of the weekly skin integrity data collection assessment dated [DATE] recorded the resident with an open area to the coccyx. The nurse ' s notes dated 02/15/11 recorded the resident noted during perineal care to have an open area on sacrum with no slough or odor noted. An order was obtained to apply a [MEDICATION NAME] dressing to that area. Review of the Pressure Ulcer Status Record dated 02/15/11 recorded a stage 2 pressure ulcer on the sacral area measuring length 2.0 cm x width 2.0 cm x depth 0.1 cm. On 02/16/11 the Pressure Ulcer Status Record documented a stage 2 pressure ulcer measured length 2.0 cm x width 2.0 cm x depth 0.1 cm on the sacral area with a pink wound bed and smooth edges. Continued wound documentation recorded measurements as follows: 02/23/11 the stage 2 pressure ulcer on the sacral area was length 2.5 cm x width 3.0 cm x depth 0.1cm with yellow slough on 25% of wound bed and smooth edges. 03/02/11 the pressure ulcer on the sacral area was worse and measured as a stage 3 pressure ulcer length 3.0cm x width 2.3cm x depth 0.1cm with yellow slough increased to 75% of wound bed with increased drainage and peri- wound maceration. 03/09/11 stage 3 pressure ulcer measured length 2.3 cm x width 2.2 cm without any depth, clean, with no slough, smooth edges, pink wound bed and peri-wound area intact. On 03/16/11 the stage 3 pressure ulcer measured length 1.8 cm x width 2.0 cm without any depth, clean, pink wound bed, edges smooth and peri-wound intact. The readmission note from the Evercare, Advanced Registered Nurse Practitioner (ARNP) dated 08/09/10 recorded the ARNP spoke with the resident's family at the bedside. The family was concerned that the resident needed to be turned. The ARNP explained to the family that the resident's mattress was designed to alternate pressure. The comprehensive care plan dated 12/27/10 lacked interventions to direct staff to assist the dependent resident with a history of open pressure ulcers on the sacral area to reposition and lacked any interventions for the prevention of pressure ulcers until 02/16/11( after the development of pressure ulcers). On 02/15/11 a hand written intervention was added to the resident ' s care plan that ordered a wound treatment of [REDACTED]. On 02/16/11 a new comprehensive care plan directed facility staff to turn the resident every 2 hours and use 2 staff to transfer the resident using the hoyer. This care plan contained further interventions for pressure relief and physical therapy treatment for [REDACTED]. facility staff did not offer the resident a choice of a meal and because no meal was offered, tDuring observation on 03/16/11 from 11:30 A.M. to 1:00 P.M. during the lunch meal service time the he resident did not eat. During observation on 03/23/11 at10:25A.M. the resident laid on the air mattress and was positioned on his/her right side with the blue bolster behind his/her back with a pillow between tDuring frequent observation on 03/21/11 from 7:00 A.M. until 10:00 A.M. the resident was sleeping in bed with bilateral half rails in the up position. The resident laid on an air mattress. The resident was positioned so the resident ' s shoulders laid to the right side with his/her head of the bed up approximately 30 degrees and the resident laid on his/her buttocks and sacral areas were on the mattress. Staff did not offer the resident a choice of any breakfast or fluids by mouth. During frequent observation on 03/23/11 from 7:15 A.M. until 8:05 A.M. the resident laid in bed on the air mattress on his/her buttocks with a blue bolster behind the right shoulder and back area positioning the resident ' s upper body tilted to the left side. The resident was positioned with a pillow under the feet and the sacral area laid on the air mattress. During observation on 03/23/11 at 10:00 A.M., " a total of 2 hours and 45 minutes, " the resident laid in bed on his/her buttocks with a blue bolster behind the right shoulder area tilting the upper body to the left. The resident was in the same position for 2 hours and 45 minutes. he ankles and legs. During interview on 03/22/11 at 10:26A.M. licensed nurse F reported staff turn the resident at least every 2 hours from side to side to prevent pressure and to ensure the resident isn't on his/her back. During interview on 03/23/11 at 9:45 A.M. licensed nursing staff A reported when the resident was admitted with 3 wounds on the buttocks which were later healed. Then the resident developed the stage 2 pressure ulcer that was small in size on the sacrum then the wound got worse and developed a yellow slough. The resident had been up in the wheelchair with a roho cushion, but then was kept in bed after developing this pressure ulcer. Staff A acknowledged the care plan for this resident dated 12/27/10 did not direct any interventions to prevent pressure ulcers for this resident with a history of pressure ulcers until 02/15/11 when the resident developed the stage 2 pressure ulcer. She/he also acknowledged nurse assistant bath skin sheets were missing after 02/01/11 until 02/22/11. During interview on 03/23/11 at 1:48 P.M. the resident's family reported staff had been turning the resident every three hours while he/she visited, but yesterday facility staff informed him/her that they would begin to turn the resident hourly. The clinical record lacked evidence to show the facility provided care and treatment to ensure this physically dependent resident with a healed pressure ulcer on the sacral area did not develop further facility acquired unavoidable pressure ulcers in the same area. The facility failed to reposition the resident to avoid pressure to an open pressure ulcer. The facility failed to offer the resident food and fluids by mouth as ordered by the physician. The facility failed to prevent the recurrence of a preventable pressure ulcer for a resident with a history of healed pressure ulcers on the sacral area.