Every finding on record at Pioneer Ridge Retirement Community

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse and mistreatment when Licensed Nurse (LN) G used an expletive and other derogatory language toward R1. Findings Included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia with other behavioral disturbance (a progressive mental disorder characterized by failing memory, and confusion, with changes in their mood, personality, or actions), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated 03/26/2026 for R1 documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 required substantial to maximal assistance for oral and personal hygiene, showers or bathing, bed mobility, and transfers to the toilet or shower. The MDS documented R1 was dependent on staff for toileting hygiene, lower body dressing, moving from a seated to standing position, and chair or bed transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/23/2025 documented R1 had a dementia diagnosis. The CAA documented R1 had clear speech, was sometimes able to make herself understood, and was sometimes able to understand others. The CAA documented staff may need to anticipate R1's needs at times. R1's 06/17/2025 Care Plan documented R1 had behavioral symptoms. The plan documented the following interventions:06/30/2025 - documented R1 took Celexa (antidepressant) for depression with behaviors of tearfulness. R1's 01/13/2026 Care Plan documented R1 had cognitive loss. The plan documented the following interventions:01/13/2026 - directed staff to introduce themselves to R1 whenever they entered R1's room and when providing R1 with care.01/13/2026 - directed staff to provide R1 with reminders for safety, with reorientation to R1's surroundings, and with cues as needed.01/13/2026 - directed staff to use positive verbal and non-verbal communication to encourage R1 to complete tasks and express herself.01/13/2026 - documented sometimes R1 would get confused and had difficulty making her needs known. The intervention directed staff to allow R1 time to talk to staff when R1 was communicating. The facility's investigation 3044396, documented on 06/15/2026 at approximately 09:30 AM, Administrative Staff A received a report from LN H stating that while providing care to R1, LN G placed her hand over R1's mouth. The investigation recorded upon receipt of the allegation; the facility immediately initiated an investigation and removed LN G from resident care duties pending the outcome of the investigation. The investigation recorded R1 had significant cognitive impairment, including a BIMS score of four. The investigation document further recorded R1 attempted to get out of bed and required staff assistance. Certified Nurse Aide (CNA) M requested assistance from LN G to provide care and assist R1 with repositioning and a brief change. The investigation recorded witness statements consistently described R1 as physically combative during care. CNA M reported seeing LN G place her hand on R1's mouth while R1 was spitting. CNA M reported that R1 bit LN G's finger. The investigation recorded following the interaction, CNA M transported R1 to the Rapid Recovery unit to separate R1 and LN G. The investigation recorded CNA N was interviewed and reported that CNA M had brought R1to the Rapid Recovery area and requested assistance with R1's care. CNA N stated that CNA M informed her of the incident involving LN G and R1. The investigation recorded CNA N further reported observing tension between LN G and R1 after the incident and reported hearing LN G make inappropriate and derogatory comments toward R1. The investigation recorded available security camera footage was reviewed and confirmed the presence of CNA M and LN G in R1's room during the timeframe and confirmed that R1 was transported to the Rapid Recovery area. The investigation recorded camera footage did not provide a direct visual recording of the care interaction occurring inside the resident's room. Portions of verbal exchanges could be heard; however, the footage did not conclusively establish the nature of the physical contact alleged to have occurred inside the room. The investigation substantiated that LN G engaged in inappropriate verbal interactions with R1 following the incident. The investigation recorded witness interviews identified that derogatory language was directed toward R1, which was inconsistent with the facility's standards of professional conduct and resident-centered care. An unnotarized, undated, witness statement for LN H recorded on or about 06/15/2026 between 01:30 AM to 02:00 AM he observed CNA M come out of R1's room while pushing R1 in a wheelchair toward the Rapid Recovery Hall. LN H recorded LN G also came out of R1's room and asked LN H where CNA M took R1. LN H recorded he told LN G that CNA M took R1 to the Rapid Recovery Hall, and LN G went that same direction. LN H recorded he assisted CNA M and CNA N with putting R1 to bed around 04:00 AM. LN H recorded that at approximately 04:40 AM CNA M pulled him aside and stated she wanted to report the incident to him. LN H recorded CNA M told him when she passed him in the hallway with R1 she was going to hide R1 from LN G. LN H recorded CNA M told him while she and LN G were putting R1 to bed, R1 scratched LN G's chest and bit LN G's finger. LN H recorded CNA M told him LN G responded by putting her hand over R1's mouth and squeezed it. LN G recorded CNA M told him LN G later followed them into a Rapid Recovery room, while she was with CNA N, and LN G said unkind words to R1 again. A notarized witness statement, dated 06/16/2026, for CNA N documented she was on the Rapid Recovery unit at the nurses' station when CNA M came over with R1. CNA N documented R1 was in a T-shirt, and a brief that was halfway complete. CNA N documented CNA M asked for help with fixing R1's brief and putting some pants on R1. CNA N documented CNA M told her that LN G had harmed R1 after R1 scratched LN G on the chest. CNA N documented per CNA M, LN G grabbed R1's mouth, screamed insults at R1, and R1 responded by biting LN G's finger. CNA N documented CNA M reported she brought R1 over to separate LN G and R1. CNA N documented she, CNA M, and LN G went to put R1's pants on her and R1 began to cuss LN G out and kept telling LN G to go away. CNA N documented R1 was getting angry, stopped doing what they needed her to do to help her, and LN G became upset with R1. CNA N documented she witnessed LN G yelling and insulting R1. CNA N documented she witnessed LN G call R1 stupid, dumb, and an [expletive]. CNA N documented CNA M asked LN G to step out of the room and LN G refused and got upset. CNA N documented they finished with R1 and wheeled her back to the nurses' station. A notarized witness statement, dated 06/15/2026, for CNA M documented she had seen R1 trying to climb out of bed at 01:00 AM. CNA M documented she asked LN G to help put R1 back in bed. CNA M documented she and LN G placed a brief on R1 and R1 began kicking and scratching the two of them. CNA M documented R1 began spitting at them and LN G grabbed R1's mouth and pushed down. CNA M documented R1 then bit LN G on the finger near her mouth. CNA M documented that they got R1 back in her wheelchair and CNA M documented she decided R1, and LN G needed time away from each other. CNA M documented she took R1 over to Rapid Recovery. A notarized witness statement, dated 06/15/2026, for LN G recorded she was helping CNA M with R1 when R1 began kicking, and hitting them. LN G documented R1 was spitting and had LN G's pointer finger in her mouth and bit down on it. LN G documented she pushed R1's head away instinctively as she tried to get her finger out of R1's mouth. LN G documented CNA M got R1 in a wheelchair and took her down to the Rapid unit. On 07/07/2026, attempts made to contact LN G, LN H, CNA M, and CNA N via phone for interview. Voice messages left for each of them. No phone calls were returned. On 07/07/2026 at 01:30 PM R1 sat in her wheelchair, in the dining room, near a table. On 07/07/2026 at 01:29 PM, Social Services X stated she had followed up with R1 the last two weeks related to the incident. She stated there wasn't too much she could get from R1 and R1 was not able to answer questions. She stated she would also follow up with nursing staff to find out if there were any changes in R1's behaviors. She stated she had not noticed and had not heard of any behavior changes from R1 related to the incident. She stated R1's behaviors were usually related to staff providing cares. Social Services X stated R1 may not always understand what staff was trying to do and would get agitated when they provide cares. On 07/07/2026 at 01:37 PM, LN I stated she heard about the incident but was not at work when it occurred. She stated she has not observed any changes in behaviors from R1 since the incident. She stated R1 is confused all the time but does have some lucid moments. LN I stated she felt R1 was at a good place with her medication and that it has helped. LN I stated R1 does get defensive if staff come at her all at once when doing cares. She stated R1's behavior was dependent on how staff approached her. She stated if staff were calmer during their approach, then R1 was more likely to be cooperative. She stated she had not noticed R1 being fearful of anyone of tearful after the incident. On 07/07/2026 at 02:14 PM, Administrative Nurse D stated he was on vacation during the time the incident occurred. Administrative Nurse D stated he reviewed the camera footage when he returned, and he stated he saw CNA M take R1 to the rehab side of the facility. He stated he saw CNA M and CNA N with R1, and he saw LN G walk into camera view. Administrative Nurse D stated LN G was in front of R1 at that time and had referenced R1 biting her. Administrative Nurse D stated he was pretty sure he heard LN G reference R1 being an evil [expletive] related to biting her. He then stated he heard CNA N say that was not very nice. Administrative Nurse D stated he felt the response from CNA N was used to attempt to deescalate the situation but could not tell who CNA N's comment was directed towards. Administrative Nurse D stated there was a shouting match between LN G and R1, he stated they told each other to shut up back and forth. He stated LN G eventually went back to the side she was scheduled on and CNA M and CNA N stayed with R1. He stated he felt the CNAs handled the situation appropriately by trying to remove R1 from the abuser, updating the nurse, and making sure R1 was okay. Administrative Nurse D stated LN G followed CNA M and R1 over to the other side and he did not understand why she would do that. He stated LN G was suspended and then terminated. On 07/07/2026 at 02:32 PM, Administrative Staff A stated she was the one that completed the investigation related to this incident. She stated she reviewed the camera footage as well. Administrative Staff A stated when she reviewed the camera footage, she was unable to hear everything that was said while they were in R1's room. She stated she saw CNA M go into R1's room first, and LN G went in after. She stated she could not tell if it was the resident not wanting care or if it was LN G getting hit. She stated the door was slammed shut. She stated she could hear some commotion in the room but wasn't sure exactly what was said. Administrative Staff A stated the door then opened, and CNA M came out of the room and pushed R1 in the wheelchair. She stated LN G came out of the room later. She stated the camera footage revealed CNA M took R1 down the Rapid Recovery Hall and CNA M met up with CNA N. She stated at first, she did not hear anything on the camera, and they went into another room. She stated they later came out and she saw LN G coming down the hallway to Rapid Recovery. Administrative Staff A stated she then heard them all talking, and she could hear LN G using inappropriate language that staff should not say to a resident. Administrative Staff A stated she could not remember what was said, but that it caught her off guard and she was pretty sure LN G was cursing. Administrative Staff A stated LN G was saying R1 you bit me and R1 said something back that did not make sense. Administrative Staff A stated R1 was angry, and she believed R1 stated she did not bite LN G and LN G kept saying yes you did to R1. She stated the two other CNAs were right there and LN G was facing all three of them. Administrative Staff A stated LN G kept saying she bit me and was cursing at R1. Administrative Staff A stated they all went into a room and changed R1 and after they left the room, CNA M took R1 to the nurses' station. Administrative Staff A stated CNA M reported the incident to LN H and LN H texted Administrative Nurse D, who was on vacation. She stated she was later notified, she believed around 08:00 AM to 09:00 AM and she told the team she needed to investigate the situation. Administrative Staff A stated they suspended LN G and later terminated her. She stated LN G did not work any other shifts after suspension. Administrative Staff A stated Social Services X followed up with R1 for psychosocial and made note of any behavior changes. Administrative Staff A stated as of now no one has reported any behavior changes from R1 and R1 has not had any incidents of going after staff like she did with LN G. Administrative Staff A stated they did not cover this incident in the QA meeting for June as it happened after. She reported it will be covered in July's meeting and will be followed up until resolved. Administrative Staff A stated Social Services X has provided updates as have nursing staff. She stated Administrative Nurse D has also followed up on the incident as well. Administrative Staff A stated they provided education to LN H and CNA M related to reporting incidents of abuse in the future to ensure it is reported timely. She stated they also provided abuse and dementia care and communication education for all staff after the incident. The facility's Abuse, Neglect, and Exploitation policy, with a revision date of November 28, 2017, documented the resident has a right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, misappropriation of resident property and injuries of unknown origin. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: (1) threats of harm, and/or (2) making statements to frighten a resident. On 06/17/2026, the facility completed corrective actions which included an all-staff in-service on preventing abuse, neglect, and exploitation, understanding dementia, and communicating with residents with dementia education. CNA M and LN H completed additional reporting abuse education. LN G was suspended and terminated. The corrective actions were completed prior to the onsite survey therefore the deficient practice was cited as past noncompliance at a scope and severity of D.

Based on observation, record review, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to alarms to prevent the elopement of Resident (R) 1, who was cognitively impaired, had a history of wandering and exit seeking, and was at risk for falls. On 04/26/26 at 01:44 AM, R1 pushed on the Blue-Hall emergency exit door, which sounded the alarm immediately when pushed, then opened after 15 seconds, and R1 exited the facility. Licensed Nurse (LN) G sat at the nurse's station with a clear view of the emergency exit door but did not look up or respond to the door alarm. At 02:05 AM, Certified Nurse Aide (CNA) M approached the nurse's station and asked LN G where the alarm was coming from, and LN G stated it was likely an exit door. CNA M and CNA N immediately started looking for the source of the alarm. They identified Blue-hall emergency exit door as the source and shortly after, LN G heard knocking on a door near the nurse's station and instructed CNA M and CNA N to go through the front door to see who was outside. CNA M and CNA N located R1 outside in front of the building and brought her back inside at approximately 02:09 AM. R1 was unsupervised outside in the dark in 60 degrees Fahrenheit (F) weather for approximately 25 minutes. This deficient practice placed R1 in immediate jeopardy. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and restlessness and agitation. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R1 had no behaviors. R1 used a walker and required partial/moderate assistance with walking 10 feet, and walking 50 feet with two turns was not attempted due to R1's medical conditions or safety concerns. R1 had one noninjury fall since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/05/26, documented R1 had severe cognitive impairment. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 05/05/26, documented R1 needed assistance from staff for many ADLs such as dressing, toileting, hygiene, transfers, and mobility. The Falls CAA dated 05/05/26, documented R1 was at risk for falls due to a previous history of falls. R1's 06/05/24 Care Plan for mobility and fall risk documented the following interventions:06/05/24- R1 needed supervision when she walked with her walker, and she potentially needed breaks for longer distances.06/05/24- R1 needed supervision with transfers. R1's 06/15/24 Care Plan for behavioral symptoms documented the following interventions:11/18/24- R1 had dementia and no longer had control over all aspects of her life, which caused her to become restless, agitated, and tearful. Staff involved her family in all care planning and decision making.11/18/24- Staff monitored R1's behaviors for agitation, crying, and restlessness. Staff documented her behaviors and the results of monitoring for side effects.11/18/24- Staff helped R1 stay in touch with her son and daughter-in-law.04/27/26- R1 sometimes worried about where her husband was, and she talked about leaving; because of that, she wore a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering). R1's 02/12/26 Care Plan for cognitive loss documented the following interventions:02/12/26- Staff assessed R1 for acute changes in her condition, such as increased confusion and contacted her primary care provider (PCP) as needed.02/12/26- Staff introduced themselves to R1 when they entered her room and provided cares.02/12/26- Staff spoke calmly and directly to R1 when providing her with directions and/or instructions.02/12/26- Staff used positive verbal and non-verbal communication to encourage R1 to complete tasks and express herself.02/12/26- Staff reminded R1 of what things took place in the facility multiple times a day and helped her go to the things she needed or wanted to attend. R1's Care Plan did not have resident-specific interventions to direct staff during R1's wandering and exit seeking behaviors. R1's EMR revealed the following: An Elopement Risk assessment on 10/14/25, documented an answer of Yes to the following questions: history of wandering off unit or elopement, verbalized desire to leave facility or exit seeking, wandered off unit or into other residents' rooms, wandered on her unit, experienced periods of altered perception, experienced periods of restlessness, her mental function varied over the course of the day, she had a diagnosis of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure)/Dementia, and she had a diagnosis of mental illness. The analysis documented R1 had moments of confusion and hallucinations/delusions where she began exit seeking. A Behavior Note on 02/28/26 at 01:00 PM, documented R1 continued to pace and walked to the doors, stating she was leaving today. Staff employed redirection and alternative activities with little benefit. Staff administered R1's as needed (PRN) Ativan (medication used to treat anxiety [mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear]) medication. R1 sat in her bed reading her Bible after medication administration. An Orders- Administration Note on 03/17/26 at 07:29 PM, documented R1's Ativan fell off of the orders. The order was renewed and administered for R1's pacing and exit seeking. An Admission/Quarterly/Annual/Significant Change Assessment on 04/21/26, in section four Fall Risk, documented No to the following questions: ambulated independently, ambulated with assistance, had a visual impairment that could not be corrected, used equipment that could present a hazard, received any of the listed classes of medications, and had any of the listed diagnoses. The assessment documented Yes to the following questions: R1 used an assistive device, was incontinent of bowel or bladder, had fallen in the past three months, had issues with her gait or balance, and had confusion. An Orders- Administration Note on 04/25/26 at 01:19 PM, documented R1 was pacing and exit seeking. Staff provided redirection and reorientation, which were ineffective. Staff administered as needed Ativan. R1's EMR lacked a note regarding the elopement on 04/26/26. An Orders - Administration Note on 04/26/26 at 04:33 AM, documented staff administered as needed Ativan. R1 had anxiety and was crying and exit seeking. A late entry Behavior Assessment Progress Note effective 4/26/26 at 04:49 AM, created on 04/27/26 at 08:58 AM, documented R1 had anxiety and agitation. Staff provided one-on-one, redirection, and distraction and R1 settled down briefly. Staff reminded R1 that her family did not abandon her. The facility's Investigation dated 04/30/26, documented on 04/27/26 at approximately 08:50 AM, Administrative Staff A and Administrative Nurse D became aware of R1 eloping on 04/26/26 at approximately 01:44 AM. The facility reviewed the security footage, which revealed R1 repeatedly pushed on the exit door at the end of Blue-hall. The audible alarm sounded at 01:44 AM and indicated her exit via the delayed egress door. LN G sat at the nurse's station desk where he could see down the end of Blue-hall, however, LN G did not look or react to the alarm. The delayed egress alarm continued to sound while LN G looked at the computer. At 02:05 AM, CNA M approached the nurse's station and asked where the alarm came from, and LN G responded that it was likely an exit door. According to witness statements and interviews, CNA M and CNA N immediately searched for the source of the alarm once they heard it. Staff determined the alarm came from the Blue-hall exit door and shortly after, they heard banging on a door near the nurse's station. LN G instructed CNA M and CNA N to go through the front door to see who was outside. CNA M and CNA N located R1 outside the building and brought her inside at approximately 02:10 AM. LN G retrieved the alarm key at 02:13 AM and silenced it at 02:15 AM. Nursing staff completed rounds and room checks, and all other residents were accounted for in the building. Staff placed R1 on 15-minute checks. The facility concluded R1 exited the building via the delayed egress function on the door at the end of Blue-hall at approximately 01:44 AM. CNA M and CNA N visualized her on the sidewalk and escorted her back into the facility at approximately 02:09 AM. The temperature outside was 62 degrees F. R1 wore jeans, a long-sleeved shirt, shoes, and she used her walker. It appeared she remained in close proximity to the building the entire time she was outside as she was at an exit door when staff approached, and the limited outdoor video showed her on the sidewalk. Staff assessed her for injuries then took R1 to her room. R1 appeared to not want to stay in her room and she attempted to leave again. According to interviews, staff completed a new elopement assessment, placed a WanderGuard on her, and one staff member monitored her. According to the Kansas State University Historical Weather website, the temperature on 04/26/26 was 60.5 degrees Fahrenheit (F) at 01:00 AM and 59.4 degrees F at 02:00 AM. CNA M's notarized Witness Statement, dated 04/28/26, stated on 04/26/26 around 01:30 AM, she finished her first rounds when she heard sirens going off in the facility. She and CNA N checked the doors to see which one went off. She stated LN G alerted her and CNA N that R1 banged on the side exit door near the nurse's station. CNA M stated they immediately brought R1 inside and checked to see if she was alright, which she seemed to be but was confused about her surroundings. She stated they laid R1 down in her room and when staff went to turn off the exit door around 02:00 AM, she noticed R1 headed towards the exit door again and she stopped her. In an observation on 06/01/26 at 01:04 PM, the nurse's desk where LN G sat at the time of the incident had a clear view of the Blue-hall exit door. At the Blue-hall exit door, Maintenance U pushed on the door and the alarm beeped a few times before turning into a sustained tone alarm then the door opened after pressed on for about 15 seconds. Upon exiting through the Blue-hall exit door onto the sidewalk, a grassy depression was in front of the sidewalk and the sidewalk turned left. On the left side of the sidewalk were landscaping rocks and the grassy depression continued on the right side until the sidewalk turned to the left again where both sides of the sidewalk were lined with landscaping rocks. The sidewalk continued in front of the facility towards the front door. There was a parking lot in front of the facility. In an observation on 06/01/26 at 01:09 PM, while at the nurse's desk where LN G sat at the time of the incident, Maintenance U pushed on the Blue-hall exit door again and the alarm sounded. The alarm was heard while standing at the nurse's desk. On 06/01/26 at 01:11 PM, R1 lay in bed with her eyes closed. On 06/01/26 at 02:54 PM, a review of two saved facility surveillance videos on Administrative Staff A's laptop revealed the following:A video, without a time and date stamp, showed a view down the Blue-hall with the exit door visible. R1 walked with her walker into frame to the exit door. R1 had unintelligible speech while she started pushing on the exit door. The door alarm immediately started beeping, then a sustained tone occurred, and the door opened after about 15 seconds. R1 pushed open the exit door and held it open with her left arm while she pushed her walker outside and exited the facility. The door alarm continued to sound.A video, dated 04/26/26 at 01:43:21 AM, showed a view of the front of the nurse's station and LN G sat at the desk that faced Blue-hall. LN G looked at the computer. There was music possibly from a television or radio heard on the video. At 01:44:19 AM, the door alarm began beeping. LN G remained at the nurse's desk and did not look up from the computer. At 01:47 AM, CNA N walked from the front entrance area past the nurse's station out of camera view. She walked back through to the front entrance area. The video ended at 01:50:49 (AM).Administrative Staff A stated she did not save the videos from when staff found R1 outside and brought her back in. On 06/01/26 at 12:50 PM, Administrative Staff A stated the elopement on 04/26/26 happened on a weekend and she found out about it that following Monday. She stated the facility gathered information on the elopement, involved their regional team, started interviews, and collected statements. She stated she asked LN G why he did not report the elopement, and his answer changed several times. Administrative Staff A stated she reviewed the camera and LN G sat at the nurse's station with a clear view of the Blue-hall door. She stated R1 pushed on the door and the alarm went off, but nobody reacted. She stated she turned the volume up on the video and could hear some noise on the footage like a television, but she still heard the door alarm. Administrative Staff A stated she observed two CNAs going by the nurse's station, but she did not know why it took them so long to respond to the alarm. She stated LN G told the CNAs to go down the hall to look for the location of the alarm. Administrative Staff A stated after seeing LN G's delayed response to the alarm, she suspended him. She stated she asked him if there was any noise that interfered with him hearing the alarm and he stated no. She stated she was unaware if R1 had an exit seeking behavior prior to this elopement. On 06/01/26 at 03:53 PM, CNA O stated R1's typical behaviors included crying, talking about her husband leaving her, and wandering the hallways, especially after dinner. She stated that sometimes R1 was redirectable. CNA O stated when a door alarm sounded, she went to the door to see what happened. If a resident tried to leave, she redirected them and if a resident went out, she went outside to get them back into the facility. CNA O stated if she could not find the resident outside of the door, she walked the perimeter of the facility and went back inside to alert everyone at that point. On 06/01/26 at 04:10 PM, LN H stated R1's behaviors included wandering with her walker, pacing back and forth, and looking for her husband or the man she planned to marry. She stated R1 became restless, and she knew R1 hardly slept at all during the night based on the reports she received. LN H stated if a door alarm sounded, she immediately looked at the cameras located at the nurse's station. She stated that if she was in the hallway, she went to the door. LN H stated from where she sat at the nurse's station when she worked on Blue-hall, she could hear which direction the alarm went off. She stated if a resident eloped, she went to the door, scanned outside for the resident, had staff do a room search and headcount, had staff do a perimeter sweep, and notified the on-call manager immediately. On 06/01/26 at 04:31 PM, Administrative Nurse D stated when he arrived at work on 04/27/26, LN G was still at the desk, and he made a comment that he was going to text Administrative Nurse D but LN G never said what for. Administrative Nurse D stated a staff member asked him if he heard about what happened that weekend and they told him about the elopement. He stated he asked LN G if the elopement occurred and LN G confirmed it did. Administrative D stated he initiated elopement protocol including informing the State Agency (SA) and their regional team. The regional team gave the facility an outline of things to look for. He stated he completed an elopement assessment on R1, placed a WanderGuard on her, and completed elopement and sentinel event reporting education with staff. Administrative Nurse D stated if a door alarm went off, he expects staff to see who set it off and redirect them away from the door then turn off the alarm. He stated if staff did not see a resident near the door, he expected them to walk to the door alarm and go outside to look for the resident outside. If staff could not find the resident, he expected staff to come back inside and complete a headcount. Administrative Nurse D stated he expected the nurse to initiate the full elopement protocol and notify him or Administrative Staff A immediately and notify law enforcement if the resident was not located. He stated staff continued to do headcounts and outside perimeter checks until the resident was found. On 06/02/26 at 10:50 AM, CNA M was unavailable for interview. On 06/02/26 at 11:06 AM, CNA N stated around 01:30 AM, she answered a resident's call light on the other hall and was in their room when she heard the alarm go off. She stated the alarm sounded for maybe 10 to 20 minutes before she exited the resident's room and went to the nurse's station. CNA N stated LN G sat at the computer at the nurse's station and he told her and CNA M to walk around to see where the sound came from. She stated there was no television or radio playing at the nurse's station to block the door alarm sound. CNA N stated she last saw R1 a little after 12:00 AM when R1 tried to go to Red-hall and CNA N walked R1 back to her room. She stated when a door alarm sounded, she was supposed to stop what she was doing and check the doors and check all the residents. On 06/02/26 at 01:10 PM, LN G stated on 04/26/26, R1 was in bed and talking to herself but then she had become quiet, and he thought she went back to sleep. He stated he did not remember what time that was. LN G stated eventually, he heard the alarm sound, and it alarmed for about 15 minutes before a CNA figured out it was on Blue-hall. He stated he sat at the nurse's desk and had one of the CNAs run back and forth to the front entrance to see where the alarm came from because it sounded like it was up front. LN G stated that staff thought it was the WanderGuard alarm but after they put the code in, the alarm did not stop. He stated one of the CNAs realized the alarm was on Blue-hall and that the door had been opened. He stated while they were checking resident rooms, he went back to the desk and heard tapping on a window. LN G stated he saw R1 in the window and he called for the CNAs to bring her inside. He stated when she came back inside, she immediately tried to go straight back to the Blue-hall exit door. LN G stated prior to the alarm sounding, he was charting and did not pay attention to the end of the Blue-hall hallway. He stated he thought R1 was still sleeping and had hoped it would be an uneventful night for R1 because she usually got up and wandered at night. LN G stated he did not get up to check the alarm when it initially sounded due to having a hard time getting around and needing a walker. The facility's Elopement policy, revised 11/28/17, directed the facility to ensure each resident received adequate supervision and devices to deter elopement. The policy directed the facility updated the resident's care plan to include wandering and the potential for elopement interventions. The policy directed the facility utilized an elopement monitoring bracelet if the facility determined a resident was at risk for elopement. On 06/01/26 at 04:00 PM, Administrative Staff A was presented with the Immediate Jeopardy [IJ] Template and was notified of the facility's failure to provide adequate supervision to prevent the elopement of R1 on 04/26/26, constituted immediate jeopardy at F689. The facility identified, implemented, and completed the following corrective measures:1. The facility updated R1's care plan to include her WanderGuard usage on 04/27/26.2. The facility completed a new Elopement Assessment on R1 and any independently mobile residents on 04/27/26.3. The facility completed elopement, door alarm responses, and reporting elopements with all staff from 04/27/26 to 04/29/26. Due to the facility's completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a J (isolated, immediate jeopardy).

The facility identified a census of 62 residents. The facility had one main kitchen and two dining areas. Based on observation, interview, and record review, the facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals documented freezer and refrigerate temperatures. The facility also failed to staff donned hairnets and beard guards and maintain dairy food at the appropriate temperature. Findings included:- During the initial tour of the kitchen and dining room area on 12/01/25 at 07:10 AM, an open undated gallon of milk sat in a brown tub without ice. Dietary Staff EE tempted the open milk, which was 46 degrees. The Milk was discarded. Dietary Staff EE lacked a hairnet when setting up the breakfast serving line. Dietary Staff CC carried two juice glasses, touching the tops of the glasses where the resident would drink from. On 12/01/25 at 07:45 AM, review of the Low Temperature Sanitizing Dish Machine Log, Refrigerator Temperature Log, and the Freezer Temperature Log for November 2025 revealed the following ten days lacked documentation on 11/21/25, 11/22/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, and 11/30/25. On 12/02/25 at 12:45 PM, Dietary Staff DD failed to don (put on) a beard guard as he worked in the food prep area. On 12/03/25 at 10:01 AM, Dietary Staff BB stated staff should always wear a hairnet and facial hair net when in the kitchen food prep area. She stated that staff should hold the glasses at the base of the cup and not touch the part of the glasses where the resident would drink from. Dietary Staff BB stated the temperatures for the dishwashing machine, refrigerators, and freezers should be recorded daily. Dietary Staff BB stated dairy products should always be kept on ice to ensure they do not spoil.The facility's Food Storage policy, revised 04/06/20, documented food would be stored on shelves in a clean, dry area, free from contaminants. Food would be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Check refrigerator temperature regularly. Conduct random temperature checks of food items.

The facility had a census of 62 residents. The sample included 17 residents. Five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.Findings included: - Review of the facility's performance evaluation and in-service records revealed the following:CNA N, hired 09/30/23, had no yearly performance evaluations provided upon request.On 12/03/25 at 09:30 AM, Administrator A stated the facility did not have a performance evaluation for CNA N.On 12/03/25 at 02:43 PM, Administrative Nurse D stated that yearly evaluations were completed on all direct care staff. He stated the evaluations were used to gauge performance and identify areas of needed improvement for direct care staff.The facility's Staffing policy, dated 06/2017, indicated performance reviews will be conducted on each employee at least annually to identify employee strengths and goals. The policy noted that the evaluation would be utilized to determine training needs for the employee.

The facility identified a census of 62 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The facility failed to identify Resident (R) 74, who had a percutaneous endoscope gastrostomy tube (PEG- a tube inserted through the wall of the abdomen directly into the stomach), and R1, R21, R48, and R6, who had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Based on record review, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility further failed to store oxygen nasal canula in a sanitary manner, the facility further failed to ensure staff performed adequate hand hygiene, and further failed to ensure Accu-check (blood glucose monitoring test) had a barrier placed prior to being laid down in a resident's room.Findings included:- An initial walkthrough of the facility was completed on 12/01/25 at 07:13 AM. An inspection of the Red hall revealed R6's oxygen nasal cannula laid in her wheelchair. At 07:14 AM, R20's oxygen concentrator sat next to the piano in the main dining room. R20's nasal cannula laid directly on the floor next to the piano bench. On 12/01/25 at 08:25 AM, R47's oxygen nasal cannula and tubing was tightly wrapped around the handles of his wheelchair.On 12/02/25 at 07:44 AM, Licensed Nurse (LN) H gathered supplies for R21's Accu-check monitoring, insulin (a hormone that lowers the level of glucose in the blood) pen, two blue gloves, an insulin pen needle, and an alcohol wipe. LN H read the order in R21's chart, and LN H laid supplies on the counter at the nurse's station. LN H went to the dining room to retrieve R21 and take her to her room to check her glucose reading and give insulin, holding all supplies in her hand. LN H touched R21's hair and glasses and pushed her back to R21's room. LN H laid the Accu-Chek monitor on R21's bedside table without a barrier, and LN H donned gloves without hand hygiene. LN H took a glucose reading and gave insulin in the abdomen. LN H removed gloves and performed hand washing.An inspection of R74's room revealed no protective equipment (PPE) readily available for EBP. R74 had no signage or indicators R74 was on EBP. R74 had a percutaneous endoscope gastrostomy tube.An inspection of R21's room revealed no PPE readily available for EBP. R21 had no signage or indicators R21 was on EBP. R21 had a urinary catheter.An inspection of R48's room revealed no PPE readily available for EBP. R48 had no signage or indicators R48 was on EBP. R48 had a urinary catheter.An inspection of R66's room revealed no PPE readily available for EBP. R66 had no signage or indicators R66 was on EBP. R66 had a urinary catheter.On 12/02/25 at 08:00 AM, LN H stated she would place a barrier on R21's bedside table before the Accu-check monitor was laid down. She stated she would wash her hands when entering a resident's room, leaving a resident's room, or when her hands were soiled. LN H stated she would sanitize before putting on gloves, after monitoring blood sugar, and giving the insulin.On 12/03/25 at 02:22 PM, Certified Nurse's Aide (CNA) M stated oxygen cannulas not in use should be placed in a bag or just changed if they are found on the floor. CNA M stated she was not aware of enhanced barrier precautions for residents with urinary catheters and peg tubes. She stated there were residents with the enhanced barrier supplies in multiple rooms.On 12/03/25 at 01:52 PM, LN I stated Breathe an oxygen provider, checks all oxygen canisters, and changes nasal cannulas. She stated oxygen nasal cannulas should be placed in a bag when not in use. LN I stated the facility uses the standard of practice for urinary catheters and peg tubesOn 12/03/25 at 12:05 PM, Administrative Nurse D stated the facility does not need to use enhanced barrier precautions for residents with urinary catheters or ped tubes. He stated the facility used the standard of care and expected residents to wear gloves when doing residents cares. Administrative Nurse D stated oxygen tubing should be kept off the floor, and staff should put oxygen nasal tubing in the bag the tubing came out of if not in use. Administrative Nurse D stated there should be a barrier placed when an Accu-check monitor was laid down in a resident's room. He stated staff should wash their hands when entering a room, leaving a room, or whenever their hands were soiled. He stated hands should be washed or sanitized before applying gloves, and after using the Accu-check monitor, and again before giving residents insulin.The facility's Oxygen Safety and Management policy, revised 03/22/19, documented equipment used for oxygen administration (nasal cannula, mask, tubing) would be replaced every two weeks. The equipment should be marked with the name of the resident and the date it was put into use. Oxygen cannulas and masks should not be allowed to come in contact with the floor or other potentially dirty surfaces. If that occurred, they should be replaced. The cannulas or mask should be stored in plastic bags to prevent contamination.The facility's Enhanced Barrier Precautions policy, updated 04/06/23, documented EBP refer to an infection control intervention designed to reduce transmission of multi-resident organisms that employs targeted gown and glove use during high-contact resident care activities. EBP was used in conjunction with standard precautions. The facility's Hand Hygiene policy dated 11/28/17 documented general guidelines for washing hands with soap and water when hands are visibly soiled, before and after contact with the resident, after contact with blood, or visibly contaminated surfaces or other objects and surfaces in the resident environment.

The facility identified a census of 62 residents. The sample included 17 residents. Based on interviews, observation, and record review, 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:- On 12/02/25, requested the infection control log for tracking and trending infections from December 2024 through October 2025. The facility was unable to provide an infection control log for the following months December 2024, June 2025, July 2025, August 2025, September 2025, and October 2025 that included evidence of tracking and identifications of possible infection outbreaks at the facility, lacked consistent identification of infection, the antibiotic administration and the of continent documentation of the infection control surveillance. On 12/02/25 at 02:25 PM, Administrative Nurse D stated he is responsible for tracking and trending for the antibiotic use in the facility. He stated he had not completed the monthly tracking of the antibiotic use since May 2025. He stated he would review if the physician ordered antibiotic had met the criteria for administration at the end of each month to educate himself. The facility's Antibiotic Stewardship policy dated 04/27/19 documented the use of antibiotics would be reserved for those conditions that meet clinically approved indications for their use. Education would be provided to nursing staff, clinical providers, residents, and their representative on proper antibiotic use and antibiotic resistance.

The facility identified a census of 62 residents. The sample included 17 residents. Based on interviews, observation, and record review, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. Findings included:- On 12/02/25 at 02:25 PM, Administrative Nurse D stated the nurse listed as the Infection Preventionist was a corporate nurse who would answer questions and give advice as needed, but was not at the facility. Administrative Nurse D stated he was responsible for the Infection Prevention and Control Program. He stated he had not completed a specialized education for the monitoring of the Infection Preventionist. The facility was unable to provide a policy related to the Infection Preventionist as requested on 10/03/25.

The facility reported a census of 62 residents. The Sample included 17 residents. Based on observations, record review, and interviews, the facility failed to ensure safe medication storage of three of its six medication carts. Findings Included:- On 12/01/25 at 07:08 AM, an inspection of the Blue Hall revealed an unlocked and unsupervised medication cart next to the medication storage room. The cart contained prescription medications, stock medications, insulin (a hormone that lowers the level of glucose in the blood), and treatment supplies for the residents on the hall. An inspection of the Blue Hall also revealed an unsecured, smaller treatment cart that contained stock medication and treatment supplies next to the medication cart. At 07:11 AM, Certified Medication Aide (CMA) M entered the hallway and secured both carts. She stated staff were expected to lock the carts when not directly supervising them.On 12/01/25 at 07:15 AM, an inspection of the Red Hall revealed an unsecured and unsupervised treatment cart outside Resident (R) 62's room. The cart contained stock medications, treatment supplies, and insulin for residents on the hall. The cart laptop was open and contained R62's picture and protected health information (PHI) within direct view. At 07:18 AM, Licensed Nurse (LN) J opened R62's door and exited the room into the hallway. LN J stated she was not sure if the medication carts were supposed to be locked, but would lock them during the survey inspection. She stated the PHI should not be left open on the computers when not in use.On 12/03/25 at 02:43 PM, Administrative Nurse D expected the medication carts to be supervised or locked when not in use. He stated that staff received annual training related to resident safety and medication storage expectations.The facility's Storage of Medications policy, revised 01/2021, indicated that drugs and biological agents were expected to always be stored in a locked compartment or area. The Policy indicated staff were expected to supervise all medications and biologicals during times of administration or use.

The facility identified a census of 62 residents. The sample included 17 residents, with five residents reviewed for immunizations. Based on interviews, observation, and record review, the facility failed 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) 2, R4, and R8. Findings included:- Review of R2's clinical record lacked documentation of PCV20 being offered, obtained informed declination, or a physician-documented contraindication prior to surveyors entering the facility.Review of R4's medical record lacked documentation of PCV20 being offered, obtained informed declination, or a physician-documented contraindication prior to surveyors entering the facility.Review of R8's clinical record documented not eligible for PCV20; the medical record lacked documentation of PCV20 being offered, obtained informed declination, or a physician-documented contraindication prior to surveyors entering the facility. An Immunization report from the facility documented PVC 13 on 09/28/16 and Pneumococcal Polysaccharide Vaccine (PPSV23) on 08/02/19.On 12/02/25 at 02:25 PM, Administrative Nurse D stated he was responsible for tracking and monitoring the resident's immunizations. He stated that he would have to check the CDC guidelines if the residents were eligible to receive the PCV 20. He stated the facility had not offered the PCV 20 at this time.The facility's Immunization Pneumococcal policy, revised 11/28/17, documented pneumococcal vaccinations would be offered to all residents per Centers for Disease Control and Prevention (CDC) guidelines.

The facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 38 and R27's care plans to reflate changes in their care.Findings Included: - R38's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), limited mobility, muscle weakness, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R38's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted she could independently complete bathing, dressing, bed mobility, and transfers. The MDS noted she was at risk for developing pressure ulcers but had no current injuries. The MDS noted she had pressure-reducing devices in place for her bed and wheelchair. R38's Pressure Injuries Care Area Assessment (CAA) completed 06/06/25 indicated she was at risk for skin breakdown and pressure injuries. The CAA noted she had pressure-reducing devices for her wheelchair and bed. The CAA indicated she was taken off hospice services on 05/25/25. R38's Care Plan initiated 06/05/24 indicated the following interventions: 06/06/24 – The plan indicated she needed prompts and stand-by assistance to complete personal hygiene, oral hygiene, dressing, showering, and toileting. 06/17/24 - The plan noted she was at risk for skin breakdown. The plan noted she had a pressure-relieving mattress in place. The plan indicated she had low air-loss (specialized air mattress used to prevent pressure-related injuries) mattress and instructed staff to ensure the correct settings according to her weight. 10/30/24 - The plan instructed staff to perform weekly skin checks. On 12/02/25 at 07:30 AM, R38 sat up in her bed and ate her breakfast. Her bed was in the medium height (waist high) position. She had a pressure-reducing mattress, but it was not a low air-loss mattress. She stated her bed changed once she came off hospice service because she didn't need the air mattress. On 12/03/25 at 01:55 PM, Licensed Nurse (LN) G stated she had a pressure-reducing bed but didn't think she had a low air-loss mattress. She stated the care plan should be updated once the resident's needs changed, and old interventions should be removed. On 12/03/25 at 02:43 PM, Administrative Nurse D stated the care plans were reviewed quarterly and updated as needed. He stated R38 was on hospice services, and the bed was changed out once she was taken off hospice. He stated the plan was not updated. The facility's Care plan policy, revised 03/2024, indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated that the care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs. - R27's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated 10/09/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented that R27 had received respiratory treatment during the observation period. R27's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 04/29/25 documented he required staff assistance with his functional abilities. Other risk factors included limitations in mobility, incontinence, and a diagnosis of dementia. R27's Care Plan dated 07/07/25 documented the following interventions: 07/07/25 - Staff would assist him with repositioning at least every two hours. R27's plan of care lacked direction to the nursing staff for oxygen therapy. R27's EMR under the Orders tab revealed the following physician orders: Oxygen per nasal cannula as needed daily. Monitor oxygen saturation and notify physician if below 90 percent, dated 04/16/25. The physician order lacked a diagnosis for administration. On 12/02/25 at 08:30 AM, R27 sat upright at the dining room table asleep his wheelchair. There was an empty medication cup and a plastic drinking cup on the table in front of him. R27's lower extremities were on his wheelchair pedals. On 12/03/25 at 02:15 PM, Certified Nurse's Aide (CNA) M stated that only the nurse had access to the care plans. She stated that direct care staff received their instructions from the nurses during daily meetings. She stated direction for oxygen administration should be included on the resident's care plan. She stated usually the nurse would tell the CNAs how many liters per minute to set the oxygen at. On 12/03/25 at 01:55 PM, Licensed Nurse (LN) G stated that the nurses used report sheets but had access to the care plans for review. She stated a resident's care plan should include directions to staff for oxygen administration and monitoring. She stated she would modify a resident care plan when needed. She stated everyone had access to the resident plan of care, but did not have the time to review or read them. On 12/03/25 at 02:43 PM, Administrative Nurse D stated that the direct care staff and nurses relied more on the report sheets than the care plans. He stated the plans should reflect the resident's needs or care requirements. He stated the report sheet information was pulled directly from the care plans. He stated the care plans were reviewed quarterly, annually, and when changes occurred by the interdisciplinary team. He stated only the administrative staff could modify the resident's care plans, and the CNAs did not have access to review the resident's plan of care. The facility's Care Plan policy, revised 03/2024, indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated that the care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs.

The facility reported a census of 62 residents. The Sample included 17, with two residents reviewed for dignity. Based on observations, record review, and interviews, the facility failed to ensure a dignified care environment for Resident (R) 1 and R21 during meal service. Findings Included:- On 12/02/25 at 12:22 PM, an observation was completed in the main dining room for meal service.R1 (a cognitively impaired resident who was physically dependent on staff assistance) sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the table closest to the kitchen entry door. R1 had a Foley catheter (an indwelling urinary catheter with a tube inserted into the bladder to drain urine into a collection bag). R1's urinary collection bag was hung directly under his wheelchair. R1's urinary collection bag was visible and was one-third full with bright yellow urine. R1 had no privacy cover on his urinary collection bag.R21 (a cognitively intact resident who was physically dependent on staff for assistance) sat at the dining room table closest to the kitchen serving window. R21 sat in her wheelchair with her Foley catheter tubing and collection bag attached to the bottom right side of her wheelchair. R21's urinary collection was half full of yellow urine with bag had no privacy barrier in place. On 12/03/25 at 02:15 PM, Certified Nurse's Aide (CNA) M stated all the wheelchairs had bags in the bottom to place the urinary collection bags. She stated urine in the bag should not be visible.On 12/03/25 at 01:55 PM, Licensed Nurse (LN) G stated all the residents had dignity/privacy bags for the Foley catheters. She stated staff were expected to place them in the bags when transferring the residents to their wheelchairs.On 12/03/25 at 02:43 PM, Administrative Nurse D stated the resident's urine collection bags were to never be placed directly on the wheelchairs without having a dignity bag in place. He stated it was the staff's responsibility to ensure resident dignity.The facility's Urinary Catheter Usage policy, revised 11/2017, indicated staff were to ensure the appropriate placement and functionality of the catheters each shift. The policy indicated staff were responsible for maintaining the catheters with placement below the resident's bladder and ensuring sanitary practices. The policy noted that staff were to provide privacy barriers or covers.The facility's Resident Rights policy, revised 11/2017, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.

The facility identified a census of 62 residents. The sample included 17 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) 62. Findings Included:On 12/01/25 at 07:15 AM, an inspection of the Red Hall revealed an unsecured and unsupervised treatment cart outside R62's room. The cart contained stock medications, treatment supplies, and insulin for residents on the hall. The cart laptop was open and contained R62's picture and protected health information (PHI) within direct view.On 12/01/25 at 07:18 AM, Licensed Nurse (LN) J opened R62's door and exited the room into the hallway. LN J stated she was not sure if the medication carts were supposed to be locked, but would lock them during the survey inspection. She stated the PHI should not be left open on the computers when not in use.On 12/03/25 at 02:43 PM, Administrative Nurse D stated that staff have been educated to ensure the computers were locked or placed in hidden mode when staff walk away from them to protect the resident's PHI.The facility's Resident Rights policy, revised 11/2017, indicated the facility would ensure each resident's privacy and ensure all residents were educated and informed of their rights.

The facility identified a census of 62 residents. The sample included 17 residents, with five reviewed for abuse and/or neglect. Based on the record review and interview, the facility failed to ensure Resident (R) 37, R58, R61, R67, and R73 were free from abuse when their medication was misappropriated from the facility's medication cart.Findings included: - The Facility Incident Report 2599012 completed on 08/27/25 indicated R37, R58, R61, R67, and R73's pain medication showed errors in medication that occurred at the times when Licensed Nurse (LN) K worked and had possession of the narcotic keys.A record review of R37 (resident with intact cognition) documented R37 had had pain from a fracture. R37 was a long-term care resident who recently suffered a left femur fracture and underwent surgery for fixation. R37 had documented decline in her functional mobility and decline in her ability to assist in her self-care tasks.A record review of R58 (resident with moderately impaired cognition) documented R58 needed moderately/maximal assistance with activities of daily living (ADL).A record review of R61 (a resident with moderately impaired cognition) documented R61 needed staff assistance with functional abilities and balance impairments, a history of falls, and takes pain medication.A record review of R67 (resident with intact cognition) documented R67 had a subarachnoid hemorrhage (a life-threatening type of stroke caused by bleeding into the space between the brain and the thin tissues (meninges) that cover it) and a T12 compression fracture (fracture of the last vertebra in the lower back).A record review of R73 (a resident who was severely impaired) documented R73 needed partial/moderate assistance with ADLS. R73 was on hospice and received pain medication.Review of the Complaint Investigation Witness Statement dated 08/23/25, while checking for medications to reorder, a pattern was noticed on the Red Hall that had multiple oxycodone 2.5 milligram (mg) and 5 mg notations that did not appear on the Electronic Medical Record but were logged out on the medical paper Medication Administration Record (MAR). The review found several residents' MARs that were checked had inconsistencies.A Review of the Corrective Actions taken in response to the incident dated 08/23/25 documented that LN K was immediately suspended and has since been terminated. Re-education of all nurses on documentation of administration of pain and other as-needed (PRN) medications, including narcotics. One-on-one re-education of the same nurses identified as having errors in the documentation of PRN medication. The facility would conduct an audit of all PRN-controlled medications weekly over a four-week period and would present the findings in the Quarterly Quality Assurance report.A review of training presented and signed by all nursing staff documented immediately upon the discovery or suspicion of discrepancy, suspected loss, or diversion, the Director of Nursing and Pharmacist were consulted, and an investigation was conducted. If any discrepancy was found, the pharmacy and the Director of Nursing were to be contacted.On 12/03/25 at 10:45 AM, Administrative Nurse D stated that it was brought to his attention from a floor nurse that there were discrepancies in the MAR for missing narcotics. An immediate investigation was conducted with the Pharmacy Consultant. Administrative Nurse D stated that all narcotics that were discontinued, or the resident had left the facility, should be given to the Director of Nursing, who would lock them up in a two-key lock and be destroyed with the pharmacist's consultation and the Director of Nursing. Administrative Nurse D stated that training on discrepancies of medication and narcotic counts was done with all nursing staff, as a group and one-on-one. Administrative Nurse D stated he felt the breakdown in the medication misappropriation was that narcotics were not taken out of the cart immediately after the medication had been discontinued.On 12/03/25 at 01:52 PM, LN I stated it required two nurses at the end of the shift and the start of the shift to verify narcotics. LN I stated the facility does in-services on misappropriation of narcotics and the importance of narcotic counts.The facility's Abuse, Neglect, and Exploitation policy, revised 11/28/17, documented misappropriation of a resident meant the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involutory seclusion, neglect, exploitation, misappropriation of resident property, and injury of unknown origin.

The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 50. Findings included:- R50's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypotension (low blood pressure) 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). The admission Minimum Data Set (MDS) dated 11/17/25 documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R50's Falls Care Area Assessment (CAA) dated 11/25/25 documented she triggered for falls related to impaired balance and history of falls. R50's Care Plan dated 10/31/25 documented: 10/31/25 - R50 planned to return home. On 11/03/25 at 08:00 AM a Communication Note documented R50 was found on the floor by her bed. R50 was transferred by ambulance to the hospital. On 12/02/25 at 08:33 AM, R50 sat upright in her wheelchair at the dining room table. R50 visited with other residents at the dining room table. R50's hair was combed. On 12/03/25 at 10:21 AM, Administrative Staff A stated there was no written notification or bed hold provided to R50 or her legal representative for her facility-initiated transfer to the hospital on [DATE]. She stated was to provide the bed hold information to the resident or their legal representative at the time of transfer. Administrative Staff A stated the nursing staff would notify the social service of the transfer. She stated that social services was responsible for providing the written notification and follow-up on the bed hold. The facility's Discharge Criteria policy dated 11/28/17 documented residents were permitted to remain in the facility and not be transferred or discharge unless appropriate discharge criteria was met.

The facility identified a census of 62 residents. The sample included 17 residents with five reviewed for care plan. Based on observation, record review, and interviews, the facility failed to implement a comprehensive care plan for Resident (R) 54 related to his activities of daily living (ADL).Findings Included: - R54's Electronic Medical Records (EMR) noted diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), dysphagia (difficulty swallowing), and dementia (a progressive mental disorder characterized by failing memory and confusion).R54's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS noted he had impairments in both legs. The MDS noted he required supervision during meals but was dependent on staff for toileting, dressing, oral hygiene, bathing, bed mobility, and transfers. The MDS noted he was frequently incontinent of bladder and always incontinent of bowel. The MDS noted he was at risk for falls but had none since his admission.R54's Dementia Care Area Assessment (CAA) completed 07/09/25 indicated he usually would understand others, but instructed staff to anticipate his needs. The CAA noted he worked with speech therapy services to improve cognition.R54's Urinary Incontinence CAA completed 07/09/25 indicated he was at risk for skin breakdown and incontinence related to his cognitive impairment and limited mobility. The CAA noted he worked with occupational and physical therapy services to improve his functional abilities. The CAA instructed staff to anticipate his needs and assist with toileting as indicated.R54's CAA did not trigger for his functional abilities. R54's Care Plan initiated 06/30/25 indicated the following interventions:06/30/25 - The facility was to follow his advanced directives and indicated he was a Full Code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest).06/30/25 - He took medications with Black Box Warnings (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration)10/31/25 - He had nutritional concerns, and staff were expected to offer feeding assistance during mealtimes.R54's Care Plan did not acknowledge his identified incontinence needs, his activities of daily living preferences or required level of assistance, and that he required a Hoyer lift (total body mechanical lift) with two staff member assistance for transfers.On 12/02/25 at 11:03 AM, R54 sat in his Broda Chair (specialized wheelchair with the ability to tilt and recline) in his room. R54's Hoyer lift sling was underneath him. R54's resident representative sat next to him. She stated the facility continually lacked communication between the management and direct care staff related to how and when cares were performed on the residents. She stated she attended the care plan meetings and felt the care was not being completed as discussed in the meetings. She stated she continually had to remind the facility to provide bathing and toileting care.On 12/03/25 at 01:55 PM, Licensed Nurse (LN) G stated that the nurses used report sheets but had access to the care plans for review. She stated R54 required full assistance from staff and was transferred with a Hoyer lift. She stated the care plans should reflect the resident's current or changing needs. She stated R54 was incontinent and required frequent checks and care.On 12/03/25 at 02:15 PM, Certified Nurse's Aide (CNA) M stated that only the nurse had access to the care plans. She stated that direct care staff received their instructions from the nurses during daily meetings.On 12/03/25 at 02:43 PM, Administrative Nurse D stated that the direct care staff and nurses relied more on the report sheets than the care plans. He stated the plans should reflect the resident's needs or care requirements. He stated the report sheet information was pulled directly from the care plans. He stated the care plans were reviewed quarterly, annually, and when changes occurred by the interdisciplinary team.The facility's Comprehensive Care plan policy, revised 03/2024, indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated that the care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs.

The facility identified a census of 62 residents. The sample included 17 residents, with one reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure the physician order was followed for a daily weight for R45 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). Findings included:- R45's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypotension (low blood pressure), CHF, and atrial fibrillation (rapid, irregular heartbeat). The admission Minimum Data Set (MDS) dated 11/10/25 documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated intact moderately impaired cognition. The MDS documented R45 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R45's Dehydration Care Area Assessment (CAA) dated 11/16/25 documented he had triggered for dehydration related to constipation. The nursing staff would monitor for signs or symptoms of dehydration. R45's Care Plan dated 11/14/25 documented:11/14/25 - R45 received medications that had black box warnings, and the nursing staff would monitor for any adverse reaction and notify the physician. R45's EMR under the Orders tab revealed the following physician orders: Weigh daily to monitor for signs of CHF, dated 11/04/25. Lasix (Furosemide- diuretic) tablet 40 milligram (mg), give one tablet by mouth two times a day for edema (swelling resulting from an excessive accumulation of fluid in the body tissues), dated 11/04/25. Review of R45's EMR under the Vitals tab, the Medication administration Record (MAR), the Progress Notes, and the Treatment Administration Record (TAR) from 11/04/25 to 12/01/25 (27 days) lacked evidence staff measured and recorded R45's weight on following seven dates 11/06/25, 11/10/25, 11/12/25, 11/15/25, 11/16/25, 11/19/25, and 11/20/25. R45's clinical record lacked documentation of any refusals of any daily weights and any physician notification of daily weights that had not been obtained. On 12/02/25 at 12:56 PM, R45 sat upright on his bed. R45's bedside table was pulled across his lower extremities, which had three cups of fluid on the table. R45 was awake and watched his TV. On 12/03/25 at 01:45 PM, Licensed Nurse (LN) I stated it was ultimately the nurse's responsibility to ensure daily weights were obtained and documented. LN I stated if the resident refused to be weighed, she would notify the physician and document the refusal on the TAR and in the progress notes. On 12/03/25 at 02:24 PM, Certified Nurse Aide (CNA) M stated the nurse would write on the report sheet if a resident was a daily weight and the expectation was to obtain their weight before breakfast. CNA M stated she would then notify the nurse of the resident's weight. CNA M stated if the resident refused to be weighed, she would notify the nurse. On 12/03/25 at 02:45 PM, Administrative Nurse D stated he would expect the physician order to followed. Administrative Nurse D stated if the resident was to refuse be weighed then the nurse would notify the physician and write a progress not in the residents' EMR.The facility's Physician Orders policy dated 09/21/21 documented physician orders would be followed related to the care needs of individual residents.

The facility identified a census of 62 residents. The sample included 17 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) 2, and further failed to ensure R2's Low air loss (LAL) mattress (medical device that uses continuous airflow through small holes in the surface to reduce moisture, keep skin cool and dry, and redistribute pressure to prevent and treat pressure ulcers) was set at the proper weight. Findings Included:- R2's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), senile degeneration of brain (a progress degeneration of the brain with age), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R2 was dependent on the staff for bathing and toileting. The MDS documented R2 had one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below), and two unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure wounds. The MDS documented R2 had a pressure-reducing mattress in her chair and on her bedThe Pressure Ulcer/Injury Care Area Assessment (CAA) dated 09/22/25 documented R2 triggered CAA due to risk for skin breakdown related to incontinence and impaired bed mobility. The CAA documented multiple pressure injuries were noted, and treatment orders were in place per provider orders. The CAA documented staff would assist R2 with repositioning as needed, and a pressure-relieving mattress and cushion were in use for prevention. R2 was admitted to Hospice services on 09/15/25.R2's Care Plan documented the following:09/29/23 - staff to apply protective barrier to R2's skin after incontinence.12/02/24 - Licensed Nurse (LN) was to check R2's skin weekly for any injury and report to the physician with any skin injury.R2's plan of care lacked staff direction and interventions for pressure injuries/ulcers on the heels and coccyx.R2's plan of care lacked staff direction for monitoring of R2's LAL mattress.R2's physicians' Orders documented the following:Ensure heel protectors are on patients' feet/heels to reduce the risk of pressure sores every shift, dated 1028/25. Magic Butt (paste compound formula) two times a day for wound care to the coccyx, dated 10/28/25.Wound care to left heel: cleanse left heel with normal saline, pat dry with gauze, and apply skin-prep (liquid skin protectant) to left heel, dated 11/05/25.Wound care to the right heel, cleanse right heel with normal saline, pat dry with gauze, apply skin-prep to right heel would apply Calcium alginate (a gel-like substance derived from seaweed that is commonly used for medical dressings), to wound bed with ABD (thick dressing) pad then Kerlix (stretchy gauze bandage) and change daily and prn every day shift, dated 11/18/25.R2's EMR lacked direction for staff monitoring of her LAL mattress.R2's EMR under 'Weights and Vitals documented a weight of 121.2 on 11/17/25.On 12/01/25 at 08:32 AM, R2 laid on her back in her bed with her eyes closed. R2's heels were wrapped with kerlix and laid on a pink chuck directly on the mattress. R2 did not have boots on her heels, and R2's heels were not offloaded. R2's LAL mattress, which was controlled with a dial, was set at 180 pounds.On 12/02/25 at 10:17 AM, R2 laid in her bed with her head elevated and eyes open. R2 did not have boots to her heels. R2's heels were wrapped with kerlix and were offloaded on a pillow covered with a pink chuck. R2's LAL mattress, which was controlled with a dial with pre-set weights, was set at 180 pounds.On12/03/25 at 01:52 PM, LN I stated the facility had a provider that takes care of checking the LAL mattresses, and the settings were set at the correct settings. LN I stated she did believe the facility had requested R2's boots. R2 stated it was the floor nurse and the Certified Nurse Aides' (CNAs)responsibility to ensure boots were applied to a resident's heels, or heels were floated.On 12/02/25 at 12:10 PM, Administrative Nurse D stated he had made calls to R2's hospice provider to request R2's boots. He stated the facility had requested the boots for R2 a couple of times and had not received the boots. He stated staff should be offloading R2's heels while she was in bed. Administrative Nurse D stated, Breathe A provider sets the LAL mattress; he stated the mattress dial was set by weight. He stated the only time the staff would touch the mattress was if the mattress was not working.The facility's Wound Assessment, Prevention and Treatment policy, revised 11/28/17, documented a resident who enters the facility without pressure ulcers would not develop them unless the individual. The clinical condition demonstrates that they were unavoidable. A comprehensive, individualized care plan would be developed to address prevention of development of pressure ulcers, management of risk factors, and treatment strategies for residents with pressure ulcers. The strategies would be developed through collaboration between the resident, the representative, the physician, the dietitian, and the clinical staff.

The facility identified a census of 62 residents. The sample included 17 residents, four residents were sampled for accidents and hazards. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 2's fall interventions as directed by her care plan.Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), senile degeneration of brain (a progress degeneration of the brain with age) and dementia (a progressive mental disorder characterized by failing memory and confusion).The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R2 was dependent on the staff for bathing and toileting. The MDS documented R2 had falls since admission or reentry or the prior assessment. The MDS documented R2 had two or more falls with injury during the observation period.The Falls Care Area Assessment (CAA) dated 09/22/25 documented R2 triggered for falls CAA due to the risk for falls related to impaired balance. The CAA documented other risk factors, including cognitive (impaired thought process) impairments, incontinence, limitations in mobility, opioid (use for pain), dementia, and senile degeneration of the brain. The CAA documented R2 had clear speech and was often able to understand others. The CAA documented R2 was admitted to hospice on 09/15/25.R2's Care Plan documented the following fall interventions:06/24/2025 - nonskid strips placed in front of the recliner to help keep my feet from sliding out from under me.06/24/25 - Place call light within reach.09/22/25 - Place a fall mat next to the bed.09/22/25 - Bed in the lowest position.08/25/25 - Staff to check R2 every 2 hours.10/03/25 - Staff to provide non-slip socks.On 12/03/25 at 02:22 PM, Certified Nurse's Aide (CNA) M stated she did not have access to the care plan. CNA M stated she would know who needed a fall mat by the daily CNA report and the nursing report. CNA M stated the fall mats should be placed on the side of the bed, and if the resident was a fall risk, the bed should be in a low position. On 12/03/25 at 01:52 PM, Licensed Nurse (LN) I stated she was unsure if everyone had access to the care plan. LN I stated the expectation was that the CNA would put the fall mat down when putting the resident to bed. She stated she was unsure if beds should be in a low position, as it was different for each resident. On 12/02/25 at 10:22 AM, Administrative Nurse D stated that fall mats should be on the side of the bed that R2 would roll out of bed on. Administrative Nurse D stated the fall mat should not be under the bed. He stated the last staff member to leave a resident's room should ensure the fall mat was in place, and the bed was in the lowest position. Administrative Nurse D stated that all staff would know if a resident needed a fall mat or bed, which should be in the lowest position on the daily report sheet. Administrative Nurse D removed R2's fall under her bed and placed it on the side of her bed.The facility's Falls policy, revised 04/27/18, documented the facility would implement systems to reduce the risk of falls based on resident assessment. An individualized care plan intervention would be developed for residents identified through assessment as being at risk of falls. The interventions would be reviewed and updated on a regular basis when a fall occurred.

The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for respiratory care. Based on interviews, observation, and record review, the facility failed to ensure there was physician indication for oxygen administration for Resident (R) 27. Findings included:- R27's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS) dated 10/09/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented that R27 had received respiratory treatment during the observation period. R27's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 04/29/25 documented R27 required staff assistance with his functional abilities. Other risk factors included limitations in mobility, incontinence, and a diagnosis of dementia. R27's Care Plan dated 07/07/25 documented the following interventions:07/07/25 - Staff would assist him with repositioning at least every two hours.The plan of care lacked direction for the nursing staff related to R27's oxygen therapy. R27's EMR under the Orders tab revealed the following physician orders: Oxygen per nasal cannula as needed daily. Monitor oxygen saturation and notify the physician if below 90 percent dated 04/16/25. The physician's order lacked a diagnosis for administration. On 12/02/25 at 08:30 AM, R27 sat upright at the dining room table, asleep in his wheelchair. There was an empty medication cup and a plastic drinking cup on the table in front of him. R27's lower extremities were on his wheelchair pedals. On 12/03/25 at 01:45 PM, Licensed Nurse (LN) I stated oxygen was a medication and required a diagnosis for any medication. LN I stated she would call the physician to obtain a diagnosis. On 12/03/25 at 02:45 PM, Administrative Nurse D stated he would expect that all medication would have an indication for administration. He stated he would expect the nurse to call and get a diagnosis. The facility's Oxygen Safety and Management policy dated 03/22/19 documented oxygen would be administered in a safe manner to residents who require it. Oxygen would be provided to residents based on their physician's orders. Concentrators and oxygen tanks would be available for resident use. Physician orders for oxygen use would include the rate of oxygen flow (liters/minute), the route of administration, the mask, and the frequency of administration.

The facility identified a census of 62 residents. The sample included 17 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood), and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 7's dialysis.Findings included:- R7's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid) and end stage renal disease (the final stage of chronic kidney disease, where the kidneys have permanently stopped working and can no longer function at a level needed to sustain life).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R7 was impaired on one side of his body. The MDS documented R7 required dialysis during the observation period.R7's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 08/14/25 documented R7 admitted to the facility following hospitalization. The CAA documented R7 was admitted for therapy services. The CAA documented R7 required additional assistance with his activities of daily living (ADL). The CAA documented R7 received dialysis on Monday, Wednesday, and Friday.R7's Care Plan documented the following:08/12/25 - R7 wanted to remain safe during his stay in the facility.08/12/25 - R7 planned to return home after therapy.08/12/25 - R7 needed help obtaining the services and resources to be able to go home.R7's plan of care lacked direction for staff to care for his dialysis treatments.R7's EMR under the physicians' Orders tab lacked direction for nursing to care for R7, who needed dialysis.The EMR lacked a physician order for R7's dialysis.The EMR lacked direction for staff to access R7's dialysis shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) in his left arm.The EMR lacked direction for staff for R7's dialysis location, transportation provider, and the date and times that R7 received dialysis.On 12/03/25 at 02:22 PM, Licensed Nurse (LN) I stated the process to ensure a resident's standard of care for dialysis would be to check the Treatment Administration Record (TAR), nursing report, and the care plan for specific orders for dialysis. LN I stated nursing staff do not check the residents' shunt, she stated dialysis takes care of the residents' dialysis needs. LN I stated the facility ensured residents had a lunch to take with them to dialysis.On 12/03/25 at 02:43 PM, Administrative Nurse D stated the nurses would know a resident was on dialysis by the nursing report sheet and nurse-to-nurse communication. Administrative Nurse D stated he did not know who had access to the care plans; he thought just the administrative staff. He stated he could see where having direction for nursing in the TAR, and the care plan would be good, along with the nursing report sheet.The facility's Dialysis policy, revised 11/28/17, documented dialysis services would be provided for residents with end-stage renal disease. A physician's order would be obtained at the time of admission for the provision of dialysis treatment. The facility would arrange for dialysis services and transportation to and from the dialysis unit for any resident who required them.

The facility reported a census of 61 residents, with 9 sampled. Based on observation, interview, and record review the facility failed to ensure the staff provided Resident (R) 1 a peanut-free meal, per his reported allergies upon admission. On 03/07/25 at 06:30 PM, the staff provided R1 a peanut butter cookie with his dinner and the staff failed to verify his documented allergies on his meal ticket. R1 had an anaphylaxis allergic reaction to the peanut butter that resulted in vomiting. The facility could not provide epinephrine to R1 to prevent further potential anaphylaxis-related symptoms and the facility transferred R1 to the hospital. R1 received the epinephrine at the hospital and was admitted to the hospital on 03/07/25 for anaphylaxis. This deficient practice placed R1 in immediate jeopardy and any resident with a food allergy at risk to their health and safety. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), blindness of right eye, acute kidney failure, and fracture (broken bone) of the right femur (thigh bone). R1's EMR indicated he admitted on [DATE] for therapy services related to his recent right femur fracture. R1's EMR indicated a Minimum Data Set (MDS) was not completed. No Brief Interview for Mental Status (BIMS) or Care Area Assessments (CAAs) were completed. R1's Care Plan completed 03/06/25 indicated he was admitted to the facility for therapy services and would return to his home upon discharge. The plan noted he had vision and hearing impairments. The plan noted he had allergies to peanut-based foods. The plan noted he required assistance from one staff for personal hygiene, toileting, dressing, bathing, transfers, bed mobility, and walking. The plan noted he was alert and cognitively intact. The plan noted he was on a regular diet and preferred to eat in his room. R1's EMR under Assessments revealed his Admission Assessment completed on 03/06/25 noted he had peanut allergies. R1's EMR under Progress Note revealed a Nutrition Note completed on 03/07/25 at 10:00 AM. The note indicated he was admitted on [DATE] with an order for a regular diet. The note indicated he ate in his room without assistance or adaptive equipment. The note indicated he had no issues with chewing or swallowing. The note indicated he was allergic to peanuts. R1's provided Meal Ticket dated 03/07/25 for his dinner meal indicated he was served pork tenderloin on a bun, sweet potato puffs, creamy coleslaw, and an assorted dessert. The ticket noted he had peanut allergies. R1's EMR under Progress Note revealed a Communication Note completed 03/07/25 at 06:45 PM. The note indicated R1's nurse was notified by his representative that R1 had an allergic reaction to a peanut butter cookie he was served for dinner. The note revealed R1 had facial swelling and vomited. The note revealed R1 was transported to an acute care facility for emergency treatment. R1's EMR under Progress Note revealed a Communication Note completed 03/07/25 at 11:45 PM. The note revealed R1 was admitted to the acute care facility for anaphylaxis. A Facility Incident Report #4060 completed on 03/11/25 indicated R1 was sent out for emergency medical treatment on 03/06/25. The report noted Licensed Nurse (LN) H responded to R1's room for an allergic reaction from a peanut butter cookie he was served on his dinner plate. The note indicated the nurse failed to locate an epinephrine injection pen during the episode and called for emergency medical services. The note indicated EMS arrived and immediately transported R1 to an acute medical facility for emergency treatment. The Staff Witness Statement completed on 03/11/25 by Dietary Staff CC noted on 03/07/24 at 05:30 PM Dietary Staff CC went to the Rapid Recovery hall to assist with meal delivery. The statement noted as she delivered R1's meal tray she noticed his tray had no dessert. The statement noted Dietary Staff DD placed a cookie on his tray as Dietary Staff CC delivered the food to the room. The statement noted Dietary staff DD did not see what kind of cookie it was before delivery. The Staff Witness Statement completed on 03/13/25 by Dietary Staff DD documented Dietary Staff DD assisted in plating the food in the dining hall for room delivery. The statement noted she accidentally put a peanut butter cookie on R1's tray instead of a raisin cookie. During an observation on 03/19/25 at 12:05 PM, dining hall service began for lunch. An inspection of prepared meal trays revealed each tray had a ticket. Dietary Staff EE inspected the meal tickets as he plated the food. The meal tickets remained on the tray as they were delivered to the residents. On 03/19/25 at 03:35 PM, an inspection of the facility's emergency medication kit (E-Kit) revealed the facility supplied epinephrine in vials instead of injectable pens. A review medication record revealed the facility had epinephrine in the facility during the emergency. On 03/19/25 at 02:15 PM, Dietary Staff BB stated the facility used an electronic meal ticket system that printed out the daily meals for each resident. She stated the tickets contained the type of diet, menu, allergies, and resident information. She stated staff were expected to use the tickets to verify the correct diet for plating food and during delivery to the resident. She stated all staff were expected to inspect the meals upon delivery to verify the correct diet and food allergies. On 03/19/25 at 02:45 PM, Certified Nurse Aide (CNA) M stated meal tickets were provided for each resident during meal service. She stated staff were expected to check the meal tickets before serving the food to ensure the residents received the correct diet and avoided potential food allergies. She stated the tickets clearly identified what food allergies each resident had and their dietary needs. On 03/19/25 at 03:30 PM, Administrative Nurse D stated all staff were expected to verify the diet and potential food allergies with the food being served during meal service. The facility's Meal Identification / Resident Meal Card policy revised on 04/13/20 indicated the facility safely provided meal services. The policy noted staff was to utilize meal cards to identify each resident's food preferences, dietary orders, food allergies, and other nutritional needs. The facility failed to follow R1's dietary restrictions related to his peanut allergy. This deficient practice resulted in a severe allergic reaction and hospitalization for anaphylaxis. On 03/19/25 at 05:04 PM Administrative Staff A was provided a copy of the IJ template and notified the facility failured to provide R1 with a meal that aligned with his dietary restrictions in regard to his peanut allergy and caused him to suffer an anaphylaxis allergic reaction and hospitalization , placed the resident in immediate jeopardy. The facility implemented and completed the following corrective actions related to this incident: 1. R1 was immediately assessed and provided emergency medical treatment. 03/07/25 2. The facility identified all at-risk residents with potential food allergies. 03/07/25 3. The facility provided in-service education for all staff related to reviewing meal cards, dietary requirements, and allergies. 03/08/25 4. The facility provided one-to-one education for the Dietary Staff CC and DD. 5. The facility completed interviews with three identified residents with potential food allergies. 03/11/25 6. The facility will provide ongoing routine in-services related to food services to all staff. Due to the corrective actions completed on 03/11/25, prior to the onsite visit on 03/19/25, the deficient practice was deemed past non-compliance at a J (isolated, actual harm) scope and severity.

The facility reported a census of 49 residents. The sample included three residents at risk for falls. Based on record review, observations, and interviews, the facility failed to ensure staff provided care planned fall interventions for Resident (R) 1 to prevent a fall. On 01/26/22 at 01:34 PM, R1 fell from a Sit-To-Stand lift (mechanical device used to help mobility impaired residents transition from a seated to a standing position) when one staff member assisted in the transfer, instead of the care planned two staff assistance. Consequently, the inappropriately applied lift sling, separated on one side of the lift, and caused R1 to fall backwards, striking R1's head on the tile floor. R1 sustained a scalp laceration which bled profusely, required emergency medical treatment, seven staples, and a four day stay at a local hospital. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of: hemiplegia and hemiparesis following cerebral infarction affecting the left side, (a stroke which caused paralysis of partial or total body function on one side of the body), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and traumatic subarachnoid hemorrhage with loss of conscious (bleeding in the brain and loss of consciousness following an injury to the head). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 had a Brief Interview for Mental Status score of 14 which indicated R1's cognition was intact. The MDS documented R1 required extensive assistance of two staff members with most activities of daily living (ADL), such as bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS recorded R1 had impairment of upper and lower extremities on one side of R1's body. The assessment further documented R1 was unsteady and unable to stabilize without human assistance during transfers. R1 was six feet, one inch tall, weighed 205 pounds, and used a wheelchair maneuvered by staff for ambulation. Review of R1's Care Plan revised 10/17/22 recorded R1 was at risk for falls, and documented R1 could not ambulate, used a wheelchair propelled by staff for locomotion. The care plan documented R1 transferred by use of a Sit-to-Stand lift and two staff member assistance. Staff were further directed to assist R1 with placement of R1's right upper extremity on the lift. A Nurse Progress Notes dated 01/26/23 at 03:27 PM recorded staff notified R1's responsible party of R1's fall and transfer to the hospital emergency department. A Nurse Progress Notes dated 01/26/23 at 04:17 PM recorded R1 transferred to the hospital with a diagnosis of subarachnoid hemorrhage (brain bleed). The EMR lacked further documentation related to the residents fall which included analysis of how the fall occurred or nursing observations of the resident at the time of the fall. The Hospital Consultation/Progress Notes dated 01/27/23 at 06:52 PM documented R1 had a fall with small bifrontal contusions (blood or bleeding under the skin due to trauma) and possible scattered traumatic subarachnoid hemorrhage (SAH) in the left frontal area. R1's posterior scalp laceration was washed and repaired at the bedside with 5 milliliters (ml) lidocaine (local anesthetic) and seven staples. A dressing was applied using Xeroform (petrolatum based non-adherent bandage to maintain a moist wound area) gauze, four by four pads, and bleeding was controlled. A Nurse Progress Notes dated 01/30/23 at 05:18 PM recorded R1 returned to the facility at 03:49 PM (four days after a fall) with two emergency medical staff, on a stretcher. Multiple bruises were noted, with incision to the posterior area of the head, and seven staples in place. This same note documented that per the hospital, R1 was to be transferred with a Hoyer lift (full body lift). Review of the Facility's Investigation documented on 01/26/23 at approximately 01:45 PM, Certified Nurse Aide (CNA) N reported R1's shirt was put on while R1 was seated; then the staff stood R1 up with the Sit-To-Stand lift to pull R1's pants up. CNA N maintained the lift harness and/or sling was attached correctly. The investigation speculated that the left sided loop of the sling/harness became dislodged while CNA N pulled in an upward motion and adjusted R1's pants. The investigation concluded that if an additional staff member had been present while the lift was moved toward the wheelchair, it would have been unlikely that the fall could have been prevented. The notarized Witness Statement dated 01/26/23 signed by CNA N documented CNA N gave R1 a shower and placed R1 in the Sit-To-Stand Lift. The loops on the lift sling were secured. During the transfer, R1 fell from the lift in the middle of the transfer and hit his head on the tile floor. The notarized Witness Statement dated 01/26/23 signed by Licensed Nurse (LN) G documented someone screamed come here. LN G went to the shower room and found R1 on the floor laying on his back with his legs laid across the base of the stand-up lift; the sling remained attached to the lift, on one side. R1 had his clothes on. LN G noted there was a large amount of blood on the floor beneath R1's head and R1 stated he fell . LN G raised R1's head and noted gushing blood and told the other nurse to call 911. LN G documented CNA N was in the shower room with the resident. The notarized Witness Statement dated 01/26/23 signed by LN I documented on 01/26/23 at 01:40 PM, LN G was near the shower room and heard yelling and banging noises. The statement noted LN G opened the door and CNA N stated the lift sling fell off the lift. LN I documented R1 was laying on R1's back on the floor, with the Sit-to-Stand lift in front of R1, and the sling hung from the side of the lift. On 02/07/23 at 10:30 AM CNA M demonstrated use of the Sit-to-Stand lift with the sling and stated, two people were typically used with the Sit-To-Stand lifts. On 02/07/23 at 11:03 AM R1 sat in a Broda (a specialty cushioned wheelchair) chair in the facility dining room engaged in a bingo game with other residents. R1's scalp wound was clean and dry, with seven metal staples clearly visible. Interviewed on 02/07/23 at 11:03 AM, R1 remembered the event up to the fall but could not remember immediately after the fall. R1 stated he was in the shower and had his shirt, socks, and shoes on. R1 said his pants and brief were pulled up to his knees. R1 said he was raised in the lift and the young man was not very experienced. R1 said he was unsure what happened but though staff said the loop came off. R1 could not recall if the sling waist belt was attached. He said he fell and hit the floor and maybe blacked out because he did not remember much after that. R1 said he could not remember if the lift tipped and or the base lift legs were widened. R1 stated the young man who performed the transfer was just not quick enough to keep R1 from falling. R1 stated he never had any previous falls. Interviewed on 02/07/23 at 12:00 PM, LN H said she was not working when R1 fell but stated there was supposed to be two persons assisting with the lifts. Interviewed on 02/07/23 at 12:10 PM, LN I stated she responded to the shower room after the resident fell , the other nurse was already there, so LN I activated emergency medicals services (EMS). LN, I said she observed the lift sling was hanging on the right side of the lift. Interviewed on 02/07/23 at 12:45 PM, Administrative Nurse D reported he was not present in the facility when R1 fell but said she assisted with the investigation. Administrative Nurse D noted the investigation omitted if CNA N operated the lift alone. Interviewed on 02/07/23 at 12:45 PM, Administrative Staff A acknowledged the lift was used improperly and stated CNA N, as well as all staff, received instruction on the use of lifts. The facility's undated Following the Care Plan policy directed the certified nursing assistant worksheet was updated with the care plan either daily or as needed and must be followed when assisting residents with their activities of daily living. The facility failed to ensure staff followed R1's care plan which directed two staff for use of the lift for transfers. As a result, R1 fell from the lift and received an injury that required emergent hospitalization , treatment, and staples. On 01/27/23, prior to the survey, the facility completed corrections related to the incident which included, training and in-service education on following resident care plans, and use of the lift which included ensuring adequate staff were present. Due to the corrective measures implemented prior to the survey, the deficient practice was cited as past noncompliance at a G (isolated, with actual harm) scope and severity.

The facility identified a census of 69 residents, and the sample included 3 residents reviewed for pressure ulcers (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). Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent the development of 8 facility-acquired (occurrence in the facility) pressure ulcers as follows: one Stage 3 (a pressure ulcer which extended into the muscular tissue), one deep tissue injury (injury to the tissues underneath the skin without leaving an opening on the skin) on the left foot, one Stage 2 (a pressure ulcer which extended into the fatty tissue under the skin) on the right lower leg, and deep tissue injuries on the left ankle, left heel, the top of the left foot, right ankle and right foot for 1 resident (#3). Findings included: - The electronic medical record for resident #3 included the [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2, which indicated severely impaired cognition. The resident required extensive assistance with transfers, toileting, and bed mobility, limited assistance with eating, and was frequently incontinent (involuntary loss of urine or bowel) of bowel and bladder. The resident weighed 198 pounds (lbs). The resident was at risk for pressure ulcers, and had two stage 2 pressure ulcers. Staff provided a pressure reducing device for the bed and the chair, turned and repositioned the resident, provided nutritional interventions, pressure ulcer care, and applied ointments. The quarterly MDS dated [DATE] documented a BIMS score of 1, which indicated severely impaired cognition. The resident needed extensive assistance with bed mobility, transfers, and toileting, required supervision with eating, and was frequently incontinent of bowel and bladder. The resident weighed 205 lbs and was 66 inches tall. The resident was at risk for a pressure ulcer, and had one stage 3 pressure ulcer. Staff provided a pressure reducing device for the bed and the chair, turned and repositioned the resident, provided nutritional interventions, pressure ulcer care, and applied ointments. The Care Area Assessment (CAA) dated 9/20/16 for cognition documented the resident had a poor memory. The CAA for pressure ulcers revealed the resident was at high risk for pressure ulcers and skin breakdown due to being confined to a bed or a wheel chair, memory loss, the need for extensive assist for all transfers, and incontinence (inability to hold the urine or bowel movement). The resident currently had two pressure ulcers which required treatment. The care plan revised on 7/18/16 documented staff provided a pressure reducing wheelchair cushion and a pressure reducing cushion for the recliner, and provided assistance with toileting, bed mobility and transfers. The care plan documented the resident slept in his/her recliner and needed help to reposition every 2 hours. The care plan documented the resident wore foam padded boots at all times. Staff applied a protective skin barrier after each incontinent episode and provided extensive assistance with toileting, and reported to licensed nursing staff when the resident consumed less than 25 percent of a meal. The care plan lacked documentation of the resident's eating ability. The Braden Skin Assessments dated 10/11/16, 12/8/16, and 12/12/16 revealed the resident was at a high risk for pressure ulcer development, and the assessments dated 9/22/16 and 1/21/17 revealed the resident was at a very high risk for pressure ulcer development. The shower sheet/skin check dated 1/26/17 failed to identify any open areas. The wound assessment, dated 1/21/17, documented the right lower leg wound started on 1/19/17 as [MEDICATION NAME] tissue (new skin) and measured 8.0 centimeters (cm) by 5.5 cm with no depth. The care plan lacked evidence of new interventions after the development of this right lower leg wound. The wound assessment, dated 1/21/17, documented the right ankle wound started on 1/19/17 and measured 2.7 cm by 1.8 cm with no depth. The care plan lacked evidence of new interventions after the development of this right ankle wound. The wound assessment, dated 1/21/17, documented the right foot wound started on 1/19/17 and measured 0.4 cm by 1.2 cm with no depth. The care plan lacked evidence of new interventions after the development of this right foot wound. The wound assessment, dated 1/21/17, documented the left ankle wound started on 1/19/17 and measured 0.6 cm by 1.7 cm with no depth. The care plan lacked evidence of new interventions after the development of this left ankle wound. The wound assessment, dated 1/21/17, documented the left foot wound started on 1/19/17 and measured 0.3 cm by 2.8 cm with no depth. The care plan lacked evidence of new interventions after the development of this left foot wound. Review of the electronic record up to and including the time of review on 1/26/17 lacked documentation about the wound on the resident's left buttock. Review of physician KK's progress note dated 12/15/16 identified the onset of the pressure ulcer on the bottom of the resident's left foot. The progress note dated 1/5/17 identified the onset of pressure ulcers on the resident's right ankle and right lower leg. The progress note dated 1/19/17 identified the onset of the pressure ulcers on the top of the resident's left foot, left ankle, and right ankle. The progress note dated 1/26/17 identified a pressure ulcer on the resident's left heel. Review of the meal intake logs dated 1/1/17 through breakfast on 1/26/17 documented staff offered the resident 76 meals. The log documented the resident refused 44 meals or 58 percent (%), and had a poor intake for the remaining 32 meals. The nurse's note dated 12/9/16 documented the resident required staff assistance for eating, and wore foam boots at all times. Staff applied barrier cream after incontinence. The nurse's note dated 12/12/16 documented the resident wore foam boots at all times. On 1/25/17 at 11:50 AM, the resident sat at the dining room table. He/she wore regular socks. He/she fed himself/herself, but only ate a few bites. Observation revealed the resident did not wear protective foam boots as care planned. On 1/25/17 at 1:06 PM, direct care staffs O and P assisted the resident with toileting. The resident's brief was wet, and Staff O and P provided cleansing. Neither staff applied barrier cream to the resident's bottom as directed on the care plan. On 1/26/17 at 10:10 AM, there was a pressure reducing mattress on the resident's bed, and foam boots laid on the resident's bed. There was not a pressure reducing seat cushion in the recliner in the resident's room as care planned. On 1/26/17 at 12:11 PM, the resident sat at the dining room table with his/her head down with a full plate of food in front of him/her. He/she wore regular socks. At 12:20 PM (9 minutes later), staff asked the resident's tablemates if the resident had eaten anything. Staff offered an alternative of a grilled cheese sandwich, which he/she agreed to. At 12:29 PM (9 minutes later), staff sat by the resident and assisted him/her to eat. The resident ate 2 bites of the sandwich. Observation revealed the resident did not wear protective foam boots as care planned. On 1/26/17 at 1:36 PM, direct care staff P assisted the resident with toileting. The resident's brief was wet, and Staff O and P provided cleansing. Obervation revealed a wound on the resident's left inner buttock, which measured 2 cm by 1 cm and was red and yellow in the center, surrounded by red swollen tissue. On 1/26/17 at 2:42 PM, physician KK assessed the wounds on the resident. The right lower leg wound measured 10.5 cm by 3.8 cm with black tissue covering the wound. The left heel wound measured 3.2 cm by 3.5 cm. The left foot wound measured 0.9 cm by 1.2 cm with a yellow center surrounded by red tissue. The right foot/ankle wounds measured 8.6 cm by 2 cm together with red tissue. The left lower leg wound measured 4 cm by 1.4 cm with pink and black tissue. On 1/26/17 at 3:40 PM, licensed nursing staff I assisted the resident with toileting and assessed the area on the left buttock, which measured approximately 2 cm by 1 cm with a yellow center and red surrounding skin. On 1/25/17 at 1:00 PM, direct care staff O stated the resident was at risk for a pressure ulcer, and had one on his/her bottom. He/she reported the resident needed assistance with toileting, bed mobility and eating. Staff O reported the resident's bottom had healed, so the barrier cream was no longer needed. Staff O further stated staff repositioned the resident every 2 hours. On 1/26/17 at 1:52 PM, licensed nursing staff G stated the resident had deep tissue injuries and the foam boots were used during transfers only. The resident did not have a pressure reducing cushion in his/her recliner, because the resident did not stay in the recliner often. Staff G further stated he/she was not aware why the wounds were not improving. On 1/26/17 at 3:40 PM, licensed nursing staff I acknowledged there was not a pressure reducing cushion in the resident's recliner, where he/she spent the majority of his/her time. On 1/26/17 at 2:00 PM, dietician DD stated he/she made recommendations of pertinent nutritional laboratory tests if the resident had wounds. Staff DD further stated he/she followed up with the resident monthly if the resident had wounds. On 1/26/2017 at 3:33 PM, administrative nursing staff D stated he/she expected staff to apply barrier cream on the resident's buttocks to prevent skin break down. Staff D further stated he/she only was aware of one wound on the resident's left foot. On 1/26/17 at 2:57 PM, physician KK declined knowledge of the new open area on the resident's buttock. On 1/26/17 at 4:00 PM, physician KK stated there were new wounds, likely from medicated gauze bandages which were applied too tight. The facility's undated Comprehensive Care Plan Policy documented a resident, who had a wound, would receive necessary treatments and services to promote healing, prevent infection, and prevent new wounds from developing. If a resident had a wound, the designated skin nurse will assess weekly from admission or date of wound identification. The facility failed to develop and implement interventions to prevent 8 facility acquired pressure ulcers for this cognitively impaired dependent resident.

The facility reported a census of 72 residents with 20 residents in the sample. Based on observation, interview, and record review the facility failed to develop and implement timely interventions to prevent development of and promote healing of 1 unstageable pressure ulcer (localized injury to the skin as a result of pressure), which developed in the facility and increased in size and shape for 1 of 3 resident's sampled for pressure ulcers. (#46) Findings Included: - Review of resident #46's unsigned physician order [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 5/7/2015 documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she did not reject cares during the 7 day observation period. The resident required limited assistance of one staff with bed mobility and transfers. The resident was not at risk for developing pressure ulcers and had no pressure ulcers or other skin issues. He/she received a pressure relieving device for his/her bed and nutrition/hydration to manage skin problems. Review of the quarterly MDS (Minimum Data Set) dated 7/28/2015 documented a BIMS score of 15, which indicated intact cognition. He/she did not reject cares during the 7 day observation period. The resident required extensive assistance of one staff with bed mobility and limited assistance of one staff with transfers. The resident was at risk for developing pressure ulcers and had a stage 2 pressure ulcer (a superficial open sore in the upper layer of the skin), which developed on 6/23/2015. He/she used a pressure reducing device for his/her bed, received pressure ulcer care, and staff applied a nonsurgical dressing with the ointments/medications. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 5/11/2015 documented the resident ambulated with a walker and had [MEDICAL CONDITION] to his/her lower extremities. The resident was at risk for physical decline and skin breakdown. Review of the Pressure Ulcer CAA dated 5/11/2015 documented the resident had multiple factors which placed him/her at risk for skin breakdown to include; pain, anxiety, depression, and use of medications. The resident wore a dressing to his/her heel due to history of moisture related maceration (wet and softened skin), and had OCD and used excessive amounts of moisturizers. Review of Braden Skin Risk Assessments documented the following results: On 5/7/2015- a score of 19 indicated a risk for skin breakdown (before stage 2 wound developed) 6/24/2015- a score of 21 indicated no risk for skin breakdown (after stage 2 wound developed) 7/29/2015- a score of 22 indicated no risk for skin breakdown (after stage 2 wound developed) Review of the care plan dated 5/15/2015 documented the resident had multiple factors which placed him/her at risk for skin breakdown. The care plan directed staff to complete a Braden Skin Assessment, assess the resident's skin with bathing and during cares, inform the nurse of any new skin issues, remind him/her to move and shift positions frequently, provide a pressure reducing mattress, and to position pillows between the resident's legs and around him/her to avoid pressure to the knees and ankles when lying on his/her sides. The facility revised the care plan on 6/24/2015 to include an open area to the resident's right lateral ankle. The care plan directed the staff to follow physician ordered treatment, complete an assessment at least weekly of the open area, notify physician if signs/symptoms of infection were present, and physical therapy ordered to evaluate and treat. The facility revised the care plan on 7/10/2015 and directed staff to make sure the yellow foam trough (a customized cushion with a long narrow area) was under his/her right lower extremity and to respect the resident's wishes if he/she refused to wear. The facility revised the care plan on 7/13/2015 and directed staff the resident was to wear the customized foam device while lying in bed. Review of a CNA (certified nursing assistant) communication worksheet dated 9/7/2015 lacked information of the resident's right lateral ankle wound and use of a foam device to the resident's right lateral (outer) ankle. Review of wound measurements to the right lateral ankle documented the following.: On 6/24/2015- 1.0 cm (centimeters) x (by) 0.6 cm stage 2 pressure ulcer. On 6/30/2015- 1.0 cm x 0.5 cm. On 7/7/2015- 1.0 x 0.5 cm x 0.2 cm On 7/13/2015- 0.4 cm x 0.8 cm On 7/20/2015- 1.2 cm x 0.4 cm On 7/27/2015- 0.8 cm x 0.8 cm On 8/3/2015- 0.6 cm x 1.0 cm On 8/10/2015- 1.0 cm x 0.8 cm On 8/17/2015- 1.2 cm x 1.2 cm with eschar (dead tissue) On 8/24/2015- 1.5 cm x 1.5 cm with slough (dead tissue, usually cream or yellow in color) On 8/31/2015- 1.0 cm x 1.5 cm with slough and eschar On 9/7/2015- 1.3 cm x 1.7 cm x 0.1 cm with slough and eschar The facility failed to identify the stage of the pressure ulcer from 6/30/2015 through 9/7/2015. Review of a physical therapy note dated 6/30/2015 documented after several attempts for a proper fit, the facility made a customized pressure relieving device for the resident. On 7/8/2015 the resident did well with the custom ankle pressure relief device, checked the ankle float device in place for comfort, wrote communication to nursing pertaining to the proper application of the foam device, and discontinued therapy on 7/9/2015. Review of the interdisciplinary communication form from therapy to nursing dated 7/8/2015 directed the staff to make sure the yellow foam trough was under the resident's right lower extremity to elevate the right ankle off the mattress for pressure relief anytime the resident was in bed. Nursing staff signed the form dated 7/8/2015. During an observation on 09/09/2015 2:55 P.M. direct care staff O assisted the resident into bed using limited assistance to sit on the edge of the bed from a standing position. The resident required extensive assistance from staff O to get his/her legs into the bed. Staff O placed a pillow between the resident's legs, a foam device under his/her right hip/upper leg, and positioned the resident on his/her right side. The resident's right ankle laid directly against the pressure relieving mattress. Staff O asked the resident if the foam went on his/her right foot and the resident replied the foam went under his/her hip. During an observation on 9/9/2015 at 3:37 P.M. licensed nursing staff H removed the resident's dressing to his/her right lateral ankle. The dressing had a small amount of light brown drainage. The wound was dime sized with a solid yellow substance covering 80 percent of the wound bed. Following the wound treatment staff H placed a pillow between the resident's knees and did not place the foam device. The resident's right ankle laid directly against the mattress. At 4:05 P.M. staff H provided the resident extensive assistance to sit on his/her bedside from a lying position. The resident remained with pressure to his/her right lateral ankle for one hour and 10 minutes without a pressure relieving device in place. During an interview on 09/09/2015 at 9:55 A.M. the resident stated the wound to his/her right ankle developed in the facility, was told by staff the wound was small, and he/she did not worry about the wound. The resident said he/she had a foam device, which he/she wore under the right hip/upper leg to relieve pressure to his/her right foot. During an interview on 9/9/2015 at 4:02 P.M. the resident said staff did not inform him/her of any other area to place the foam device. During an interview on 09/09/2015 at 12:30 P.M. direct care staff R stated the resident did not have interventions in place to prevent skin breakdown. During an interview on 09/09/2015 at 4:19 P.M. direct care staff Q stated the resident had a wound on his/her heel. Staff Q said the aides had access to a CNA worksheet, which informed staff of any special devices the resident used. He/she stated the resident had a foam wedge under her right side, which staff tucked under his/her leg when he/she slept. Staff Q stated the resident did not refuse cares. During an interview on 09/10/2015 at 6:10 A.M. direct care night staff S stated staff really don't bother (him/her) during the night shift and waited until he/she woke up at 5:30 A.M. to assist with cares. Staff S stated he/she knew the resident had something to both of his/her feet, but the resident's feet were covered so staff S was unaware if the resident had pressure ulcers. Staff O stated he/she was unaware of interventions to prevent skin breakdown and said the resident did not have a foam device to his/her feet, he/she wore non-skid socks. During an interview on 09/10/2015 at 7:07 A.M. licensed nursing staff I said the resident slept at night and staff assisted the resident when he/she awoke between 5:30 A.M. and 6:00 A.M. Staff I stated the resident had a wound on his/her right outer ankle with a dressing. Staff I reported current interventions to prevent skin breakdown were to float his/her heels, however stated he/she did not float the resident's heels and he/she was not aware if the aides floated the resident's heels. During an interview on 09/10/2015 at 8:35 A.M. licensed nursing staff J stated the resident required some staff assistance with lifting his/her legs in and out of bed. Staff J reported the resident had a stage 1 pressure ulcer (red intact skin) and received wound treatment to his/her right ankle once daily and as needed. Staff J reported current interventions to promote wound healing and prevent further skin breakdown included; the use of a foam block, which he/she wore on his/her right foot at night and when in bed. Staff J confirmed he/she did not encourage the resident to wear the foam block today when in bed. Staff J said the resident did not refuse the foam block and he/she did not ensure proper positioning because the resident only slept for a couple of hours at a time. Staff J stated the resident needed the foam properly placed at all times when in bed and the resident needed a reminder to use the foam block. During an interview on 09/10/2015 at 8:53 A.M. therapy consultant HH stated physical therapy completed an initial evaluation on 6/25/2015, after being notified of a stage 2 pressure wound the resident had to his/her right lateral ankle. Staff HH stated the findings of the evaluation were the resident slept on his/her right side in a fetal position and physical therapy planned to find a device to keep pressure off the right ankle while still allowing the resident to sleep on his/her preferred side. Staff HH stated physical therapy trained available nursing staff and a CNA training book was at the nursing station with the expectation that all new CNAs would review the training book for direction. Staff HH stated he/she was unaware of whether the resident still wore the foam device and relied on nursing to notify therapy if the resident had difficulties with the foam device or was no longer wearing the device. During an interview on 09/10/2015 at 11:32 A.M. administrative nursing staff C stated he/she was unaware of the current status of the resident's wound. Staff C stated administrative nursing staff D spoke with him/her today and requested staff revise the care plan to direct staff to respect the resident's wishes if he/she did not want to wear the foam device. Staff C reported staff should place the foam device provided by therapy on the resident's right foot. Staff C confirmed the skin care plan directed staff the resident wore a foam device, but lacked specific placement of the foam device. Staff C reported staff should know that staff should position the foam on the right foot because the wound was located on the right ankle. During an interview on 09/10/2015 at 12:10 P.M. administrative nursing staff D stated the resident developed a stage 2 pressure wound to his/her right lateral ankle on 6/23/2015 and the wound worsened and had eschar. Staff D stated the wound nurse encouraged the resident to relieve pressure to his/her right ankle on 8/31/2015, with no documented refusals by the resident. Staff D reported the resident preferred to place the foam device under her/his left hip with a pillow between his/her legs and the resident was aware staff should place the foam device on the right foot/ankle. Staff D stated today was the first time he/she knew of the resident's refusal to wear the foam device when he/she attempted to place the foam device on the resident's right foot and the resident declined to wear. Staff D stated the resident revealed he/she did not want to wear the foam device on his/her ankle because he/she did not like the device placed there and his/her ankle did not bother him/her. At 3:10 P.M. staff D stated the staff did not stage the wound since identified as a stage 2 on 6/24/2015 and requested the administrative nursing staff C stage the wound. During an interview on 9/10/2015 at 3:15 P.M. administrative nursing staff C stated the wound worsened and progressed to an unstageable pressure ulcer (full thickness tissue loss where the base of the ulcer was covered by slough and/or eschar in the wound bed). During an interview on 09/10/2015 at 2:57 P.M. dietary consultant GG stated the resident's weight and BMI (Body Mass Index, a measurement of body fat) were normal for him/her, nutritional choices were good, and he/she had no signs of malnutrition (a diet with not enough nutrients). During an interview on 09/10/2015 at 2:24 P.M. physician II stated he/she expected staff to follow therapy recommendations and expected staff to notify him/her and therapy if the resident refused interventions. Physician II stated he/she expected the wound would heal with pressure relief. Review of the facility's undated Wound Assessment, Prevention, and Treatment policy documented a resident who entered the facility without pressure ulcers would not develop a pressure ulcer and staff would provide the necessary treatment and services to promote healing, and prevent the development of new wounds. The facility failed to promote healing of a wound, which developed in the facility and worsened in stage and size by failing to ensure the proper placement of a therapy developed foam device to relieve pressure to the resident's right lateral ankle.

The facility had a census of 67 residents. The sample included 18 residents. Based upon record review, observation and interviews the facility failed to develop and implement timely and effective interventions to promote the healing of a pressure ulcer for 1 (#146) of 2 residents sampled for pressure ulcers. The resident's pressure ulcer increased in size. Findings included: - Resident #146's Admission Minimum Data Set (MDS) 3.0 dated 4/18/14 included the resident scored 12 (moderately impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required extensive staff assistance for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene, frequently incontinent of bowel and bladder, did not walk in the room/corridor and required staff supervision with eating. The MDS include the resident had a functional impairment on 1 side of his/her lower extremity, received as needed pain medication, had almost constant pain which limited his/her day to day activities. The MDS identified the resident had a stage 1 or greater pressure ulcer, was at risk for the development of pressure ulcers, had (1) unstageable pressure ulcer due to a non-removable dressing/device present upon admission, (1) unstageable pressure ulcer due to coverage of slough (non-viable tissue) and/or eschar (dead tissue) present upon admission and (1) unstageable due to suspected deep tissue injury (SDTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or sheer) present upon admission. The MDS recorded the dimensions of the resident's unstageable pressure ulcer, or stage 3 or 4 pressure ulcer measured 6.0 centimeters (cm) by 1.3 cm by 0.3 cm. The MDS identified the most severe tissue type of the resident's pressure ulcer was eschar and the resident had a pressure relieving device for his/her bed/chair and was on a turning/repositioning program. The resident's Activity of Daily Living Care Area Assessment (CAA) dated 4/23/14 included the resident was admitted with a stage 2 pressure ulcer, was incontinent of bowel and bladder and was at risk for further skin breakdown. The resident's Pressure Ulcer CAA dated 4/23/14 included the resident admitted with a pressure ulcer on his/her coccyx, at times declined to change position and also lacked awareness or motivation to notify staff of the need to toilet. The CAA included the resident had pain and anxiety that increased the resident's risk for skin breakdown and the resident was incontinent of bowel and bladder. The resident's temporary care plan dated 4/11/14 included pressure/skin breakdown would be prevented/healed. Staff followed the facility's skin care protocol, and performed treatment as physician ordered to the resident's coccyx. Staff turned the resident every 2 hours and as needed and a licensed nurse performed a weekly skin assessment. The care plan included staff administered routine and/or as needed pain medication as ordered, monitored and documented the resident's pain level and effectiveness of the medication using the appropriate scale and staff provided pharmacological and non-pharmacological measures. The resident's care plan dated 4/29/14 included the resident had a pressure ulcer on his/her coccyx and was at high risk for further skin breakdown, the resident resisted changing positions and was frequently incontinent of bowel and bladder. Staff encouraged the resident to position from left to right when in bed and staff changed the resident's position at least every 2 hours. Staff continued to educate the resident regarding skin healing and promotion of healthy skin and advised the resident of consequence of not changing position and importance of following toileting schedule to maintain dry/clean skin for healing. The resident had a pressure reducing cushion in his/her recliner, a low loss air mattress on his/her bed, and received a liquid protein for wound healing. Staff turned the resident every two hours and as needed from left to right only. Staff positioned the resident at the following times to help prevent further skin breakdown: at 5 A.M. right side, at 10 A.M. left side, at 2 P.M. right side, at 4 P.M. left side, at 8 P.M. right side, at 11:00 P.M. left side, at 1 A.M. right side and at 3 A.M. left side. The care plan included pain interventions effective 4/30/14 that included the resident recently had surgery due to a [MEDICAL CONDITION], the resident had a pressure ulcer and needed extra measures to manage his/her pain. Staff performed a pain assessment 4 times a day using a scale from 0 to 10. Staff observed the resident for pain during exercises, while performing care and before treatments. Staff could administer the pain medication 30 minutes before an activity, exercise or treatment so the resident would less likely experience pain. Staff monitored the effectiveness of the pain medication. Staff notified the resident's physician if the resident received the PRN medication (as needed) "a lot" to see if the pain medication should be scheduled. Staff monitored the effectiveness of the pain medication and if the pain medication was not effective staff notified the resident's physician regarding other alternatives. A hospital's discharge summary dated 4/11/14 included the resident had a small Stage 2 pressure ulcer on his/her coccyx (no description or measurements were included) and staff should cleanse the pressure ulcer with saline, apply skin prep around the area, apply a very thin dressing and change the dressing every 3 days and as needed. The facility's Admission Nursing assessment dated [DATE] with a time of admission at 2:30 P.M. documented the resident had a pressure ulcer on his/her coccyx, staff cleansed the pressure ulcer with saline, applied skin prep around the area, then applied [MEDICATION NAME] (an extra thin dressing) and staff would change the dressing every 3 days and as needed. The admission nursing assessment did not include a description or measurements of the pressure ulcer on the resident's coccyx. A nurse's note timed 4/11/14 and timed 11:28 P.M. documented the resident arrived to facility at 2:30 P.M. from a local hospital. The resident had 12 staples on his/her left hip, multiple skin tears on his/her left arm, right hand, and right shin and staff changed the dressings. Staff administered as needed pain medication and the resident was incontinent of bowel/bladder. The nurse's note did not document the resident had a pressure ulcer on his/her coccyx. The resident's April 4/11/14 to 4/30/14 Treatment Administration Record included an entry dated 4/13/14 timed 2:00 P.M. to 6:00 P.M. that included staff changed the dressing on the resident's coccyx and the area was purple/red in color and no open areas observed. The TAR did not include any measurements of the wound. The resident's clinical record lacked documentation of the pressure ulcer on the resident's coccyx from 4/13/14 until 4/18/14. A nurse's note dated 4/18/14 timed 6:38 P.M. documented the red area present upon admission on the resident's coccyx was open, the area was red with a small white area and had no drainage or odor. Staff cleaned the area per physician order [REDACTED]. The resident's clinical record lacked any description of the pressure ulcer on the resident's coccyx from 4/18/14 until 4/22/14. An initial wound assessment dated [DATE] included the resident had an unstageable pressure ulcer on his/her coccyx that measured 6.0 cm by 1.3 cm by 0.3 cm. The top of the wound was black in color with no open areas noted. Right below the blackened area was an open area with some greenish discoloration noted to the edges, the wound bed was white/ pink in color and had a very strong foul odor. The facility contacted the resident's physician and obtained a physician's orders [REDACTED]. Staff observed blanchable (circulation returned after pressure relieved from the area) redness to the surrounding tissue and a measurement including the red area was 14.0 cm x 5.0 cm and the area was warm to the touch. A follow up wound assessment dated [DATE] included the resident's unstageable coccyx pressure ulcer measured 9.5 cm by 5.5 cm by 2.0 cm, had purulent drainage and foul odor. The edges of the pressure ulcer had 0.2 cm of undermining (is a wider area of wound that lies beneath the wound opening), and staff noted slough in the center of the wound bed and the resident continued on Keflex. New treatments included the facility applied negative air pressure via a vacuum (therapy to promote wound healing) to the resident's coccyx area at 125 mm Hg (millimeters of Mercury- pressure amount the vacuum would function at) and staff changed the [DEVICE] every Monday, Wednesday, Friday and as needed until healed. Interventions included staff repositioned/turned the resident every 2 hours. A follow up wound assessment dated [DATE] included the resident's unstageable coccyx pressure ulcer measured 8 cm by 4.5 cm by 1.5 cm, 1.2 cm of undermining from the 12 o'clock area counter clock wise to the 6 o'clock area and 2.0 cm of undermining to the 3 o'clock area. The wound bed was pink in color and slough was minimal at this time, approximately the size of a nickel at the 1 o'clock area. Staff still noted odor however was not as strong as previously and the wound had a moderate amount of drainage was noted. Interventions included staff repositioned/turned the resident every 2 hours. A follow up wound assessment dated [DATE] included the unstageable pressure ulcer on the resident's coccyx measured 5.8 cm by 2.8 cm by 1.5 cm. The wound bed was red and beefy in appearance and had a moderate amount of drainage. The wound had 1.2 cm of undermining from the 12 o'clock area counter clock wise to the 9 o'clock area, 0.8 cm of undermining at the 6 o'clock area, 1.8 cm of undermining at the 3 o'clock area and the resident voiced some tenderness during the dressing change. A follow up wound assessment dated [DATE] included the unstageable pressure ulcer on the resident's coccyx measured 5.8 cm by 3.0 cm by 1.0 cm. Undermining of 1.2 cm from the 12 o'clock area to the 3 o'clock area. 0.5 cm at the 6 o'clock area, the wound bed was pink in color and no foul odor noted at time of the dressing change. The resident denied any pain during the dressing change and stated "It is more bearable now when you change the dressing". Review of the resident's clinical record lacked evidence the facility assessed the resident's tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure, without adverse effects). Review of the resident's Medication Administration Record [REDACTED]. Further review revealed the staff did not always document the effectiveness of the medication using a pain scale. Review of the resident's clinical record lacked evidence the facility thoroughly assessed the resident's pain management program to determine if the resident would benefit from a scheduled pain medication to avoid the peak and valleys of pain that could interfere with the resident's willingness to reposition at times. On 5/20/14 at 2:45 P.M. the resident laid in bed on his/her left side. Observation revealed a low air loss mattress on his/her bed and a pressure relieving device in his/her wheelchair. On 5/21/14 at 7:30 A.M. the resident sat in his/her wheelchair in his/her room. During interview at that time, with the resident he/she stated he/she had an open area on his/her buttock. The resident stated staff did not reposition him/her because he/she independently got up and down. On 5/21/14 at 7:45 A.M. the resident sat in his/her wheelchair at dining room table. At 8:00 A.M., 8:15 A.M., and 8:35 A.M. the resident sat in his/her wheelchair and ate his/her breakfast meal. At 8:50 A.M., 8:55 A.M., 9:00 A.M. and 9:12 A.M. the resident sat in his/her wheelchair in his/her room. On 5/21/14 at 4:00 P.M. administrative nursing staff D and administrative nursing staff F performed the treatment on the resident's coccyx. Observation revealed the resident laid in bed on his/her left side, no devices between the resident's knees to prevent skin to skin contact and the resident's feet without heel protectors and not offloaded. Observation revealed the resident could not reposition by themselves. Further observation revealed the resident had a low air loss mattress on his/her bed and a [DEVICE] in place at 125 mm HG. The treatment lasted from 4:00 P.M. to 4:30 P.M. and during this time the resident complained of pain during the treatment. Observation revealed the resident required extensive assistance of the 2 staff with bed mobility. Administrative nursing staff D stated the resident's coccyx pressure ulcer was a Stage 3 . Administrative nursing staff D stated the resident sat in the wheelchair only for a short period of time. The resident was the last resident staff got up in the morning and the resident returned to bed after his/her meals unless he/she had therapy. On 5/22/14 the resident sat in his/her wheelchair at a dining room table at 9:00 A.M., 9:15 A.M., and 9:30 A.M. At 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., and at 11:15 A.M. the resident sat in his/her wheelchair in his/her room. On 5/21/14 at 3:30 P.M. administrative nursing staff F stated the resident admitted with a pressure ulcer on his/her coccyx. Administrative nursing staff F stated the resident's admission MDS was inaccurate and the resident did not have an unstageable pressure ulcer due to a non-removable dressing or an unstageable pressure ulcer due to slough/eschar. Administrative nursing staff F stated he/she assessed the resident's pressure ulcer on 4/16/14 but did not document his/her assessment/measurements in the resident's clinical record. Administrative nursing staff F stated he/she took the measurements home with him/her, went on vacation and documented his/her findings after he/she returned from vacation. Administrative nursing staff F presented a wound notification sheet that read staff measured the resident's wound on 4/16/14 and staff first observed the wound on 4/11/14. Further review of the wound notification sheet revealed on 4/16/14 the ulcer on the resident's coccyx measured (without redness) 4.5 cm by 1.0 cm without depth and including the redness (did not indicate where the redness was) the wound measured 5.0 cm by 2.0 cm and without depth. The notification sheet did not include the stage of the resident's pressure ulcer. On 5/22/14 at 10:37 A.M. direct care staff V stated the resident did not go to bed between breakfast and lunch. Direct care staff V stated the resident required extensive assistance of 2 with bed mobility, transfers and staff repositioned the resident at least every 2 hours. On 5/22/14 at 1:35 P.M. the surveyor asked administrative nursing staff F if the facility had evidence to support the facility measured and/or staged the resident's coccyx pressure ulcer prior to 4/16/14. At 2:00 P.M. administrative nursing staff presented a wound measuring ruler dated 4/14/14 that read the resident had an "unstageable blackened center open" and the area measured 5.0 cm by 3.5 cm and without depth. The documentation did not include the location of the area. Administrative nursing staff F stated he/she had lost the measurements; therefore the measurements were not in the resident's clinical record. On 5/22/14 at 1:30 P.M. licensed nurse J stated staff repositioned the resident every 2 hours. Administrative nursing staff F was present at that time and he/she relayed to licensed nurse J the resident was on a specific turning schedule and referred him/her to the portion of the resident's care plan that included the resident's repositioning/turning schedule. Licensed nurse J then stated the resident's repositioning /turning program as described in the care plan that staff positioned the resident (5 A.M. right side, at 10 A.M. left side, at 2 P.M. right side, at 4 P.M. left side, at 8 P.M. right side, at 11 P.M.. left side, at 1 A.M. right side and at 3 A.M. left side). The surveyor inquired of the resident's positioning/turning schedule during the gaps and licensed nurse J stated the resident sat in the wheelchair in his/her room, attended therapy or ate his/her meals. According to the International Pressure Ulcer Treatment Guidelines ...if sitting in a chair was necessary for individuals with pressure ulcers on the sacrum/coccyx, limit sitting to three times a day in periods of 60 minutes or less. The facility's undated wound policy and procedure included if a resident had a wound he/she would receive the necessary treatment and services to promote healing, prevent infection and prevent new wound from developing. On admission staff performed a skin assessment and documented the results on the resident admission assessment form. The facility failed to develop an effective individualized turning/repositioning program, failed to timely assess the resident's pressure ulcer upon admission and failed to prevent skin to skin contact for this cognitively impaired dependent resident admitted with a Stage 2 pressure ulcer which increased in size and stage.