Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring for 1 of 1 sampled resident (Resident #1) with an elopement. Failure to adequately monitor and supervise a resident with a known elopement risk placed the resident's health and safety at risk. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 10/22/24. The facility implemented corrective action and completed staff education on 10/22/24. Review of the facility policy titled Standards of Care and Practice occurred on 10/23/24. This policy, dated April 2018, stated, . Each of the following is part of the routine care provided by caregivers, unless otherwise directed. Complete rounds every 2-3 hours during the day and night. Review of Resident #1's medical record occurred on 10/23/24 and included the diagnoses of generalized anxiety disorder, unspecified dementia, and schizoaffective disorder. The care plan, edited 10/22/24, stated, . I may try [sic] elope and have a history of sleep walking. Wanderguard: Due to being disorientation [sic], there are concerns I may try to elope or even sleep walk. Please help redirect me and ensure my safety. A physician's order, dated 09/30/24, stated, Check wanderguard placement each shift . Resident #1's progress notes included the following: * 09/30/24 at 4:05 p.m. Resident noted to be anxious, confused, and wandering in common area. Resident stated she is looking for her brother. Resident's brother told SS [social services] that resident is risk for elopement and has hx [history] of UTI [urinary tract infection] with confusion and anxiety. Wanderguard brace applied on R) [right] wrist. * 10/22/24 at 1:00 a.m. Resident was anxious and confused this evening . sat one on one with resident in common area for awhile and resident calmed down, warm blanket given and walked resident back to her room and she laid down to go to sleep. * 10/22/24 at 5:50 a.m. Resident set off the door alarm this evening. Resident also then this morning followed the exit signs to the employee exit and got out without sounding the alarm. Writer found resident when writer was coming in from grabbing something from writer's car. Resident confused and was looking for a way home. During interviews on 10/23/24 an administrative nurse (#1) stated the facility investigation determined Resident #1 exited the building at 3:22 a.m. on 10/22/24 and staff returned the resident to the building at approximately 5:40 a.m. The staff member (#1) reported she expected night shift staff to complete rounds on residents every two hours at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. She confirmed staff failed to complete rounds as expected, and failed to discover the resident's elopement in a timely manner. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * All staff were educated on 10/22/24 as to the importance of monitoring residents at risk of elopement and those who currently utilize wanderguards. * The facility determined the wanderguard alarm system malfunctioned, and no alert sounded when Resident #1 exited the building. The facility contacted the alarm company immediately and reset the system to ensure proper functioning on 10/22/24. * Audits of the wanderguard system and staff rounding began 10/22/24.

Based on observation and record review, the facility failed to provide care and services to aid the healing or prevent the development of pressure ulcers for 1 of 2 sampled residents (Resident #32) with a history of pressure ulcers. Failure to apply barrier cream after toileting may result in the development of new pressure ulcers. Findings include: Review of Resident #32's medical record occurred on all days of survey. Diagnoses included a history of a pressure ulcer to the right buttocks. A nurse's note identified, . 10/10/23 Care conference note: No skin concerns. Pressure ulcer to his bottom is a scab, healing nicely. Skin protectant applied to buttocks after toileting. Current physician's orders included, Skin protectant to be applied after toileting Every Shift Day, Evening, Night. The resident's current care plan stated, . Problem Start Date: 10/12/2023 I have the potential of skin breakdown because I am incontinent and I have a diagnosis of Dementia. Approach Start Date: 10/12/2023 Protective ointment to my buttocks after toileting. Observation on 10/24/23 at 11:07 a.m. showed a certified nurse aide (CNA) (#1) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks. Observation on 10/24/23 at 4:34 p.m. showed a CNA (#2) assisted Resident #32 to the bathroom. Upon completion of toileting, the CNA failed to apply barrier cream to Resident #32's buttocks.

Based on record review, the facility failed to ensure a rationale and duration for the use of an as needed (PRN) psychotropic medication for 1 of 3 sampled residents (Resident #31) with a prn psychotropic. Failure to ensure a rationale and duration of prn medications places residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use. Findings include: Review of Resident #31's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, insomnia, and unspecified psychosis. Physician's orders included trazodone (an antidepressant) PRN at bedtime, initiated 09/16/22. Communication with the physician regarding renewals of the trazodone failed to identify a rationale for its continued use or indicate a duration (i.e., end date) for the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's status for 1 of 2 sampled residents (Resident #27) with a change in mobility. Failure to revise the care plan may limit staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility's undated policy titled Care Plans/Care Conferences Procedure stated, . Care plans are to be reviewed at least quarterly and whenever there is any significant change in the resident's condition . Review of Resident #27's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, right femur fracture, and right artificial hip joint. A quarterly Minimum Data Set (MDS), dated [DATE], identified limited assistance with transfers and a significant change MDS, dated [DATE], identified extensive assistance for transfers. The current care plan showed the following: * 05/10/21 Assist of 1 for transfers with FWW [front wheeled walker]. Use stand lift PRN [as needed] if lethargic. * 05/10/21 Can stand pivot transfer independent in room form [sic] bed, chair, and toilet from w/c [wheelchair]. Assist with transfer and use stand lift PRN, if lethargic or weak. An Interdisciplinary Care Conference Form, dated 6/1/22, stated, . Care Conference 5/31/2022 . ADL [activities of daily living] functioning: Assist of one for bed mobility, transfers, . Currently not walking at all. Nursing staff failed to revise Resident #27's care plan to reflect her need for increased assistance with transfers. During an interview on 07/07/22 at 1:48 p.m., an administrative staff member (#2) agreed the facility failed to update Resident #27's care plan to reflect current mobility issues.

Based on observation, record review, policy review and staff interview, the facility failed to provide adequate assistance for 1 of 5 sampled residents (Resident #27) observed during pivot transfers. Failure to lock wheelchair brakes and utilize a gait belt and front wheeled walker during transfer placed the resident at risk for falls, pain, and/or injury. Findings include: Review of the facility policy titled Transferring and Positioning Residents - Moving and Transferring occurred on 07/07/22. This policy, dated March 2011, stated, . Procedure: Assisting resident from bed to chair/wheelchair. 1. Place chair or wheelchair so it touches bed and faces foot of bed at a 45 degree angle. 2. Lock brakes on wheelchair and fold or lift up footrests. 3. Explain procedure to resident. 4. Assist resident to sit up and swing legs over side of bed. 5. Assist resident to step to floor, place legs close to chair, place hands on arms of chair, and sit in chair. A gait belt should be used to help support resident. Review of Resident #27's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, right femur fracture, and right artificial hip joint. A significant change Minimum Data Set (MDS), date 05/25/22, identified extensive assistance for transfers. The current care plan showed the following: * 05/10/21 Assist of 1 for transfers with FWW [front wheeled walker]. Use stand lift PRN [as needed] if lethargic. * 05/10/21 Can stand pivot transfer independent in room form [sic] bed, chair, and toilet from w/c [wheelchair]. Assist with transfer and use stand lift PRN, if lethargic or weak. * 03/02/22 I'm at risk for falling because I receive a daily scheduled antidepressant med. I have slipped and fallen in my bathroom and fractured my R) [right] hip. The facility's interventions of assist of 1 for transfers with FWW and can stand pivot transfer independent in room contradicted each other. See F657. A fall risk assessment completed 5/25/22 stated, . Gait/Balance . N/A-not able to perform function . Decreased muscular coordination . Balance Problem when walking . Requires use of assuasive devices (cane, w/c, walker, furniture) . Score=10 or more high risk for falls. Observation on 07/05/22 at 4:13 p.m. showed a certified nursing assistant (CNA) (#1) entered Resident #27's room to transfer the resident from the bed to a wheelchair. The CNA (#1) positioned the wheelchair near the foot of the bed at an angle and locked the left brake. The CNA stated she did not have a large enough gait belt and asked the resident if she needed assistance or if she could transfer on her own. The resident stated she would transfer by herself. The CNA assisted the resident to sit at the edge of the bed by holding onto the CNA's hands. The resident stood unsteadily and with much exertion, by holding onto the bed rail behind her on her right-hand side. The CNA (#1) provided no support on the resident's left-hand side until the resident was able to take three shuffling steps toward the wheelchair and grab the left arm rest. The resident then started to sit in the wheelchair as the right wheel started to swing backward. The CNA (#1) quickly stopped the resident, locked the right brake, and allowed the resident to sit down. The CNA (#1) failed to lock both wheelchair brakes, use a gait belt, or offer the front wheeled walker for support during the transfer. During an interview on 07/07/22 at 1:48 p.m., an administrative staff member (#2) stated she expected staff to lock the wheelchair brakes and provide transfer assistance as care planned.