Every finding on record at Rivergate Terrace

Deficient Practice Statement #1Based on observation, interview, and record review, the facility failed to use the proper signage for two residents with highly contagious bacterial infections (R24 and R26) of seven residents evaluated for infection control.Deficient Practice Statement #2Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R185) of two residents reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.Findings include:Deficient Practice #1 R26 On 03/24/2026 at 1:40 PM, upon entering R26's room, an observation of an Enhanced Barrier Precaution (EBP) sign was on the door (infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents with wounds or indwelling medical devices). R26 was observed in bed, wearing a hospital gown, and their eyes closed. Family Member N was observed sitting in a chair next to the resident's bed adjusting R26's blanket. Family Member N said staff bought R26's lunch in but R26 did not eat much. R26's spouse said that the Resident has been sick for a long time, stating that R26 had a bowel infection. Family Member N said they were not told of any special precautions. A review of R26's electronic medical record (EMR) revealed an admission to the facility on 1/02/2026 with the diagnosis of Cerebral Infarction, Type 2 Diabetes Mellitus, Dependence on Supplemental Oxygen, Cognitive Communication Deficit, and Candidiasis. A review of R26's Care Plan dated 1/8/2026 revealed the following: Enhanced Barrier Precautions. A review of R26's Care Plan revised on 3/24/2026 revealed the following: Contact Isolation: Wear gowns and mask when changing linens. Place soiled linens in bags marked biohazard. This Care Plan was revised after being brought to the attention of the Director of Nursing (DON). On 3/24/25 at 1:40PM, there were no linens in bags or trash marked biohazard. A review of R26's order dated 1/27/2026 revealed an order for EBP for the diagnosis of colonized Candida Auris (C. Auris), a type of yeast that can cause severe illness and spread easily among very sick individuals without causing symptoms or active infection; colonized individuals can spread the fungus and are at higher risk for developing invasive infections). A review of R26's laboratory results dated [DATE] revealed results of Clostridioides Difficile (C. diff, a highly contagious bacterium that causes diarrhea and inflammation of the inner lining of the large intestines, often infects people who've recently taken antibiotics. Antibiotics that kill other bacteria in your gut but don't kill C. diff allow it to quickly grow out of control). A review of R26's progress note dated 3/23/2026 at 4:01PM revealed the following: Resident remains on oral antibiotic vancomycin related to C. diff.Loose stool continues but is less frequent . The order in the EMR for precautions was Enhanced Barrier Precaution, dated 1/27/2026. On 03/24/2026 at 2:11 PM, an interview was conducted with Infection Preventionist Nurse O and Infection Preventionist P related to R26's positive C. diff and the type of isolation and signage necessary for that type of infection. Infection Preventionist Nurse O said, (R26) was on EBP for C Aruis. Infection Preventionist Nurse P added that R26 should be on Contact Isolation for C Diff. On 03/26/2026 at 10:20 AM, the DON was interviewed and asked about R26's positive for C. Diff on 3/12/2026 and the continuation of Enhanced Barrier Precautions. The DON answered, (R26) should be on Contact Isolation. R24 On 03/24/2026 at 2:56 PM, upon entering R24's room, an observation of an EBP sign was on the door. R24 was observed in bed watching television. R24 said that he had his knee replaced and his surgical incision opened and he developed an infection. R24 also had a left arm a Peripherally Inserted Central Catheter (PICC, line is a thin, flexible tube inserted into an arm vein and threaded to a large vein near the heart, used for long-term (weeks to months) IV therapies). On 03/25/2026 at 12:29 PM, upon entering R24's room, an observation of the door's signage was changed from EBP to Contact isolation (prevent the spread of infections transmitted by direct or indirect contact with a patient or their environment. Key measures include placing the resident in a private room, wearing gloves and a gown for all interactions, dedicated equipment use, and strict hand hygiene). Nurse D was asked about R24 change in isolation status. Nurse D said, The sign was changed this morning because (R24) has MRSA. (Methicillin-resistant Staphylococcus aureus is a highly infectious type of staph bacteria resistant to many common antibiotics, making it difficult to treat). On 03/25/2026 at 01:15 PM, Wound Care Nurse Q was observed changing R24's left knee dressing. The wound was observed to have a thin, watery, pale pink drainage. A review of R24's electronic medical record revealed an admission to the facility on 3/06/2026 with the diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA), Muscle Weakness, Diabetes Mellitus, Edema, Congestive Heart Disease, Total Knee replacement, and Bacteremia. A review of R24 care plan revealed the following: The resident is on IV (intravenous) medications r/t (related to) Methicillin-resistant Staphylococcus aureus Dated 3/09/2026. A review of R24's physician order dated 3/6/2026 revealed the following: Rifampin Oral Capsule 300 MG-Give 600 MG by mouth one time a day for MRSA for 29 days. On 03/25/2026 at 12:46 PM, the Director of Nursing (DON) was interviewed and queried about R24's admission diagnosis of MRSA, Enhanced Barrier Precaution on 3/24/2026, and R24's isolation status updated to Contact Isolation on 3/25/2026. The DON did not have a response. On 03/26/2026 at 10:20 AM, the DON was interviewed and stated that R24 was not on isolation precautions while in the hospital, therefore, did not need isolation at their facility. In addition, the DON said R24 did not have MRSA; instead, the DON insisted that R24 had a septic knee. The DON said that there was not a need for Contact Isolation. The DON was asked about R24's admitting diagnosis to their facility with MRSA. The DON repeated that R24 did not need Contact Isolation. The DON was asked if they were aware that the signage on R24's door was changed from EBP to Contact Isolation. The DON said yet again that R24 did not need Contact Isolation. 03/26/2026 10:45 AM, the Nursing Home Administrator (NHA) was interviewed and queried about R24 and R26 isolation precautions status. The NHA said there was no excuse for residents' isolation to be missed or mixed up. The Centers of Disease Control (CDC)dated 3/08/2024 noted the following: C. diff requires Contact Precautions, including a private room, dedicated medical equipment, and the use of gowns and gloves upon room entry. CDC recommends Contact Precautions (gloves and gowns) for MRSA-infected residents in nursing homes, particularly those with draining wounds, uncontrolled secretions, or high-dependency care needs. The CDC recommended on 6/27/2025, Contact Precautions for patients with MRSA in nursing homes, particularly those with draining wounds, which include placing residents in private rooms, using gowns and gloves for all interactions, dedicated equipment usage, and strict hand hygiene. These measures aim to prevent the spread of MRSA via direct contact or contaminated surfaces. A review of the facility's policy Infection Prevention and Control Program (IPCP) and Plan, revised on 6/2/2025 revealed the following: 3. The facility has established/implemented a surveillance plan, based on a facility assessment, for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks. 4. The program includes early detection, management of a potentially infectious, symptomatic resident that requires laboratory testing and/or the implementation of appropriate TBP/PPE (Transmission-Based Precautions (TBP) and Personal Protective Equipment (PPE). d. Antibiotic Stewardship activities, including prevalence of or development of MDRO (Multi-drug resistant organisms. The facility's policy for Contact Isolation was reviewed, with a revision date of 3/24/2026. This policy was revised after being brought to the attention of the DON on 2/24/2026. This policy revealed the following: Isolation should be least restrictive as possible for the resident under the circumstances, but is required as part of the facilities Infection Prevention and Control Plan. If an order has not been written, patients suspected of an isolatable condition are isolated on advice of the Infection Preventionist until an appropriate order by the physician is obtained. Discontinuation of Contact Precautions: Contact Precautions are discontinued when signs and symptoms of the infection have resolved or according to pathogen-specific recommendations. A review of CMS-20054 ([DATE]) Department of Health and Human Services Centers for Medicare & Medicaid Services Infection Prevention, Control & Immunizations revealed the following: Transmission-Based Precautions (TBP): Determine if appropriate transmission-based precautions are implemented, including but not limited to: For a resident on contact precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitor equipment) is used, or if not available, then reusable resident medical equipment is cleaned and disinfected according to manufacturers' instructions using an EPA-registered disinfectant for healthcare settings and effective against the identified organism (if known) prior to use on another resident. Objects and environmental surfaces that are touched frequently and in close proximity to the resident (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) are cleaned and disinfected with an EPA-registered disinfectant for healthcare settings and effective against the organism identified (if known) at least daily and when visibly soiled. Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g., outside of a resident's room, wing, or facility-wide). Before visiting a resident, who is on TBP or quarantine, the facility informs visitors of the potential risk of visiting and precautions necessary when visiting the resident. Before visiting a resident, who is on TBP or quarantine, the facility informs visitors of the potential risk of visiting and precautions necessary when visiting the resident. Deficient Practice #2 On 3/26/26 at 8:56 AM, the surveyor observed Licensed Practical Nurse (LPN) A administer medications via R185's peg tube. LPN A performed the medication pass without wearing a gown. On 3/26/26 at 8:57 AM, Licensed Practical Nurse (LPN) A was queried about the enhanced barrier sign posted on R185's door. LPN A said they should have worn a gown when administered medication to R185. LPN A acknowledged that a gown is required Personal Protective Equipment (PPE) that should be worn with residents on Enhanced Barrier Precautions (EBP). On 3/26/26 at 2:05 PM, interviewed the Director of Nursing (DON) and they said they expect staff to wear proper PPE when working with isolation residents. Record review revealed that R185 was initially admitted on [DATE] with pertinent diagnosis as follows: INTRACRANIAL HEMORRHAGE (bleeding on brain), DYSPHAGIA, GASTROSTOMY and TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION (stroke). Review of R185 Quarterly Minimum Data Set (MDS) dated [DATE] noted residents Brief Interview for Mental Status (BIMS) was a 15 out of 15 indicated resident was cognitively intact. Review of facility EBP Policy revised on 8/19/25 documented: EBP was indicated for residents with wounds and indwelling medical devices. The policy noted Wounds may include but are not limited to skin tears, pressure ulcers, diabetic foot ulcers, and unhealed surgical wounds. In addition, the policy noted Indwelling medical devices may include but are not limited to central lines, urinary catheters, feeding tubes, tracheostomy, and a peripheral intravenous line . when performing high contact care. According to the policy high contact care was defined as the following: hygiene, dressing, bathing, wound care, changing lines medical device care or use. The policy went on to note When performing the above care, the proper PPE is to be worn which includes a gown and gloves.

Based on observation, interview and record review, the facility failed to protect one resident's (R246) of one resident's personal medical information, resulting in the potential for the disclosure of the resident's confidential health information. Findings include. On 3/26/26 at 10:00 A.M., while surveyor was in the Therapy Department, LPN D was observed working on the medication cart parked outside of 104's room. At 10:15 A.M. upon leaving the Therapy Department the computer screen on top of the medication cart was observed opened. The computer screen was left opened by LPN D. R246's written orders, medications and diagnoses were visible to anyone walking past the medication cart. The surveyor observed the following walking by; one respiratory Therapist, one wound care nurse and a housekeeper continued to bypass the medication cart. In addition, three residents escorted by guests being transported to therapy were observed passing the medication cart.At 10:25 A.M., LPN D hurriedly returned to the medication cart just as the screen automatically closed. At this time LPN D was interviewed concerning leaving the computer screen open. LPN D stated I had to go to central supply and it's all the way around the hall. I thought I closed the screen, but I see I did not.On 3/26/26 at approximately 1:30 P.M., the Director of Nursing (DON) was interviewed and informed of the incident. The DON stated: I already know (LPN D) came and told on herself. (LPN D) knows better.Review of the admission Face sheet indicated R246 was admitted to the facility on [DATE] with diagnoses that included: bacteremia, methicillin susceptible staphylococcus aureus infection, anxiety disorder, depression, hypertensive heart disease with heart failure, myositis, chronic obstructive pulmonary disease, cognitive communication deficit, severe morbid obesity and hyperlipidemia.Review of the admission MDS dated [DATE], indicated R246 was cognitively impaired with impaired speech and ambulation.On 3/27/2026 at 10:40 A.M. review of the facility's policy for Disclosure of Protective Health Information (PHI) Release of Information, reviewed 2/13/26 documented, The facility maintains the confidentiality of the resident's medical, financial and or social information contained in the resident's records, regardless of the form of storage method of the records.

Based on observation, interview and record review, the facility failed to apply splinting devices and perform range of motion exercises as care planned for two (R1 and R2) of three residents reviewed for limited range of motion (ROM), resulting in the potential for increased joint contracture, loss of range of motion, and increased pain.Findings include:R1On 3/24/26 at 10:21 AM R1 was observed in bed wearing a gown with a right-hand splint on the bedside table. R1 was unable to answer questions when asked about care in the facility.On 3/26/26 at 9:38 AM R1 was observed in bed not wearing the right-hand splint.Review of R1's Electronic Health Record (EHR) revealed the most recent admission to facility on 8/25/2025 with diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADLs).Review of R1's orders dated 9/5/2025 revealed Splint/brace medical device: right resting hand splint apply to right hand for 4 hours. On in the AM_Off in the PM. Assess pain level circulation, and skin integrity.Review of R1's orders did not reveal a restorative ROM program.Review of R1's care plan revealed The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) muscle weakness and severe cognitive deficits: Secondary to recent CVA/rt hemi. (cerebral vascular accident/right hemiparesis) right digits 3-5 contractures Date initiated: 9/20/2022. Goal-The resident will maintain current level of function through the review date. Date initiated 5/1/2025. Interventions/Tasks Restorative Nursing Program: Passive, BLE, ROM, hip bend, ankle stretch, knee bend x10 reps x2 sets. Date initiated 11/19/2025. Restorative Nursing Program: Passive, BUE, ROM, in all planes and joints as tolerated. Date initiated 11/19/2025 revision on 3/26/2026. Restorative Nursing Program: Splint/brace putting on, removing, cleansing, AROM or PROM Right hand splint to manage contracture initiated 11/19/2025 revision on 3/26/2026.On 3/26/2026 at 9:32 AM, restorative documentation was requested for R1.On 3/26/2026 at 11:53 AM, the Nursing Home Administrator (NHA) revealed the facility did not have documentation of restorative services for R1. R2On 3/24/2026 at 11:50 AM, R2 was observed in bed wearing a gown with a left-hand flexion contracture and a palm protector was observed on the bedside table. R2 was unable to answer questions about care in the facility.On 3/25/2026 at 12:13 PM, R2 was observed in bed wearing a gown with a right-hand palm protector in place, left hand flexed not wearing a palm protector.On 3/25/2026 at 1:30 PM, Certified Nursing Assistant (CNA) K was interviewed while providing care to R2 and said she did not apply splints or perform ROM exercises and indicated the restorative aide performs that care. CNA K acknowledged R2 was not wearing a left-hand splint. Review of R2's Electronic Health Record (EHR) revealed the most recent admission to facility on 6/19/2021 with diagnosis that included contracture left hand, pain in left hand, and pain in right hand. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADLs).Review of R2's orders dated 3/19/2025 revealed Splint/brace/medical device: [NAME] guard. Apply to B (both) hands for 4-6 hours as tolerated. Assess pain level, circulation, and skin integrity, every day shift every Sat, Sun.Review of R2's orders did not reveal a restorative ROM program.Review of R2's care plan revealed Focus the resident has an ADL self-care performance deficit r/t dementia, impaired balance, BLE muscle weakness, OA, DM date initiated 7/1/2024. Goal resident will continue to participate as able with daily ADLs with assistance of staff. Revision 7/1/2026. Interventions/tasks Nursing rehab/restorative: splint/brace program Bilateral palm guard in AM 5x/wk. 4-6 hours as tolerated. To maintain strength and joint integrity as well as UE (upper extremity) ROM revision on 1/5/2026. Focus functional Goal Care Plan: resident has limited physical mobility r/t weakness revision on 5/10/2024. Goal the resident will remain free of complications related to immobility through the next review date 6/17/2026. Interventions/Tasks Nursing Rehab/restorative: Active ROM program BUE (both upper extremities) exercises 3 sets x 10 reps as tolerated. Right hand finger and thumb extensions 3 sets x10 reps. Revision on 3/19/2025. Nursing Rehab/restorative: Passive ROM Program BLE (both lower extremities) exercises 10 reps x 2sets 3x/wk. revision 12/3/2025.On 3/25/2026 at 2:12 PM, Restorative CNA L was interviewed and said she was responsible for providing restorative services for the blue hallways including R1 and R2. When asked if restorative services were provided for R1 and R2 restorative aide L said she was pulled to the floor to work so the residents didn't not get restorative services on 3/24/2026. Restorative aide L further said the residents did not receive restorative services when the facility is short staffed.Review of R2's restorative treatment log for March 2026 revealed R2's Bilateral palm guard was not applied 5x/wk. the week of March 8th, and March 16th. There were no refusals noted. R2's ROM program was not performed 3x/wk. for the weeks of March 8th, and March 16th. There were no refusals noted.On 3/26/2026 at 11:34 AM, the Director of Nursing was interviewed and said the Assistant Director of Nursing (ADON) oversaw the restorative nursing program and acknowledged there has been a lack of consistent oversite of the restorative program.On 3/26/2026 at 12:04 PM, ADON was interviewed regarding the restorative services for R1 and R2 and said both residents should be getting restorative services. The ADON did not provide documentation of restorative services for R1 upon request by survey exit.On 3/26/2026 at 12:26 PM, the DON was interviewed and said the expectation is for the residents to get the restorative services recommended, care planned and/or ordered. The DON further said that when the facility is short staffed for CNA's the restorative aides are pulled to the floor to work as CNAs.Review of the facility policy titled Restorative Nursing reviewed 9/19/2025 revealed in part.To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Measurable objectives and interventions must be documented in the care plan and in the medical record. The trained CNA will document provided techniques per the restorative care plan in the medical record. Communicate the restorative care plan and care directives to other members of the interdisciplinary team.

Based on observation, interview and record review, the facility failed to verify tube placement and assess for gastric residual prior to medication administration for one resident (R185) of two residents observed receiving medications via peg tube, resulting in the potential for aspiration, improper medication delivery, and respiratory compromise.Findings include:On 3/26/26 at 8:56 AM, the surveyor observed Licensed Practical Nurse (LPN) A crush and administer Potassium chloride 15ml, oxybutynin chloride 5mg, Coreg 12.5mg, metoclopramide 10mg, sulfasalazine 500mg, apixaban 5mg, folic acid 1mg and losartan potassium 25mg via peg tube to R185.Prior to administering the medication, LPN A did not check for tube placement and did not assess gastric residual.On 3/26/26 at 8:57APM, (LPN) A was interviewed and queried about PEG tube protocol. LPN A acknowledged they did not check placement or residual prior to administering medications.On 3/26/26 at 2:05 PM, the Director of Nursing (DON) was interviewed and said they expect staff to check for tube placement prior to administering medications.Record review revealed that R185 was initially admitted on [DATE] with pertinent diagnosis as follows: INTRACRANIAL HEMORRHAGE (bleeding on brain), DYSPHAGIA, GASTROSTOMY and TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION (stroke).Review of R185 Quarterly Minimum Data Set (MDS) dated [DATE] noted residents Brief Interview for Mental Status (BIMS) was a 15 out of 15 indicated resident was cognitively intact.Review of document titled, Medication Administration Through External Tube with revision date 11/15/24 noted that feeding tube placement should be confirmed per facility policy.

Based on observation, interview, and record review the facility failed to ensure personal belongings were within reach for one (R169) of one resident reviewed for accommodation of needs, resulting in feelings of discontentment within living environment. Findings include:On 3/24/2026 at 3:29 p.m. R169 was observed in the bedroom, sitting in a specialized wheelchair. R169 was alert, oriented to person, place, and situation and able to participate in an interview during the initial pool process. R169 expressed a concern that personal belongings were removed from the nightstand this morning by Unit Manager F. The belongings were placed in a box and placed in the closet. R169 stated, They said the State was in the building and had to be moved because it looked messy. It could have been straightened up but not moved. I don't understand. R169 was queried if able to reach belongings while in the closet. R169 said, My things were on the top shelf (closet) and definitely could not get to them there. On the floor, I may be able to bend over enough if I can get my chair close enough. On 3/24/26 at 3:35 p.m. R169's personal belongings that consisted of shampoo, deodorant, shaving cream, and body lotion, etc. were observed in a box and placed on the closet floor. R169 said the belongings were on the top of the closet and asked staff to place the box on the floor. R169 was asked if they were able to reach personal belongings while in the closet. R169 said they would not be able to reach them easily without staff assistance. When the belongings were on the nightstand, R169 could reach them easily and independently. On 3/24/26 at 3:44 p.m. Unit Manager F was interviewed and said R169's belongings were out in the open and not supposed to be on the nightstand and moved them to the closet. Unit Manager F said R169's belongings would not be easily accessible while in the closet and is out of the R169's reach. On 3/24/26 at 3:50 p.m. the Director of Nursing (DON) was interviewed. The DON said R169 had the right to have personal items on the nightstand and did not know why they were moved to the closet and out of reach. Review of the clinical record documented R169 was initially admitted into the facility on 2/19/25 with diagnoses that include dysphagia, adjustment disorder with anxiety, bipolar disorder, schizoaffective disorder, malignant neoplasm of female breast, and above the right leg amputation. According to the annual Minimum Data Set assessment dated [DATE], R169 was cognitively intact with a BIMS of 15 and required one-to-two-person assistance with most daily living activities. Review of the Activity of Daily Living care plan dated 3/6/25 documented, The resident has an ADL self-care performance deficit related to activity intolerance, impaired balance, and limited Mobility. Review of the facility's policy titled Resident Belongings and Home Like Environment review date of 5/15/25 documented in part the following: The facility will provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. Residents' possessions, regardless of their apparent value to others, must be treated with respect.

Based on observation, interview and record review, the facility failed to consistently assess and monitor a laceration (cut) for one resident (R903) out of three residents reviewed for quality of care. This deficient practice placed the resident at risk for an infection.Findings include:On 3/11/2026 at 10:15 AM, an observation revealed R903 had an intact laceration on the right side of the scalp with one staple noted to be protruding. R903 was interviewed but was unable to recall when or why the staple was placed.Record review of Progress Notes dated 2/11/26 at 1:46 AM, revealed R903 was transferred to the emergency department via emergency medical services following an unwitnessed fall resulting in a laceration to the right scalp. Further review of Progress Notes dated 2/11/26 at 8:45 AM, documented R903 returned to the facility after hospitalization.Record review of Physician/PA (Physician Assistant/NP (Nurse Practitioner) Notes dated 2/12/16 at 10:16 AM documented . Fall on 2/11, sent to ED (Emergency Department) given head trauma and laceration, staple intact, remove as directed, continue supportive care, monitor mentation .Record reviews of all of R903's care plans revealed no interventions regarding cleansing, monitoring, or assessing the laceration, and no documented order indicating a date or plan for the staple removal.Record review of Medication Administration Records (MAR) and Treatment Administration (TAR) for February and March 2026 revealed no physicians' orders for cleansing, monitoring, or assessing the laceration, and no documented order indicating a date or plan for the staple removal.Record review of Physician Orders from 2/11/26-3/10/26 documented no orders for the care of R903's laceration or staple removal.An interview was conducted on 3/11/26 at 10:30 AM with Assistant-Director of Nursing (ADON) A, who acknowledged that a physician order should have been obtained and documented to address the care, monitoring, and timely removal of the staple.An interview was conducted on 3/11/26 at 10:45 AM with Nursing Home Administrator (NHA), who reported nursing staff were responsible for ensuring appropriate orders and follow-up care were obtained and implemented.Record review of facility's policy Skin Staple, Suture, and Clip Removal revision date of 9/2021, revealed, The facility will provide skin staple, suture, and clip removal in accordance with professional standards of practice.

Based on interview and record review the facility failed to ensure upon admission and annually the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness and dementia needs in a timely manner for four residents (R22, R52, R175, and R190) of five reviewed for PASSARs, resulting in the potential for residents not to receive care and services appropriate to their mental health and dementia care needs. Findings include: R22- On 2/24/25 at 1:28 p.m. review of the clinical record documented R22 was initially admitted into the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, major depressive disorder, epilepsy, and adjustment disorder with anxiety. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R22 had severe cognitive impairment (BIMS= 3), and required supervision for most activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 4/13/24, documented the following were checked Yes: 1. Mental illness and dementia were checked for current diagnoses and received treatment. 2. The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 3. There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. 4. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. 5. The person has a diagnosis of an intellectual/developmental disability or a related condition including, but not limited to, epilepsy, autism, or cerebral palsy and this diagnosis manifested before the age of 22. Upon further record review, there was no PASARR 3878 (Exemption Criteria- for dementia) in the electronic medical record or paper chart. The 3878 was required due to R22 having diagnoses of dementia, without behavioral disturbance and epilepsy. R52- On 2/24/25 at 3:25 p.m. review of the clinical record documented R52 was initially admitted into the facility on [DATE] with the most recent readmission on 8/17/2024/2024 with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, epilepsy, and psychotic disorder with hallucinations/delusions. According to the quarterly MDS assessment dated [DATE], R52 had severe cognitive impairment (BIMS= 3), and required supervision and set-up for most activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 3/5/24, documented the following were checked Yes: 1. Mental illness and dementia were checked for current diagnoses and received treatment. 2. The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 3. There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. 4. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. 5. The person has a diagnosis of an intellectual/developmental disability or a related condition including, but not limited to, epilepsy, autism, or cerebral palsy and this diagnosis manifested before the age of 22. On 2/25/25 at1:43 p.m. Upon further record review, there was no PASARR 3878 (Exemption Criteria- for dementia) in the electronic medical record or paper chart. The 3878 was required due to R52 having diagnoses of dementia, without behavioral disturbance and epilepsy. On 2/26/25 at 10:20 a.m. Social Service Director (SSD) D was queried about the absence of the 3878 in the medical records and said the 3878 were not signed by the physician. The 3878s are generated in the OBRA system (community mental health data base). The social workers complete their part, then physician must go into the OBRA system to electronically complete and sign the 3878s to certify the dementia exemptions. The Medical Director, other physicians, nurse practitioners, and physician assistants have access to the OBRA system. They have been made aware of this process. SSD D was not able to provide an answer why the physicians have yet to complete and sign 3878s timely. R175- On 2/24/25 at 3:01 p.m. review of the clinical record documented R175 was initially admitted into the facility on [DATE] with a most recent readmission on 1/27/25 with diagnoses that included schizoaffective disorder, paranoid schizophrenia, post-traumatic stress disorder, and bipolar disorder. According to the quarterly MDS assessment dated [DATE], R175 was cognitively intact (BIMS=14), and was independent with activities of daily living. Review of the Preadmission Screening (Level I Screen, 3877) dated 9/23/23, documented the following were checked Yes: 1. Mental illness for current diagnoses and received treatment. 2. The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. 3. There is presenting evidence of mental illness or dementia, including significant disturbances in thought. On 2/25/25 at1:30 p.m. Upon further record review, there was no annual PASARR 3877 in the electronic medical record or paper chart. The 3877 was required due to R175 having mental illness diagnoses: schizoaffective disorder, paranoid schizophrenia, post-traumatic stress disorder, and bipolar disorder. The annual OBRA Level II Evaluation was also not in the electronic or paper medical records. The last OBRA Level II Evaluation was completed and dated on 10/23/23. On 2/26/25 at 10:25 a.m. SSDD was queried about the untimeliness of the annual 3877 and Level II Evaluation. SSD D stated, It's a little late. The resident has had multiple hospitalization s, and it was missed between the readmissions and discharges. On 2/26/25 at 3:13 p.m. the Administrator said the social workers will be keeping better track of the PASARRs, so they won't be missed. According to the facility's policy titled Preadmission Screening and Resident Review (PASARR), reviewed 9/26/24 documented in part the following: The facility will ensure that potential admissions are be screened for possible serious mental disorders or intellectual disabilities and related conditions . A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state- designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility . A record of the pre-screening should be retained in the resident's medical record . When a Level II PASARR screening is warranted, it must be obtained as well as determination letter prior to admission. The Level II PASARR cannot be conducted by the nursing facility . According to PASARR Mental Illness/Intellectual Developmental Disability/Related Conditions Identification Instructions for Completing Level I Screening (3/22): If any answer to items 1 - 6 in SECTION 3 is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record . When there are one or more Yes answers to items 1 - 6 under SECTION II, complete form DCH-3878, Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification only if the referring agency is seeking to establish exemption criteria for a dementia, state of coma, or hospital exempted discharge. 50634 R190- Record review of R190's Electronic Medical Record (EMR) noted R190 was admitted on [DATE]. R190's pertinent diagnoses included Dementia, Unspecified Behavior Disturbances, Falls, Bipolar Disorder, Cognitive Communication Deficit and Delirium. The Quarterly Assessment for Minimum Data Set from 1/15/25 for Brief Interview for Mental Status showed R190 was severely cognitively impaired with a score of (0/15). According to the clinical record review R190 had a PASSAR level I screening completed on 4/4/24. According to the PASSAR level I instructions by answering yes to any of the questions in 1-6, a PASSAR level II should have been completed. There was no PASSAR II in R190s EMR file. On 2/26/25 at 2:00 PM, Social Work Assistant T reported they were unable to locate R190s PASSAR II in the EMR.

Based on observation, interview, and record review the facility failed to provide adequate and appropriate care for indwelling urinary catheters (foley) for one (R211) of three residents reviewed for catheter care resulting in R211's indwelling catheter not being changed or securely anchored as prescribed and a urology consult not being scheduled in accordance with physician's orders. Findings include: During an observation on 2/24/25 at 10:48 AM, R211 was lying in bed on their left side. The resident was wearing a brief with the foley catheter's tubing pulled out through the top of the brief and over their right leg. There was no anchoring device in place to secure the catheter. R211 said they have had several urinary tract infections that are not resolving. R211 was upset and said, I called my family. They are coming up here and taking me to see my doctor. They give me pills here that aren't helping me and make my stomach sick. On 2/24/25 at 12:49 PM, Nurse Practitioner (NP) H and Registered Nurse E were at R211's bedside reviewing the resident's test results and medications with the resident and their family from the Electronic Health Record (EHR). R211's family identified the resident has had a urinary tract infection for over a month and the facility had not treated it properly, had not changed the resident's catheter, and had not made an appointment for a urologist yet. NP H said the resident was currently being treated with antibiotics for the UTI, could not determine if the resident's urinary catheter had been changed, and confirmed that no urologist appointment for the resident had been scheduled at this time. NP H ordered the resident to be sent to the emergency room per the request of the resident and their family. According to the Electronic Health Record (EHR), R211 had admitted to the facility on [DATE] with multiple diagnoses that included urinary retention, urinary tract infection, and had a foley catheter. On 1/6/25 the physician ordered; foley catheter, catheter care every shift, keep catheter bag below the level of the bladder, change catheter bag, and secure catheter with anchoring device to prevent tension on the catheter, and change device when clinically indicated. A care plan for indwelling catheter initiated on 1/6/25 included interventions that included cath care every shift and to report signs of UTI to the physician. On 2/11/25 at 2:04 PM a progress documented by Licensed Practical Nurse (LPN) J, indicated that R211 had gross hematuria (large amount of blood in the urine) and notified the physician. The physician's orders were as follows; irrigate the foley catheter every shift for 2 days with 250 ml (milliliter) of sterile water, obtain a urinalysis (urine sample), urology consult, and abdominal ultrasound, and change catheter bag. A review of a urinalysis report dated 2/11/25 R211's urine sample was collected and received by the lab on 2/11/25. On 2/13/25 the results were positive for a UTI. On 2/17/25 at 7:30 AM a progress note documented by LPN I indicated R211 complained of pain in the lower abdominal area and the resident had a urinary output of only 100 ml (milliliters) during the night shift. A bladder scan was performed (ultra sound to determine the amount of urine in the bladder) and revealed the resident had over 500 ml remaining in the bladder. The foley catheter was irrigated and 900 ml of urine flowed out in the collection bag. The Nurse Practitioner (NP) H was notified. The NP's orders were as follows; macrobid 100 mg (milligrams) every 12 hours for UTI for 7 days and change the collection bag. On 2/24/25 at 1:27 PM the NP H reviewed R211's EHR and said that both LPN J and LPN I should have changed the entire foley catheter, not just the collection bag. NP H said that her verbal order to LPN I was to change the foley, not just the collection bag. NP H said, I would never say to just change the collection bag. That makes no sense. If it (the foley) is getting obstructed and there is an infection I would order for the entire catheter and the collection bag to be changed. I believe that is a standing order for the facility. NP H confimed an order was given on 2/11/25 for the resident to see a urologist and there was no documentation to support the resident had an appointment for that at this time. On 2/25/25 at 11:35 AM during an interview and with the Assistant Director of Nursing, RN C R211's EHR was reviewed. RN C said the resident's foley catheter should have been changed, not just the collection bag after the resident had gross hematuria on 2/11/25 and also on 2/17/25 when obstruction of urine output was evident. RN C could not provide an explanation why the nurse only changed the collection bag and said, We will be conducting educational in-services on this. RN C confirmed that R211 had a positive UTI per the urinalysis collected on 2/11/25 with the results on 2/13/25 and was prescribed antibiotics on 2/17/25. RN C could not provide an explanation for the delay. On 2/25/25 at 12:40 PM both LPN J and LPN I were left voice messages to request an interview. No no return call had been made prior to the survey exit date of 2/26/25. On 2/25/25 at 12: 45 PM RN E was interviewed regarding R211's urine collection bag change on 2/11/25 and again on 2/17/25. RN E said, The resident's foley catheter wasn't changed because we did not want to introduce more bacteria into the bladder with re-inserting a catheter. The collection bag was changed. On 2/26/25 at 1:03 PM, the Director of Nursing (DON) reported that R211 had not readmitted to the facility at this time. The DON said they had reviewed R211's EHR and the nurses should have changed the resident's entire foley catheter system and not just the collection bag. The facility has purchased urinary catheters that are closed and the collection bag can not be disconnected from the catheter to keep a closed system. The facility follows [NAME] Guidelines and CDC guidelines for CAUTIs (catheter associated urinary tract infections) and the policy reflects that. According to the facility's Indwelling Urinary Catheter (Foley) Management policy last revised on 9/10/2024 in part reads: General Urinary Catheter Maintenance guidelines (CDC/HICPAC - rev 06.06.2019) 1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system a. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. b. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. 5. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Additional care practices related to catheterization 1. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter; and 2. Securing the catheter to facilitate flow of urine, preventing kinking of the tubing. Refer to [NAME] on Procedural Guidance on Routine Care Indwelling urinary catheter (Foley) care and management. According to the CDC.gov/infection/cauti/index.htm, HICPAC (Healthcare care Infection Control Practices Advisory Committee) for CAUTI 2009 page 13/61. E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.

Based on observation, interview, and record review the facility failed to administer oxygen as prescribed to one (R206) of six residents reviewed for oxygen therapy resulting in R206 sustaining a low pulse oximetry reading of 82% (device that measures the amount of oxygen in the blood, normal range is 90-100%). Findings include: On 2/24/25 at 9:39 AM, 11:01 AM, 1:40 PM, 2:50 PM, and 3:16 PM, R206 was observed lying in bed without oxygen in place via a nasal cannula (flexible tube that delivers oxygen through the nose) in place. The undated oxygen tubing and nasal cannula was observed on the floor underneath the resident's bed on all five observations (5.5 hours). The oxygen concentrator was at the resident's bedside, turned on, and set at 3 liters per minute with an undated empty humidification bottle. R206 was unable to be interviewed due to severe cognition impairment and non-verbal status. R206 was resting comfortably with normal respirations and did not appear to be in any distress on all five observations. On 2/24/25 at approximately 3:17 PM Certified Nursing Assistant (CNA) Y came into the room and was asked about the resident's oxygen. CNA Y said they would notifiy the nurse the resident needs new oxygen tubing, since this one is on the floor. According to R206's Electronic Health Record (EHR) the resident readmitted to the facility on [DATE] with multiple diagnoses that included encephalopathy (brain disease that alters brain function/structure), and pulmonary embolism (a blood clot in the lung.) The Minimum Data Set, dated dated dated [DATE], identified R206 to have severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of '00'. R206 was identified to be non-verbal and dependent on staff for all Activities of Daily Living, including bed mobility. The physician's orders included; oxygen 4 liters per minute continuously per nasal cannula (4l/nc), pulse oximetry monitored and documented every shift. The Medication Administration Record (MAR) revealed the last pulse oximetry reading was on 2/24/25 at 5:35 AM and read 99%. No further documentation was noted in the resident's EHR regarding respiratory status monitoring. On 2/24/25 at 3:18 PM, during an interview with R206's assigned nurse, Registered Nurse (RN) F she said, I'm in a class right now, talk to (name of nurse-RN E.) She is covering me. RN E was approached at the nurse's station with Nurse Practitioner (NP) H present and asked about R206's oxygen orders. Both RN E and NP H confirmed that R206 was prescribed continuous oxygen at 4 liters per minute via nasal cannula. RN E went to the resident's bedside and checked R206's pulse oximetry reading, and said It's only 82% right now, that is too low. At 3:31 PM, the Respiratory Therapist (RT) N confirmed that R206's pulse oximetry reading was still low at 84%. At 3:45 PM the resident's pulse oximeter remained at 84%. NP H was notified and prescribed a stat (immediate) respiratory treatment (Albuterol 0.5-2.5 via nebulizer). On 2/25/25 at 9:10 AM, NP H said a stat chest x-ray had been ordered on 2/24/25 for R206 and the results was normal. The resident had no changes in their chest x-ray and the pulse ox has been within normal range all night. The resident needs to have continuous oxygen at 4l/nc or they will de-sat (decrease blood oxygenation level). On 2/25/25 at approximately 12:00 PM, the Director of Nursing (DON) was interviewed about R206's oxygen levels and replied, Yes, that resident (R206) should have had the nasal cannula on at all times. I can't explain why that didn't happen. The DON acknowledged that the oxygen was not administered per the physician's orders for R206 and education had been given to the facility's nursing staff on 2/24/25 and continuing on 2/25/25. According to the facility's Oxygen Administration policy last revised on 10/11/2024 reads in part: Oxygen Administration 1. Oxygen order should be written for specific liter flow required by the resident. 2. Humidifiers are required on NC (nasal cannula) with liter flows 4 liters or greater. Infection Control 1. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed out. 2. Humidifier/ Aerosol bottles should be dated and replaced every 7 days regardless of H20 level. a. Prefilled humidifiers are recommended. If re-usable humidifier is used, refill using sterile water only. Water is to be emptied and replaced daily. Re-usable humidifiers should also be replaced every 7 days. 3. Store oxygen and respiratory supplies in bag labeled with resident's name when not in use.

Based on observation, interview, and record review the facility failed to implement interventions used to prevent the development or worsening of pressure injuries for two of five (R206 and R155) residents reviewed for pressure ulcers. Findings include: On 2/24/25 at 9:39 AM, 11:01 AM, 1:40 PM, 2:50 PM, and at 3:16 PM, R206 was observed lying on their back in bed on an alternating mattress with posey boots (soft foam booties to protect heels) in place. An elongated triangle- shaped positioning wedge was observed on the resident's right side of the bed, not in use for positioning. The resident was lying on their back without use of a positioning wedge during all five observations (5.5 hours). On 2/24/25 at approximately 3:17 PM Certified Nursing Assistant (CNA) Y came into the room and was queried about R206's repositioning schedule. CNA Y said the resident had been repositioned a couple of times throughout the day shift. CNA Y said, I checked on the residents every couple hours, throughout the day. CNA Y could not say what position the resident was in earlier. CNA Y said the resident scoots off the positioning wedge. According to R206's Electronic Health Record (EHR) the resident readmitted to the facility on [DATE] with multiple diagnoses that included encephalopathy (brain disease that alters brain function/structure), and a large unstageable sacral pressure ulcer (full loss of skin and soft tissue with the extent of the tissue damage unable to be confirmed because it is obscured by slough/eschar.) The Minimum Data Set, dated dated dated [DATE] indicated R206 had severe cognition impairment and was dependent on staff for all Activities of Daily Living, including bed mobility. Section M documented R206 had one unstageable pressure ulcer that was present upon admission. A wound care note dated 2/18/25 indicated R206's pressure ulcer was a stage 4 (full thickness tissue loss with exposed muscle, tendon, cartilage, or bone) measuring 9.4 cm (centimeters) in length, 8.3 cm in width, with a depth of 1.0 cm. The wound was described as decreasing in size, improved, and no signs or symptoms of infection. A care plan for pressure ulcers initiated on 1/7/2025 included the following interventions; avoid positioning the resident on sacrum. The resident needs positioning wedge for positioning, please reposition frequently, turn/reposition at least every two hours, more often as needed or requested. The physician's orders for the pressure ulcer treatment dated 2/18/25 was as follows: Sacrum: cleanse with dermal wound cleaner, pat dry, apply dankins-soaked stretch bandage roll on wound bed, cover w/ folded ABD (large thick pad to absorb discharge drainage) pad and cover site x2 every day. The Treatment Administration Record (TAR) for February revealed the pressure ulcer treatment administrations for 2/23/25 or 2/24/25 were blank. There was no documentation to support the pressure ulcer treatments were administered on those days. On 2/24/25 at 3:18 PM, during an interview with R206's assigned nurse Registered Nurse (RN) F, she said, I'm in a class right now, talk to (name of nurse-RN E). She is covering me. RN E was approached at the nurse's station with Nurse Practitioner (NP) H present and asked about R206's pressure ulcer. RN E reviewed R206's EHR and confirmed that R206's pressure ulcer treatments had not been signed out as administered since 2/22/25 (two days ago.) RN E proceeded to prepare the medicine and supplies to administer R206's pressure ulcer treatment. At 3:42 PM during an observation of R206's sacrum pressure ulcer treatment with RN E, the sacral dressing was saturated with clear to light yellow drainage and was dated 2/22/25. RN E said, This dressing is ordered to be changed everyday. The date is 3/22 on this dressing. On 2/26/25 at 10:18 AM during an interview with NP H she said R206's pressure ulcer was measured today and has improved and there was no signs of infection. On 2/26/25 at approximately 12:00 PM, during an interview with the Director of Nursing (DON), they stated, The facility has a policy that residents are repositioned every 2 hours and as needed. There is no explanation for why the resident's (R206) pressure ulcer dressing wasn't changed on 2/23. According to the facility's policy for Skin Integriy and Presure Ulcer Injury last revised on 7/9/2024 in part reads; The facility must ensure that -- i. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and ii. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 5. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care: a. reposition at least every 2-4 hours (per-National Pressure Injury Advisory Panel standards) as consistent with overall patient goal and medical condition; b. utilize positioning devices to keep bony prominences from direct contact; c. ensure proper body alignment when side-lying; d. heel protection/suspension if indicated; 34901 R155 On 2/24/25 at 10:48 AM, R155 was observed awake and lying in the bed. R155 said she had a wound on her leg and granted permission for the wound on her leg to be observed. R155 asked for the bed remote which was at the foot of the bed. Licensed Practical Nurse (LPN) R was requested to provide R155 with the bed remote and facilitated observation of R155's wound. When LPN R lightly touched R155's foot when the bed remote was retrieved, R155 winced. R155 stated, It would be nice if I had pillows under my feet. R155's feet were resting directly on the sheet-covered mattress. LPN R acknowledged that R155's feet should not be resting directly on the bed. During an observation on 2/25/25 at 8:59 AM, R155 was observed awake and in bed. There was a pillow under R155's knees. However, R155's heels had direct contact with the sheeted mattress. During an observation on 2/26/25 at 10:13 AM, R155 was observed awake and lying in bed. There was no pillow or other device to elevate R155's heels off the mattress. During an observation on 2/26/25 at 12:19 PM, R155 was observed awake and lying in bed. R155's heels were observed resting directly on the sheeted mattress. During an observation on 2/26/25 at 2:15 PM, R155 was observed awake, lying in bed, and participating in a one-on-one activity with an activity aide. R155 complained of pain on her left foot. During an observation and interview on 2/26/25 at 2:19 PM, Certified Nurse Aide (CNA) V said she has provided care for R155. CNA V stated, (R155) does not resist care. She's a sweetheart. R155's feet were observed resting directly on the sheeted mattress. During an interview on 2/26/25 at 2:20 PM, CNA W said she provided care for R155 today. CNA W said she did not prop up R155's feet and that the nurse would let the CNAs know if the resident's feet needed to be propped up. During an interview on 2/26/25 at 2:23 PM, Unit Manager, Licensed Practical Nurse (LPN) O said R155's feet should be elevated. If a pillow was used to elevate the resident's heels, it should have been placed at the ankle area. A review of the clinical record for R155 documented an admitted [DATE] with diagnoses that included osteoarthritis of knee and Parkinson's disease. An MDS dated [DATE], documented moderate cognitive impairment. Record review of R155's risk for break in skin integrity care plan revised 6/2/23, documented to Offload heels while in bed as tolerated. A document titled, Braden Scale for Predicting Pressure Sore Risk, dated 2/6/25, documented R155 was at a high risk for developing a pressure sore. On 2/26/25 at 2:35 PM, a review of CNA tasks with the Director of Nursing (DON) documented that R155's heels were to be offloaded while in bed as tolerated. The DON said R155's heels should be offloaded because they were worried that R155 would experience a breakdown on her heels.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for three (R85, R91 and R206) of 36 residents reviewed for care plans, resulting in the potential for unmet care needs and the lack of coordination of care. Findings include: R91 On 2/24/25 at 1:43 P.M. during and observation and interview R91 was observed in the room with his foley bag hanging from the garbage can positioned at the bedside. During the observation R91 commented he thought he was transferred to the facility for short-term rehabilitation and some services for the indwelling catheter. R91 indicated the indwelling catheter was new and staff had not educated him on the care required for the catheter. Review of the Admission Face Sheet revealed R91 was admitted to the facility on [DATE], with pertinent diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, Urinary tract infection, diabetes mellitus, abnormality of gait, morbid obesity, benign prostatic hyperplasia, and acute cystitis with hematuria. According to the Minimum Data Set (MDS) dated [DATE], R91 had a BIMs (Brief Interview for Mental Score) of 13/15 meaning the resident was cognitively intact and required supervision and set up assistance for personal hygiene and toileting. On 2/24/25 at 1:53 P.M. and 2/26/25 at 9:49 A.M., review of the care plan section of the clinical record revealed there was no comprehensive care plan addressing the indwelling catheter. On 2/26/25 at 3:05 P.M. during interview with the Director of Nursing (DON) concerning no care plan related to the indwelling catheter, the DON reported, a care plan should have been in the resident's clinical record. No reason was given why the comprehensive care plan did not address R91's indwelling catheter. On 2/26/25 at 3:30 P.M. review of the facility's Comprehensive Care plan and Revision policy dated 9/11/2004, documente: A comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment. 22349 R85 During observation and interview on 2/24/25 at 10:39 AM, R85 was observed seated in a wheelchair receiving a respiratory treatment with a nebulizer machine (medicine that is aerosolized and delivered directly into the lungs) connected to an oxygen concentrator (medical device that separates nitrogen from the air to deliver oxygen at 95%) that was at the bedside. The resident had oxygen tubing and nasal cannula resting on the bed, next to the wheelchair. R85 said, I had pneumonia and got antibiotics for it. I'm doing better but still feel short of breath sometimes and wear oxygen. Registered Nurse (RN) E was at the resident's bedside and said she had given the resident a prn (as needed) respiratory treatment for complaints of shortness of breath. RN E said R85's pulse oximetry (device that measures the amount of oxygen in the blood, normal range is 90-100%) was 96% and lung sounds were clear. RN E proceeded to remove the nebulizer treatment and place R85 on 2 l/nc (2 liters/per minute via nasal cannula.) According to the R85's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnosis that included asthma and chronic obstructive pulmonary disease. On 12/12/24, R85 had a physician's order to administer oxygen 2 l/nc to maintain pulse oximetry above 92%. A further review of the resident's EHR revealed there was no care plan for the resident's oxygen administration. On 2/25/25 at 10:16 AM Licensed Practical Nurse (LPN) X was asked to review R85's plan of care for oxygen delivery. LPN X said, Yes, the resident is prescribed oxygen and it is being administered. No there is no care plan for that. I will correct that immediately. LPN X acknowledged that R85 had oxygen prescribed on 12/12/24 and a care plan for oxygen administration should have been initiated at that time. R206 During an observation on 2/24/25 at 3:17 PM, R206 was observed with a large light brown liquid stain on the resident's gown in the abdominal area and sheet. R206 was unable to be interviewed due to severe cognition impairment with a non-verbal status. At this time Certified Nursing Assistant (CNA) Y came into the resident's room and said, The colostomy is leaking out. The nurse is going to change it now. Registered Nurse (RN) E came into the room and observed the resident's colostomy site. R206's ostomy bag was intact and half full of light brown liquid. The ostomy's barrier ring seal was compromised. Light brown liquid had leaked out of the lower portion of the barrier ring seal onto the resident's abdomen, gown, and linen. R206's skin was intact and without excoriation. RN E said, I'll need to replace this (the barrier ring seal and colostomy bag). This one is leaking around the seal. RN E was observed to change the ostomy's appliance and barrier ring without incident. According to R206's EHR the resident initially admitted on [DATE] with multiple diagnoses that included encephalopathy and necrotizing fasciitis. On 1/3/25 the resident readmitted to the facility with a diagnosis of 'colostomy.' The resident had orders for ostomy care every three days and as needed. There was no care plan for ostomy care as of 2/24/25. On 2/25/25 at approximately 3:00 PM, the Director of Nursing (DON) was interviewed and said, Yes, the resident should have had a care plan for the colostomy. The facility's policy for Comprehensive Care Plans and Revisions last reviewed on 9/11/2024 reads in part: Procedure 1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. 2. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include; a. Additional interventions on existing problems, b. Updating goal or problem statements c. Adding a short-term problem, goal, and interventions to address a time limited condition.

Based on observation, interview, and record review the facility failed to properly secure protected health information for one resident (R128) of 26 reviewed for privacy, resulting in the potential for unauthorized disclosure and access. Findings include: On 2/25/25 at 10:59 AM, a computer on a medication cart on the Blue unit was observed opened to R128's Electronic Medical Record, (EMR). Whle observing the computer screen for approximately five minutes there were several residents and other staff down the hallway with the open computer. The Unit Manager, (UM) K exited their office with the Assistant Director of Nursing, (ADON) C and stopped when they obsserved the surveyor looking at the resident's information on the computer screen. UM K walked over to the computer and closed the screen. UM K was queried about what was on the computer screen. UM K acknowledged R128's medical record was open and anyone walking by could see it. On 2/2/6/25 at 10:35 AM, the Director of Nursing, (DON) was interviewed and said leaving a computer open with a resident's information visible to the public is a violation of HIPPA. Record review documentated R128 was admitted to the facility on [DATE]. R128's pertinent diagnosis were Memory Deficit following Cerebral Infarction (stroke), Cognitive Communication Deficit, Generalized Anxiety, Major Depressive Disorder, Epilepsy and Repeated Falls. R128's Minimum Data Set, (MDS) Admission assessment performed on 12/9/24 for Brief Interview for Mental Status was cognitively intact at (13/15).

Based on observation, interview, and record review the facility failed to provide wheelchair footrests for two residents (R86 and R93) of 18 residents reviewed for accommodation of needs, resulting in the potential for injury to the lower extremities. Findings include: R93 On 2/24/25 at 9:30 A.M. during an observation and interview with Resident's family member Z (who was the resident's responsible party) complained the facility had given R93 a wheelchair without footrest. Family Member Z explained at home R93's primary caretaker and upon discharge no way could R93 be transported through the house without footrests on the wheelchair. On 2/25/at 2:30 P.M. R93 was observed being transported to therapy. R93's wheelchair did not have foot rests applied. R93's Family Member Z gestured while passing, pointing to R93's feet and stated, No footrests. Review of the clinical record for R93 revealed the resident was readmitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, psychotic disturbance, sepsis and anxiety. According to the Minimum Data Set, dated dated dated [DATE], (R93) was moderately impaired in cognition and was totally dependent on staff for ambulation and transfer. R93 was wheelchair dependent and unable to propel himself. R86 On 2/25/25 at 12:30 P.M. during a lunch observation, R86 was observed being taken to the dining room in a wheelchair. An unidentified nurse aide directed R86 to lift both feet as the aide periodically stopped and cued R86 to, keep your feet up. Upon entering the dining room, R86 was told to lift both feet again to assist the aide in moving across an inclined area of the floor. R86 who had a BIMs (Brief Interview for mental score) of 12 (moderately impaired) in cognition, was interviewed concerning the missing footrests. The resident indicated not knowing what happened to the footrests and could not say the last time the footrests were used on the wheelchair. According to the Minimum Data Set, dated dated dated [DATE], R86 was admitted to the facility on [DATE], with diagnoses of epilepsy, diabetes mellitus, muscle weakness and contracture's. R86 was wheelchair dependent. On 2/26/25 at 10:00 A.M. during an interview with anonymous staff member A concerning the availability of footrests for the residents' wheelchairs, stated, We don't have enough footrests for all the residents with wheelchairs. This has been a concern since June 2024. The resident's footrests should be in their rooms in a bag, but we just do not have enough. On 2/26/25 at 1:00 p.m. R86's closet was checked for footrests for the resident's wheelchair. No footrests were found in the closet or room for R86 or R93. On 2/26/25 at 1:20 p.m. the Director of Nursing was interviewed concerning the footrests for resident wheelchairs and indicated further investigation would be needed. On 2/26/25 at 1:25 p.m. in a follow up interview, the Administrator acknowledged the facility did not have a policy specifically addressing footrests. A policy titled Preventative Maintenance -Wheelchair was provided with a revised date of 1/11/23 and reviewed 1/29/25. This policy did not address the availability of footrests but rather the maintenance of wheelchairs.

This citation includes two DPS. Deficient Practice Statement #1: Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R206) of one resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms. Findings include: On 2/25/25 at 1:20 PM, Certified Nurse Aide (CNA) L was observed to enter R206's room with License Practical Nurse (LPN) J. Observations were made of staff gathering wet towels and performing hygiene on R206 without any PPE. CNA L exited the room with the soiled items. On 2/25/25 at 1:30 PM, LPN J was observed administering medications to R206 through their peg tube without the indicated PPE. LPN J was queried about the enhanced barrier sign posted on R206's door. LPN J said CNA L should have worn a gown when providing hygiene care. LPN J added they should have also worn a gown when administering medications through R206's peg tube. On 2/25/25 at 1:40 PM, CNA L was queried about the care they gave to R206. CNA L said they had changed R206's colostomy bag. CNA L reviewed the EBP sign on R206's door and said because they had performed personal hygiene, they should have put on a gown. On 2/25/25 at 1:45 PM, the Assistant Director of Nursing (ADON) C, was interviewed and acknowledged there was a concern with staff not wearing PPE with a resident on EBP. Review of facility EBP Policy revised on 3/21/24, documented: EBP was indicated for residents with wounds and indwelling medical devices. The policy noted Wounds may include but are not limited to skin tears, pressure ulcer, diabetic foot ulcers, and unhealed surgical wounds. In addition, the policy noted Indwelling medical devices may include but are not limited to central lines, urinary catheters, feeding tubes, tracheostomy, and a peripheral intravenous line . when performing high contact care. According to the policy high contact care was defined as the following: hygiene, dressing, bathing, wound care, changing lines medical device care or use. The policy went on to note When performing the above care, the proper PPE is to be worn which includes a gown and gloves. Deficiency statement #2: Based on observation, interview, and record review the facility failed to implement preventative measures for one resident (R221) of one reviewed for IV antibiotics resulting in the potential for the transmission of infectious organisms. Findings include: On 2/25/25 at 11:37 AM, License Practical Nurse, (LPN) R was observed administering R221's IV antibiotics. The connector for the IV- line was connected into the IV-line port. LPN R unscrewed the line from the port and connected the IV-line to R221. Record review showed R221 was admitted on [DATE]. R221's diagnosis included Intracranial Abscess, Disorder of the Brain, Cerebral Edema, Anxiety Disorder, Cognitive Communication Deficit, Disorientation Respiratory Disorder (Acute Respiratory Distress), and Pneumonia. Record review of R221's Admission Assessment on 2/11/25 for Minimum Data Set (MDS) for Brief Interview for Mental Status is cognitively intact at (12/15). On 2/25/25 at 3:20 PM, LPN R was interviewed after they reviewed the facility policy on administration of intermittent infusions. LPN R agreed the IV-line should not have been connected into the IV-line port. On 2/25/25 at 3:20 PM, the Assistant Director of Nursing, (ADON) was interviewed. After reviewing the policy ADON agreed that the IV-line should have been capped off with a sterile cap in between IV use. 2/25/25 at 3:20 PM, during an interview, Unit Manager (UM) M reported they recognized that by LPN R removing the connector piece from the IV-line port and connecting it to R221 could cause an infection due to poor sterile technique. On 2/26/25 at 10:35 AM, the Director of Nursing, (DON) was interviewed and said LPN R should have known to cap the IV-line with an IV cap after use. The DON said the nurse on the previous shift had capped the line improperly. The DON reported LPN R should have recognized that the line was improperly capped and should not have used it. The DON said they have plenty of caps in the supply room and the staff should have utilized them instead. Record review of facility policy Administration of an Intermittent Infusion, last reviewed on 6/1/21 noted, Nurses should maintain aseptic non touch techniques. In addition, the policy noted, When administration of medication is completed a new sterile end cap should be placed on the end of the administration set if it will be used again within 24 hours.

Based on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly in a resident's room (R85) resulting in the potential for fire hazards. This deficient practice had the potential to affect the two residents (R85 and R145) that resided in that room facility. Findings include: On 2/25/25 at 9:59 AM three oxygen tanks were observed in R85's room. R85 was not present in the room and R145 was laying in bed. One of the oxygen tanks was observed to be leaning against the resident's dresser and not inside a metal carrier. R145 was asked about the oxygen tank and said, It's not for me. It's for my roommate. I don't pay no attention to it. At this time Respiratory Therapist (RT) N entered R85's room and was interviewed about oxygen tank storage. RT N said, We do not store oxygen tanks like this! These tanks are flammable and must be stored in a metal carrier. This is a safety and fire hazard. RT N left the room to acquire a metal carrier to safely transport the oxygen tank to the oxygen tank storage area. On 2/26/25 at approximately 9:30 AM the Environmental Director (ED) U was asked about oxygen tank storage in the facility. ED U said they were made aware by staff that an oxygen tank had been unsafely stored in a resident's room yesterday. ED U said, The facility uses a metal carrier and cage to safely store oxygen tanks. They (oxygen tanks) are flammable and need to be stored in metal cage or carrier to prevent any safety issues. According to the facility's Oxygen Administration, Safety, Storage, and Maintenance policy last revised on 10/11/24 reads in part; To assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. Safety: 2. Do not fasten oxygen tanks to a resident's bed. Tanks must be either installed on a stable, wheeled dolly or on a portable oxygen stand . Storage: 1. Assure that oxygen tanks kept in storage rooms are either chained to the wall or installed on a stable, wheeled dolly or floor stand.

This citation pertains to intake MI00147768. Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R912) of three residents reviewed for elopement, resulting in a cognitively impaired resident walking through the front door and into the parking lot unsupervised with the potential for injury. Findings include; According to a Facility Reported Incident (FRI) on 10/20/24 at 1:34 PM, R912 walked out the front door of the facility behind a visitor. R912 was returned to the facility on 1:39 PM by another visitor that was entering the facility without injury. The Investigation report indicated that the receptionist was not adequately supervising the front door when they pressed the release button to open the front door for the visitor to leave and did not notice the resident (R912) following closely behind. On 10/29/24 at 8:15 AM upon entry into the main entrance of the facility, the first set of doors opened automatically into a foyer area where a receptionist was seated behind a desk. The second set of doors that led directly into a sitting area with offices, couches and a coffee machine had to be activated by the receptionist before opening. The third set of doors that led directly into the resident's living area of the facility were not locked and easily opened by either pushing or pulling on them. On 10/30/24 at approximately 11:00 AM R912 was observed walking independently at a fast pace in 'Happy Feet' activity (supervised activity of walking throughout the facility with staff). R912 had one-to-one supervision. R912 was alert to person only and could not be meaningfully interviewed. A review of R912's Electronic Health Record (EHR) indicated the resident had been residing in the facility since 4/15/204 with diagnoses that included Alzheimer's Disease. Elopement Risk Evaluation assessments conducted on 4/15/24 and again on 10/20/24 identified R912 to be at risk for elopement due to cognitive impairment, independent ambulation, and a history of exit-seeking behavior prior to admission at the facility. A care plan for elopement was initiated on 4/15/24 and included frequent monitoring and a picture of the resident had been placed in the 'elopement book' that was at the front desk. On 10/20/24 R912 was placed on one-to-one supervision, on 10/28/24 the resident was initiated in the Happy Feet Program to increase activity involvement. On 10/30/24 at 3:00 PM the Nursing Home Administrator (NHA) said the receptionist was bending down underneath her desk replacing coffee cups for the Koerig machine when the resident (R912) walked out behind the visitor. The NHA said, the entire staff has been educated on facility's elopement policy earlier in the year including that receptionist. That receptionist no longer is employed by the facility. At this time the NHA provided a Past-Non-Compliance packet and it was reviewed. On 10/30/24 at approximately 4:00 PM the Maintenance Director (MD) reviewed the exit door alarm checks and elopement drills that were conducted on 10/21/24 and 10/25/24. Review of the facility's policy titled Unsafe Wandering and Elopement Prevention revised on 9/25/24 documented in part the following: 1. Accurate and thorough assessment of the resident is fundamental in determining indicators for unsafe wandering and elopement. Not all residents exhibit unsafe wandering behaviors or verbalize the desire to leave facility unplanned. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. After review of the facility reported incident, the facility provided evidence of Past Non-Compliance on 10/20/24. The Past-Non-Compliance was reviewed and accepted by the reviewing surveyor. The facility was found to be in substantial compliance with F-tag 689 on 10/30/24 when the following interventions were noted to be put into place by the surveyor on 10/30//24. The following plan has been implemented for resident involved: Family, Physician, Executive Director, and the Director of Nursing was notified of this incident. Pain, Skin, and Trauma Informed Care assessments were completed and no concerns identified. Resident was placed on 1:1 monitoring after the incident. Initiated Happy Feet Program to increase activity involvement, safety, supervision, thus reducing wandering. Resident will attend Happy Feet Program starting 10/28/2024 during the day time till 5 pm, then resident will be placed on 1:1 supervision through out the remainder of the shift till morning. The Maintenance Director checked all exit doors for functionality 10/21/2024 by the Maintenance Director and no concerns identified. The Maintenance Director has changed the key pad entry code weekly to the sliding double doors at the front lobby On 10/22/2024. An elopement drill was conducted on 10/21/24 and 10/25/24 by the Maintenance Director. Social services completed wellness checks to ensure resident is safe. Any abnormal findings will be reported to the nurse/psych services for follow-up and no concerns identified. Resident was seen by psych on 10/22/2024. The resident council was held on 10/24/24, where elopement and Leave of Absence (LOA) policy was discussed by the Activities Director to the residents. How the facility identified others who may potentially be affected: An audit was conducted by the charge nurses on the units of current residents residing at the facility to assess any residents at risk for elopement. Any residents identified as at risk for elopement, the care plans were updated or revised as appropriate by the clinical IDT on 10/21/2024. Any new/re-admissions will also be assessed for elopement with care plans updated as needed on a weekly basis by the Director of Nursing. Areas identified requiring quality improvement: A QAPI meeting was held on 10/25/2024. The organization's elopement policy and procedures were reviewed and deemed appropriate by the committee. Actions to prevent occurrence/re-occurrence: Education initiated for all staff on the Elopement Policy and Procedures by the Staff Development Coordinator. Any staff who have not received education will do so prior to their start of the shift by 10/30/24. The Director of Nursing will discuss in daily morning clinical meetings for any new/re-admissions drat triggers elopement risks. Any residents identified, their care plans will be updated as needed by the IDT team. The residents who are at risk for elopement, will be discussed in behavior management meetings weekly with care plan reviews and modification made as needed by the IDT team. The exit door alarms will be checked weekly by the Maintenance Director. The elopement drills will be conducted quarterly by the Maintenance Director. QAPI meetings will be held monthly for 3 months to review results of audits and determine the need for additional interventions. The facility leadership (Executive Director/DON/Designee along with IDT Team) will continue to conduct leadership meetings and clinical meetings daily (Monday-Friday) to discuss any observed new or worsening wandering and/or exit-seeking behaviors of residents. The facility will assign MOD (managers on duty) during the weekends and will communicate any issue/concern identified to the Executive Director and the Director of Nursing. The DON/Designee will review the electronic medical record for 5 residents weekly for 4 weeks to identify new or worsening behaviors to include wandering and exit seeking behaviors. Any concerns will be addressed immediately. The audit will continue monthly for 3 months. The items which will be audited include new/worsening behaviors, notification of MD/NP and resident/resident representative of new/change of behavior, review care plan and to ensure interventions are implemented. The information will be documented on the Elopement Management Tool. The results of audits will be submitted to the QAPI Committee to assure sustained compliance.

This citation pertains to intake MI00146019. Based on observation, interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of three residents reviewed for injuries of unknow origin, resulting in a fracture of the right lower leg and hospitalization . Findings include: Review of an Admission Record revealed, R601 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included dementia, Alzheimer's disease late onset, age-related osteoporosis (thinning of bone), and fracture of upper and lower end of right fibula (8/8/24). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R601 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7 out of 15. In an observation and interview on 8/9/24 at 9:26 a.m., R601 laid in bed, had a soft cast on the right lower leg and wore heel boots. Certified Nursing Assistant (CNA) A reported R601 does not get out of bed often. Review of a progress note with a date of 7/29/24 at 5:14 p.m. revealed, Writer notified of discoloration to right ankle by CNA. Residents right foot slightly leaning to the right, pain to touch and with movement. Discoloration noted to inside right ankle measuring 1.2cm X0.9cm. 2 discolorations also noted to outer ankle measuring 3cmX1.8cm and 2X1.8cm. Resident unaware of how bruising occurred, only able to say, it hurts. (Physician G) in facility and aware of situation, new order for STAT (immediately) XRAY 2 views of right foot . Review of a Physician progress note with a date of 7/29/24 at 6:48 p.m. revealed, Right ankle swelling, ecchymosis and pain. Notified by nursing that patient was noted to have increasing right ankle swelling with bilateral malleolar bruising. Patient has advanced dementia. Limited history obtainable. As per nursing staff no known recent injury or falls. 2 view right ankle x-ray ordered this afternoon. Right ankle x-ray reviewed. Noted distal fibular and medial malleolus (lower leg) fractures . Review of a progress note with a date of 7/2/24 at 10:58 p.m. revealed, Received stat x-rays results for resident. Result states, 'There are distal fibular and medial malleolar fractures.' UM notified. (Physician G) notified. New order to transfer resident out to the hospital . Review of a Xray dated 7/29/24 at 9:36 p.m. revealed, R601 had a distal fibular and medial malleolar fractures. Review of a progress note with a date of 7/30/24 at 7:45 a.m. revealed, Resident returned from the hospital, non new orders obtained. Resident has a soft cast to right ankle; splinted and wrapped with ace wrap . Review of a progress note with a date of 7/31/24 at 3:16 p.m. revealed, Writer interviewed staff nurse and cna. Staff informed writer resident is dependent with all care. Resident don't get out of bed. Received bed bathes. Appetite is poor. 48 hour meeting held in room. Soft cast to right ankle area r/t (related to) distal fibular and medical malleolar fx (fracture) . Review of a care plans revealed focus, The resident has an ADL (Activities of Daily Living) self-care performance deficit . Interventions included, TRANSFER: mech lift with two assist for transfers initiated on 3/1/24. Review of hospital records for R601 with a date of 7/29/24 CT revealed Pt to ED via EMS from (facility name) for a right ankle fracture. Per EMS pt was trying to get up and fell . Pt has confirmed xray for right fibular and malleolar frxs . Review of an emergency department (ED) note for R601 with a date of 7/29/24 revealed, Writer spoke with (facility name) RN (Registered Nurse) for some clarifying questions. Per (facility name) staff patient is completely bedridden and immobile. (Facility name) staff stated the only way she is moved out of bed is by the staff at the facility full assistance and denies knowing of any recent falls. In an interview on 8/9/24 at 12:07 p.m., Licensed Practical Nurse (LPN) E reported R601 is usually in bed. LPN E then reported R601 uses a Hoyer (mechanical lift) lift for transfers. In an interview on 8/9/24 at 12:19 p.m. CNA C reported on 7/25/24 she transferred R601 from bed to shower chair then shower to bed with assistance from CNA D. CNA C reported that they did not use a mechanical lift when they transferred R601. CNA C stated, we two armed her and demonstrated a motion of using one arm under R601's arm. In an interview on 8/9/24 at 12:23 p.m. Physician G R601 had osteoporosis and it is easier to get fracture due to the diagnosis. In an interview on 8/9/24 at 12:30 p.m. the Director of Nursing (DON) reported R601 required two people to assist with transfers. In an interview on 8/9/24 at 12:43 p.m. Unit Manager F reported CNA C told her that she used a Hoyer lift to transfer R601 on the day of 7/25/24. In an interview on 8/9/24 at 12:47 p.m. CNA D reported they did not use a mechanical lift to transfer R601. CNA D reported they sat R601 on the side of the bed and then transferred R601 onto the shower chair. In an interview on 8/9/24 at 1:07 p.m., CNA C reported being unaware that R601 required a Hoyer lift for transfer and acknowledged she did not look at the care guide. Review of a Limited Lift Program policy revised 2/20/24 documented, . Associates will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated . Procedure . 5. The facility will provide education upon hire and annually to associates on the proper use of lifts in accordance with the manufacturer guidelines. The education will include the need to have two associates present during the transfer .

This citation pertains to Intake MI144703 Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R701) or two residents reviewed for elopements, resulting in a cognitively impaired resident with risk for elopementr exiting the facility unsupervised and the potential for injury. Findings include: Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 5/15/24, revealed that it was reported R701 exited the facility to the outside through the main entrance following an activities aide at approximately 2:56 p.m. Resident #701 was brought back into the facility at approximately 2:58 p.m. by the Director of Rehab with no injury. Review of the clinical record documented R701 was admitted into the facility on [DATE] with diagnoses that included dementia, history of falling, anxiety, and psychotic disorder with hallucinations. According to the admission Minimum Data Set assessment dated [DATE], R701 had severe cognitive impairment, required supervision with walking, and had wandering behavior that occurred 1-3 days. Review of the Elopement care plan date initiated 5/10/24 documented: Focus: At risk for elopement. (Resident's name) wonders without purpose through the building and is often seen exit seeking. Family reports this is a reoccurring behavior regarding to dementia. Goal: The Resident will not leave facility unattended through the next review date (8/7/24). Review of the following progress notes documented: 5/10/24- Psychosocial Note: Resident was added to facility elopement list r/t new admission, independent ambulation, and wandering. 5/12/24- Behavior Note: Resident noted exit seeking this pm shift. Noted door alarm sounding. Resident did NOT exit building and nurse on duty had in visual sight. Resident pushed door open in vestibule and maintained in between doors. Returned to green unit and placed with 1:1hospitality. On 6/5/24 at 9:45 a.m. upon entry into the main entrance of the facility, the first set of doors opened automatically. The second set of doors had to be activated by the receptionist from behind the receptionist desk for everyone to enter the facility. A keypad was located next to the doors. The third set of doors that lead unto the units (pass the receptionist desk and through the lobby) were not locked and can be easily pushed or pulled open. On 6/5/24 at 11:10 a.m. the Maintenance Director A was interviewed and said prior to the incident on 5/15/24, staff had access to open the doors using a pass code. Staff no longer have the pass code for the keypad to get out. On 6/5/24 at 12:01 p.m. the Nursing Home Administrator (NHA) submitted a Past Non-Compliance plan to be reviewed and considered. The NHA was interviewed and said employees were terminated following the investigation of the incident. The nurse aide providing one to one supervision was supposed to provide supervision for the resident and their whereabouts were unknown at the time of the incident; the receptionist received an in-service on Elopement due to a previous incident in April. All doors are to be monitored by everyone and the front door is the receptionist's responsibility; and the activity's aide the resident followed out of the building who went to their car while not on break. The resident and activity aide were walking side by side (outside) while the aide looked down the entire time at a cell phone. She never looked up. On 6/5/24 at 2:59 p.m. the video surveillance was reviewed with the NHA and Maintenance Director A present. The video revealed at 2:56 p.m. Activity's Aide B was observed exiting the main entrance of the facility walking towards the parking lot, looking down at a cell phone. R701 was walking slightly behind the aide then next to the aide. Activity's Aide B never looked up from the phone. R701 was then observed walking towards the west side of the building as the aide proceeded to the parking lot. On 6/5/24 at 3:17 p.m. an attempt to interview Activity's Aide B via telephone was made. A message was left on the voicemail for a return call. Activity's Aide B witness statement was reviewed and read, I made a mistake. I didn't realize it was a resident. Had I realized it was resident, I would have stopped them. On 6/5/24 at 3:41 p.m. an attempt to interview Receptionist C via telephone was made. A message as left on the voicemail for a return call. Receptionist C witness statement was reviewed and read in part, Unfortunately I was not able to see the resident come pass me while I was talking to 2 staff as they were signing out and 2 guest were signing in. I missed her . On 6/5/24 at 4:30 p.m. R701 was observed on the Village (dementia) Unit of the facility. R701 was unable to recall the incident. Review of the facility's policy titled Unsafe Wandering and Elopement Prevention dated 9/14/23 documented in part the following: 1. Accurate and thorough assessment of the resident is fundamental in determining indicators for unsafe wandering and elopement. Not all residents exhibit unsafe wandering behaviors or verbalize the desire to leave facility unplanned. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. After review of the facility reported incident, the facility provided evidence of Past Non-Compliance on 6/5/24. The Past-Non-Compliance was reviewed and accepted by the reviewing surveyor. The facility was found to be in substantial compliance with F-tag 689 on 5/17/24 when the following interventions were noted to be put into place by the surveyor on 6/5/24. The facility's past non-compliance indicated the following: Immediate Actions: Policy Review & Staff Education A. The Executive Director and DON reviewed the facility's policies related to elopement and supervision on 5/15/24. There was no revision necessary. The policy meets the standards of best practice. B. The Reception desk staff was provided with training by the Director of H.R. related to the policy with emphasis on redirecting wandering or exit seeking residents and to consult the nurse or social services for resident's care plan or notify the DON/Administrator/MDS Nurse/Social Worker of any new or worsening wandering or exit-seeking behaviors. The training also includes but is not limited to the Front desk staff's responsibility to provide adequate supervision to prevent elopement for a resident with a history of wandering, exit seeking, and assessed to be at risk for elopement. C. The same training was provided to all staff in the non-clinical departments. The training was done by the Department Heads, DON, Asst. Administrator, MDS, Social Worker or Designee. All Receptionists were educated by Human Resource Director. Actions to Prevent Occurrence/Recurrence A. An RCA (root cause analysis) using the Fishbone diagram was done on 5/20/24. It was identified that Resident #18546 N.D. had been at risk for elopement. The error that led to the incident was related to being a 'Human error' verses a 'system failure'. B. Based on the RCA, the following interventions are implemented to address the alleged deficiency: INTERVENTIONS BELOW . a. 1:1 supervision, room change, labs, Happy Feet-activities. b. The At Risk residents' elopement assessments were reviewed on 5/20/24 by the DON (Director of Nursing), Social Worker and Nurses. c. To ensure any subtle resident's changes are identified, the DON/Care Plan Nurse & the Social worker will review all elopement assessments monthly for the next three (3) months, and quarterly and PRN, thereafter. d. Care Plans will also be reviewed monthly for the next three (3) months. C. All doors will continue to be checked for proper function x5/week, to ensure all doors are secured, and functioning appropriately by the Nurse Manager or Maintenance Director. The Manager on Duty will complete door checks on weekends. Any concerns will be immediately addressed and reported to the Director of Nursing and Maintenance Director. No concerns have been identified at this time. D. The 2nd set of double doors behind the front collapsible doors is being evaluated to get door alarm & coded pad to provide a second layer of security at the front door. In addition, another set of cameras to be installed for the front door with a monitor facing the reception desk.

This citation pertains to intake MI00142660. Based on observation, interview, and record review, the facility failed to implement appropriate safety interventions for two residents (R579, R44) out of 10 residents reviewed for accidents, resulting in a fall with injury (traumatic cerebral hemorrhage and subsequent death) and oxygen equipment not stored safely. Findings include: It was reported to the State Agency that a resident fell out of bed, sustained a head injury, and not long after passed away. On 3/12/24 at 9:07 AM, the family member/guardian for Resident #579 (R579) said R579 passed away on 1/22/24 from a brain bleed that resulted from a fall at the facility. A copy of R579's death certificate was provided. On 3/12/24 at 9:21 AM, a document titled, Certification of Vital Record and Certificate of Death, dated 1/30/24 was reviewed and revealed in part the following: -Decedent's Name: (R579) -date of death : 1/22/24 -Enter the chain of events - diseases, injuries, or complications - that directly caused the death: Traumatic Cerebral Hemorrhage -Approximate interval between onset and death: Days -Manner of death: Accident -Date of injury: 1/11/24 -Describe how injury occurred: Patient fell from bed at (current facility) SNF (skilled nursing facility). A review of the clinical record for R579 documented an admitted [DATE] and discharge date of [DATE] to an acute care hospital. R579's diagnoses included Alzheimer's disease, fractures of the cervical vertebra and left femur, age-related osteoporosis without current pathological fracture, and history of falling. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A MDS assessment dated [DATE] documented extensive two+ persons physical assistance for bed mobility and transfers, always incontinent of bowel and bladder, and total dependence with two+ persons physical assistance for toileting. A review of R579's care plans documented in part the following: Focus: ADL (activity of daily living) self-care performance deficit. Revised 6/20/23. Interventions: Extensive assist with toileting with two-person assist. Two-person extensive assist with transfers, weight bearing as tolerated. Focus: Resident is at risk for falls. Revised 6/20/23. Interventions: Assist with ADLs as needed. Provide adaptive equipment or devices as needed. Concave mattress. Focus: The resident has bowel and bladder incontinence related to decreased mobility, dementia. Revised 6/20/23. Intervention: The resident uses incontinent briefs. Review of R579's clinical record further documented in part the following: 1. Nursing progress note of 1/11/24 at 11:20 PM - author LPN (Licensed Practical Nurse) Q: Resident had a fall from her bed and hit the back of her head. Resident was bleeding from the back of the head and her blood pressure at the time was 151/112 with a pulse of 60. Pupils were equal and reactive. Resident's bed was in a high position. Writer had called 911 to send resident out to the hospital. When paramedics arrived, paramedic stated, resident did not need stitches and was not unconscious and had no change in her mental status, so they were not going to take her out. 2. Nursing note of 1/12/24 at 12:22 AM - author LPN Q: Writer was called in resident's room. Observed resident lying on the floor with blood on the floor from the back of her head. Resident was assisted back in bed. Pupils were equal and reactive. All assessment complete. No other injuries at this time. Writer had called 911 to send resident out. Paramedics states, resident did not need any sutures and since she is not on any blood thinners and not unconscious, they would not take her out. Daughter notified. Third eye health on-call physician (APN [Advanced Practice Registered Nurse]) R notified. Physician did recommend sending resident out for imaging due to resident's baseline confusion unable to determine deviation. Paramedics denied transport. Neuro checks initiated per facility protocol. 3. Nurse Practitioner note of 1/12/24 at 1:56 AM - author APN R: Telehealth evaluation performed. Date of Service: 1/11/24 10:37 PM CT (11:37 PM Eastern Standard Time). Primary Chief Complaint: Fall With Head Injury. History Present Illness: [AGE] year-old female with past medical history of dementia, history of falls, weakness. The nurse is reporting a fall with injury. Patient hit head that was bleeding, which has resolved now with a bump to head. Patient is not on anticoagulants. States fell from her bed. Patient is in a regular bed. Patient's family was notified per nurse, medics were called, arrived and declined to take the patient stating - patient did not need sutures. and since only on aspirin therapy they did not need to take her to hospital and they left. Review of Systems: as per HPI (history of present illness), all other systems reviewed and are negative. Other pain assessment: Resident fell off her bed and hit the back of her head. It was bleeding initially but has stopped now. Resident has a bump on the back of her (head). Resident is not on any blood thinners just aspirin. Physical Exam: Exam findings per nurse and video observation. Physical Exam - Notes: alert with confusion per baseline, pupils equal and reactive, normal respiratory effort, resting in bed NAD (no acute distress), ROM (range of motion) intact, + (positive) abrasion to back of head. The patient's condition is stable. Fall precautions. The patient's condition is guarded. This is an acute new problem. Patient hit head, unwitnessed, with dementia so unable to determine deviation of orientation, is on asa (aspirin) therapy. Recommend head imaging, at this time medics have denied transport. Neuro checks monitor closely. Orders: Neuro checks per protocol. Fall precautions per protocol. Monitor closely for pain or injury. Log the primary (care physician) to follow up in the AM. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology Used: Audio and video with patient and nurse present. 4. Nursing note of 1/12/24 at 8:05 AM - author Registered Nurse (RN) S: Resident was up in geri-chair in the dayroom, eyes were open and staring at the ceiling to the right side. Resident was not responsive verbally, left arm were flaccid, pupils were reactive to light. Resident had a fall last night with a cut at the back of head per report by midnight nurse. She was not vomiting. Dr. (Primary Care Physician [PCP] CC) was paged. 5. Nursing note of 1/12/24 at 8:15 AM - author LPN T: Notified of residents change of condition, upon assessment writer noticed resident with twitch like activity. Eyes bulging and twitching, resident non-responsive to name, breathing rapidly spo2 98% RA (oxygen saturation on room air), arms crossed in front of patients chest and shaking without resolution. Twitching lasting approximately 2 minutes, resident became calm and staring at ceiling, arms flaccid and not at current baseline. Followed through with send to hospital. 6. Nursing note of 1/12/24 at 8:44 AM - author RN S: Resident is not having labored breathing, SPO2 was 98% at room air, remained with flaccid left arm and made a sound, not following direction, (PCP CC) updated of resident's changes and ordered to send to hospital. (R579's family member) informed of resident's condition and plan to send to hospital. ER nurse at (local hospital) informed and 911 initiated. They came and transported resident, unit manager aware. Review of the facility's file related to R579's fall on 1/11/24 documented in part the following: - Document titled, Interdisciplinary Post Fall Review, received during the current survey documented in part the following: Date of fall: 1/11/24 at 10:25 PM. Unwitnessed. If injury occurred, specify: laceration to back of head. Description of Fall: Resident in bed and restless, aide in bathroom. Resident fell out of bed, hitting head, 911 refused transport. - LPN Q statement dated 1/12/24, Yesterday on Thursday 1/11/24, CNA (Certified Nurse Aide) came and got me saying resident had a fall. CNA states he was in the bathroom preparing to change resident's bed and he heard a loud collision and went out to see resident on the floor. The bed was a little high since resident was being changed. I was the only nurse on the unit at that particular time . During an interview on 3/13/24 at 1:07 PM, LPN Q said when she learned that R579 fell out of the bed, hit her head, and was bleeding, her first instinct was to call 911. When the emergency medical technicians (EMTs) arrived, they told LPN Q that R579 looked fine, the bleeding had stopped, and they were not going to transport the resident to the hospital. LPN Q said she called and spoke with the medical provider (APN R) after the EMTs left. Initially APN R wanted to sent R579 out to the hospital but once informed that the EMTs came and refused to transport the resident, APN R provided instruction to monitor R579 and notify the medical provider of any changes. LPN Q said CNA U reported that R579 had fallen out of the bed. LPN Q said R579 was known to move around in the bed and to try and slip out. R579 had a concave mattress. CNA U was in R579's room to change her brief and had R579's bed in a high position because he was trying to change her. When CNA U left R579's bedside to go into the bathroom, R579 fell out of the bed and hit her head. LPN Q said CNA U heard a thud, saw the resident, and came and got me. LPN Q said CNA U was going to change R579 by himself. LPN Q said CNA U no longer works in the facility. During an interview and record review on 3/13/24 at 1:26 PM, the Human Resource Director (HRD) said that CNA U no longer works here. A resident was left unattended and fell out of the bed. CNA U allegedly went into the bathroom to get a towel. A facility document titled, Termination Form, dated 1/15/24, documented in part the following: Associate: (CNA U). Current incident description: Associate left a resident's bedside, with bed elevated. Resident had a fall resulting in head injury. Reason for Termination: Failure to ensure resident safety. Consequence to Company: State citation, injury to patient. During an interview on 3/14/24 at 1:35 PM, the Assistant Director of Nursing (ADON) stated R579's bed was in a high position and CNA U should not have left her unattended. He should have had all his supplies together and if he was going to leave the resident, the bed should not have been in the high position. The bed should have been left in the lowest position to prevent fall with injury. A facility policy titled, Activities of Daily Living (ADLs), revised 2/12/24, documented in part: Utilize appropriate safety measure and any necessary equipment to maintain resident safety. On 3/14/24 at 6:00 PM during the exit conference, the Nursing Home Administration and ADON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. 39465 R244 On 3/12/2024 at approximately 9:30 a.m. an oxygen tank was observed on the floor of R44's room not stored in an oxygen carrier. On 3/14/2024 at 1:33 p.m. an oxygen tank was observed still on the floor of R44's room not stored in an oxygen carrier. R44 was lying in bed alert and was able to be interviewed. During an interview R44 stated, The oxygen tank been sitting in the corner ever since I went out on an appointment, I believe Saturday (March 9th, 2024). I used it to go out with them (staff). There is some (oxygen) left in there when I returned. On 3/14/2024 at 1:40 p.m., Certified Nursing Assistant (CENA) X was interviewed and asked what the proper storing of oxygen tanks was. CENA X said oxygen tanks should not be on the floor, it should be in a wheel cart carrier. On 3/14/2024 at 1:43 p.m., Licensed Practical Nurse (LPN) Y was interviewed and asked what the proper storing of oxygen tanks was. LPN Y said oxygen tanks are transferred by a nurse or CENA on a crate and it should not be on the actual floor. LPN Y stated, the oxygen tanks should not be in the resident's room . On 3/14/2024 at 4:09 p.m., the Assistant Director of Nursing (ADON) was interviewed about the oxygen tank being on the floor in the resident's room. The ADON stated, No. If it was in a holder and know the resident was going to use it, that's okay, but not stored in the resident's room. It can cause combustion. According to the facility's electronic medical record, R44 was admitted into the facility 1/5/2024 with Diagnoses of Pneumonia, bipolar disorder, acute respiratory infection, and dependence on supplemental oxygen. R44's quarterly Minimum Data Set (MDS) with a reference date of 12/16/2023 indicated R44 was cognitive intact with a BIMS (brief interview for mental status) score of 0/15. According to the facility's policy titled Oxygen Administration (Safety, Storage, Maintenance) revised date 2/27/2024 documented, To ensure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. -Safety: .Portable liquid carriers should be stored up off the floor when not in use, preferably hung on a hook or a holder. -Storage: .Assure that oxygen tanks kept in storage room are either chained to the wall or installed on a stable, wheeled [NAME] or floor stand.

This citation pertains to Intake MI00142807. Based on interview and record review, the facility failed to adequately provide infection control surveillance for all residents resulting in missed opportunities to decrease the potential risk of the spread of infections. Findings Include: Record review of the facility's Infection Control Book revealed no completed documentation of infection surveillance for January 2024 and February 2024. There was no evidence that data was compiled and monitored in a timely manner during those months to provide an overview of the facility's infection control practices. During an interview on 3/14/22 at 12:22 PM with Assistant Director of Nursing (ADON), it was reported that the facility did not have anyone consistently monitoring infection control program in January of 2024 until the end of February 2024. It was reported that the facility could not provide documentation or evidence that a complete line listing (names of residents with probable or diagnosed infections); or mapping (a color-coded map of facility to show possible clusters of infections of residents) during those months. Record review of policy Surveillance of infections revised 5/19/23, documented the following: 'The facility will use an established routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., HAI (house acquired infections) and community-acquired), infection risks, communicable disease outbreaks, and to maintain or improve resident health status. As part of the system of surveillance, identification and prevention, the facility should determine how it will track the extent to which associates are following the facility's Infection Prevention Control Plan (IPCP) policies and procedures, and facilities would want to particularly address any areas that are related to a corrective action. The facility's surveillance system should use nationally recognized surveillance criteria such as but not limited to CDC's (Centers for Disease Contril and Prevention) National Healthcare Safety Network (NHSN) Long Term Care Criteria to define infections or updated McGreer's criteria. Furthermore, the facility knows when and to whom to report communicable diseases, healthcare-associated infections (as appropriate), and potential outbreaks (e.g., list of communicable diseases which are reportable to local/state public health authorities). The facility will document follow-up activity in response to important surveillance findings (e.g., outbreaks).

This citation pertains to intake MI 193. Based on observation, interview, and record review, the facility failed to: 1.) identify, assess, monitor, and implement timely and consistent wound care treatments for 2 of 6 residents (R#45, #47), and 2.) ensure weekly skin assessments were consistently completed on 4 of 6 residents (R#s 45, 46, 47, 48) reviewed for quality of care, resulting in delay in the identification and worsening of a wound, dried dressing adhering to resident's skin, resident pain and anxiety, the potential for delay in wound healing and development of wound infection, and the potential for other care needs to go undetected. Findings include: Resident 45- During interviews on 10/13/2021 at 2:30 PM, 10/14/2021 at 9:46 AM, and 10/18/2021 at 2:55 PM, Resident #45 (R45) was observed in his room awake, dressed, and sitting in his wheelchair. R45 stated, About a month ago (9/29/2021), I was having pain in my ankle. I felt a tingling in my ankle and knew something was going on. I went to the nurse's station and asked for help. R45 indicated that when the nurse unwrapped his ankle in his room, she screamed. R45 stated, I was relieved when the dressing was changed. They used a bottle of liquid to soften the bandage before removing it. R45 said his pain level during the procedure to remove the old bandage was 4 out of 10. R45 stated prior to 9/29/2021, They never change the dressing here. He indicated the bandage that was removed was from his last hospitalization . R45 was discharged from the hospital on 8/19/2021. During an interview on 10/18/2021 at 1:00 PM, LPN D stated, (R45) came to the nursing station and asked if someone could look at his wound. I told (R45) to go back to his room. When LPN D went into R45's room, He had on a sock and his foot was propped up on the bed. The sock looked soiled with dry blood. I pulled his sock back and it appeared as if his skin had adhered to the sock. The sock was soggy. It looked like his wound was open. Nowhere (in his medical record) did it show he had an open wound. No other nurse was aware he had an open wound. I kinda screamed because I thought I saw something moving. I calmed down and told the resident not to move. LPN D asked another staff member to call the infection control nurse (Registered Nurse [RN] E) who came and cleaned out the wound. During an interview on 10/18/2021 at 1:56 PM, Infection Preventionist, RN E stated, The nurse called me down and said, 'I think I see something in this wound.' When RN E arrived to R45's room she observed he had on a sock with dried blood on it. RN E stated the dressing on R45's ankle was outdated and R45 said, 'My leg hurts.' RN E stated, I cut the sock off because the bandage and sock were stuck to (R45's) leg. The sock was stuck to the bandage and the bandage was stuck to (R45's) leg. I used peroxide to loosen it, so I didn't pull the skin away. I let the peroxide sit (on the bandage) and cut the bandage off. RN E denied seeing anything move on the wound or bandage. RN E stated, (R45) has a history of vascular wound and an appliance put in that leg, so at the very least we should have been monitoring it (his ankle) and that wasn't being done. A review of the clinical record for R45 documented an initial admitted [DATE] and readmitted [DATE]. R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented intact cognition and no venous/arterial ulcers were present. The MDS dated [DATE] documented the presence of one venous/arterial ulcer. A review of R45's progress notes, wound observations, hospital discharge documents, and physician orders documented in part the following: 1. Readmission skin/wound note dated 8/20/2021: Resident noted to have a large bump on his left buttock. Scrotum noted to be enlarged. Red area to left upper eyebrow area. Multiple scattered area of discolorations noted to chest, back, arms, face and head. Multiple scattered area of discoloration noted to abdomen, bilateral arms. Large scab noted to right outer ankle. 2. Progress note of 9/29/2021 at 7:24 AM (written by LPN (Licensed Practical Nurse D)): Resident has c/o (complained of) right ankle pain. Writer observed open wound to right ankle. Writer notified (Nurse Practitioner N). She states that she will be in to assess resident. No new orders. Treatment notified as well. Wound cleansed and dry dressing applied. 3. Wound Observation Tool dated 10/1/2021 documented R45 admitted to the facility on [DATE] with a right outer ankle wound. The wound was presently described as a full thickness (past the first two layers of skin and can go to the bone) venous ulcer. The size documented was length 5.5 cm (centimeters), width 2.0 cm, and depth 0.5 cm. Additional comments: Resident stated this is a recurring that occurred s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Hospital discharge document from 7/19/2021 hospitalization documented past ankle surgical procedure on 8/4/2020 to remove a plate. 5. Physician Orders: -Ace wrap to bilateral lower extremity every day in AM and off at HS (hour of sleep) ordered 8/27/2021 (hospital discharge orders). -Wound care to right ankle for vascular wound. Clean with normal saline. Apply [MEDICATION(S)] and dry dressing daily. Every day shift. Ordered 9/29/2021. Discontinued 10/1/2021. -Wound care to right ankle for vascular wound. Clean with normal saline. Apply [MEDICATION(S)] and dry dressing daily. Every two days for wound treatment. Ordered 10/2/2021. 6. Weekly Skin Integrity Data Collection (i.e. weekly skin assessment) completed on R45 was dated 10/17/2021 and revealed a right outer ankle open area. Interviews and review of R45's clinical record were conducted with the Director of Nursing (DON) on 10/14/2021 at 4:20 PM and on 10/19/2021 at 4:14 PM. In reference to the large scab noted to right outer ankle in the readmission note dated 8/20/2021, the DON, stated, You would want to protect the scabbed wound with a dressing, but they did not apply a dressing. The DON said if weekly skin assessments had been completed on R45, nursing would have documented the progression (condition) of the scab. (R45's) scab opened and there was drainage that cause it to stick together and to his skin. The DON acknowledged that hydrogen peroxide was used to soften and loosen the area to promote the dressing removal without damaging the skin. Per chart review, the only skin assessment completed on R45 was dated 10/17/2021. A review of the Wound Observation Tool dated 10/1/2021 documented R45 admitted to the facility on [DATE] with a right outer ankle wound. The DON confirmed the first wound treatment order and dressing change occurred on 9/29/2021. The DON stated, I would say there was a delay in starting (R45's) wound treatment. Upon review of R45's October 2021 Treatment Administration Record (TAR), the DON stated, His dressing should be done every two days. The TAR documented that wound care treatments were not provided on 10/4/2021 and 10/10/2021 as ordered. The DON stated, It is a concern because we need to follow doctor's orders and (R45) needs his treatments. Resident #47- A review of the clinical record for Resident #47 (R47) revealed a recent admitted [DATE]; discharge date of [DATE]; readmitted [DATE]; and discharge date of [DATE]. R47's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] documented intact cognition. A review of R47's clinical record with the DON on 10/19/2021 at 4:51 PM revealed no weekly skin assessments had been completed on R47. A review of R47's care plans documented in part the following: -Focus: The resident has potential for skin breakdown, injury and pain related to peripheral vascular disease. Dated 7/9/2021. -Focus: The resident has potential for impairment to skin integrity. Dated 7/7/2021. -Interventions: Give medications as ordered. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] R47's physician orders included: -Right 4th toe: apply [MEDICATION(S)] to toe every Monday, Wednesday, Friday and cover with conventional dry dressing. Ordered 6/8/2021; discontinued 6/15/2021. Per review of R47's Treatment Administration Record (TAR) this dressing was not administered on 6/9/2021 and 6/14/2021. -Right lower extremity: cleanse and pat dry. Apply Iodosorb (wound treatment), cover with Durafiber (fiber dressing) and cover with conventional dry dressing Monday, Wednesday, Friday and prn. Per TAR review this dressing was not administered on 6/9/2021 and 6/14/2021 -Right groin incision: cleanse and pat dry. Apply cdd (conventional dry dressing) every day. Ordered 6/8/2021; discontinued 6/15/2021. Per TAR review this dressing was not administered on 6/10/2021 and 6/14/2021. -[MEDICATION(S)] Powder. Apply to groin topically two times a day for itchy groin. Ordered 6/9/2021 until 6/15/2021. Per TAR review the HS (hour of sleep) treatment was not applied between 6/9/2021 through 6/14/2021. Resident #46- A review of the clinical record for Resident #46 (R46) revealed a recent admitted [DATE]; discharge date of [DATE]; and readmitted [DATE]. R46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] documented severe cognitive impairment. Weekly skin assessments were completed on 6/3/2021, 6/14/2021, 8/1/2021, 8/10/2021, 9/7/2021, 9/21/2021, 9/28/2021, 10/5/2021, and 10/14/2021. During an interview on 10/19/2021 at 4:31 PM, the DON concurred with the findings regarding the frequency of skin assessments completed for R46. The DON stated, The floor nurses are capable of doing these (weekly skin assessments). It was the floor nurses' responsibility to complete the skin assessments. There is not a particular reason why they were not being done. Resident #48- A review of the clinical record for Resident #48 (R48) revealed an admitted [DATE]. R48's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS dated [DATE] documented moderate cognitive impairment. Weekly skin assessments for R48 were completed on 9/1/2021, 10/2/2021, 10/3/2021, and 10/15/2021. During an interview on 10/19/2021 at 4:14 PM, the DON stated the skin assessments were not done consistently. It is a concern (that skin assessments were not done weekly) because we have to assess patients to see what is going on with their skin; to determine if anything is developing; to assess if there are any changes in their skin. The DON said it was her expectation that weekly skin assessments are completed on all residents because all residents are at risk for skin breakdown. The skin is weakened in the elderly. They could have bumped into something. Review of the facility policy titled, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility document titled, Documentation & Assessment of Wounds, revised 8/23/2021, revealed the following: -To guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced surgical wounds and other (not otherwise specified). -A wound assessment/documentation is required to occur at a minimum 'weekly'. Nurses performing the treatment would perform a prn (as needed) assessment/documentation if noted change has occurred i.e. wound has healed/resolved, appears infected, or appears to have declined . -Documentation is located in the EHR (electronic health record) - progress notes, Wound Observation Tool (WOT), and/or Skin Integrity Data Collection Tools A review of the facility document titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, revised 8/24/2021 revealed the following: -A comprehensive skin inspection/assessment on admission and re-admission to the center may identify pre-existing signs of possible deep tissue damage already present . -A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout points of care provided by CNAs during ADL care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. -Certain risk factors have been identified that increase a patient's susceptibility to develop or impair healing of pressure ulcers. Examples include - but are not limited to: .a history of a healed ulcer. -A skin assessment/inspection should be performed weekly by a licensed nurse.

This citation pertains to MI 543. Based on interview and record review, the facility failed to properly assess and implement timely care and medical interventions for one resident (#201) reviewed for quality of care, resulting in acute [CONDITION(S)] and emergency hospital admission. Findings include: The complainant reported to the State Agency that a resident was not provided proper assessment, diagnoses, and treatment in a timely manner upon his change in condition, resulting in hospitalization and death. The complainant stated the resident of concern died three days after his hospitalization . A review of the clinical record for Resident #201 (R201) documented an admitted [DATE]. R201 was discharged to the hospital on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Stage 3 chronic kidney disease was listed as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented severe cognitive impairment, supervision with one-person physical assistance for bed mobility, transfers between surfaces, and ambulation throughout his room and housing unit. Additionally, no rejection of care or use of a mobility device were noted in the referenced MDS. A quarterly review nutrition note dated [DATE] documented R201's usual food/fluid intake at ,d+[DATE]%. A review of the number of behavior notes in R201's clinical record since [DATE] included: Three behavior notes in [DATE] Four behavior notes in [DATE] Three behavior notes in [DATE] Two behavior notes in [DATE]; One behavior note in [DATE]; And, ten (10) behavior notes [DATE]. [DATE] behavior notes documented the following: 1. -[DATE] at 1:57 PM: Resident observed in day room flipping side tables and chairs over. When staff attempted to redirect resident, he refused to let go of the chair. Resident also noted dumping cups of water on the floor and laughing. Staff clean water up and encouraged resident to watch tv. Resident went to the hallway and began spinning around then jogging up and down the hall. Resident closing eyes, making noises and laughing. Staff redirected resident to room. Resident is sitting in room at this time. Call light in reach. 2. -[DATE] at 5:46 AM: writer was notified by nursing assistant that resident had put himself onto the floor and started scooting and that's where he obtained a small abrasion to his left thigh. Staff safely transferred resident into the bed and then he received patient care. 3. -[DATE] at 10:20 PM: Resident found by writer on floor in his room at 8 PM. Resident was lying on back side next to bed, no injuries noted, resident denied complained of pain and stated he did not hit his head during the fall. 4. -[DATE] at 7:01 PM: Late entry for [DATE] 6:30am to 6:30pm. Resident uncooperative with AM care. Will not stand for CNA (Certified Nurse Aide). Three staff to assist with AM care. Resident resisting pushing his body towards the floor. Resident in bed after AM care. Bed in lowest position. Resident continuously taking his clothes off AM and first part of afternoon shift. Took brief and [CONDITION(S)] bag off multiple times also. Resident kept laying in his roommate's bed. Refusing to get up out of bed. Two to three extensive assist to transfer resident to his bed. Resident did eat 75 to 100% of breakfast and lunch. Refused his dinner. 5. -[DATE] at 7:11 PM: Resident up at start of shift. CNA assisting him from his room to the day room. She was holding his hands while he walked with his eyes closed. Shuffling, small steps. Resident sitting on couch. Slid off onto the floor. Refused to get up off floor. Mattress placed on the floor in front of the entertainment center. Extensive assist of two to transfer resident from floor to the mattress. Resident resisting. He did lay on mattress for a short time. But then he slid off mattress, scooting himself across the floor. Just before lunch resident did get up with assist of two staff. One walking backwards holding his hands. Second holding him from behind. Resident not opening his eyes. Resident trying to sit down as he was being assisted to his room. Resident rested in bed. Bed in lowest position. Resident taking off his [CONDITION(S)] bag multiple times. Resident refused his AM meds. Took his 2 PM meds. Resident refused his dinner. Will continue to monitor. 6. -[DATE] 10:06 AM: Resident noted standing in day room with pants down and urinating on chair. Staff redirected resident to room. Assisted with peri care. Resident refusing to stand. Staff assisted to chair. Resident sitting in room at this time. Will continue to monitor. 7. -[DATE] 11:08 AM: Resident noted sitting in chair in day room. Writer observed resident slide buttocks off of front of chair while holding onto the arms of chair. Writer encouraged resident to sit back in chair. Resident stated no and continued to slide onto knees. Resident on knees on floor and refused to stand up. Staff assisted resident to room. Resident is resting in bed at this time. Refusing to stand with staff. Will continue to monitor. 8. -[DATE] 6:35 PM: Resident sliding out of bed. Refusing to stand or assist with care. Mattress placed on floor. Abdominal binder in place over [CONDITION(S)] bag. Resident taking it off. Along with his gown and brief multiple times throughout the AM and PM shift. Binder soiled AM and PM shift. Soiled binder sent to the laundry to be washed. Poor appetite this AM and PM shift. Extensive assist of two to transfer resident from bed to wheelchair. Up in wheelchair in the dining room at this time. Resident to be seen by physical therapy. Will continue to monitor for safety. 9. -[DATE] at 1:56 AM: Resident is not opening his eyes, slouched over and is not standing on his own. resident continues to pull [CONDITION(S)] bag off. it took 3 people to give resident care during rounds. resident was cleaned up, a new [CONDITION(S)] bag was applied. resident is up in day room. safety maintained. 10. -[DATE] 7:38 PM: Resident up at the start of day shift. Sitting in the day room at a table. Writer noted resident to be sliding down in his chair multiple times. Extensive assist of 2 to 3 with repositioning of resident. Resident transferred to his room for safety. Slid out of his bed. Mattress placed on the floor. Resident resisting with care. Taking [CONDITION(S)] bag off throughout the day and afternoon shift. Refusing to eat or drink this AM or PM shift. Resident did drink a little chocolate milk while writer giving him his prn (as needed) [MEDICATION(S)]. (Psych PA H) in. New orders obtained. [MEDICATION(S)] dosage changed to 250mg twice a day. First dose to be held tonight per PA H. [MEDICATION(S)] given at 6:20pm. Will monitor to see if effective with PM care. Will continue to monitor. On [DATE] at 12:54 PM, when Nurse K was queried if she was familiar with R201, she said, I worked with (R201) for over a year. When queried if she had observed worsening of his behaviors, she said, He would act goofy and then zone out. In January (2021) it seemed as if it was every day. He wouldn't talk; he wouldn't open his eyes. The psych doc upped his med and there was no change. On [DATE] at 1:31 PM, Nurse G was interviewed via the telephone. When queried if she was familiar with R201, she stated yes because his unit was her main work assignment. When queried if she had observed worsening of his behaviors, she said, He was having behaviors and they were escalating more often. He was being seen by psych and they were evaluating him. It was harder and harder to redirect him. It was harder to get him to open his eyes. When queried if she had observed more behaviors during [DATE], Nurse G said, Most definitely. A review of staff documentation of the percentage of meals eaten by R201 revealed the following: [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner (not documented) [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner ,d+[DATE]% [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner (not documented) [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner ,d+[DATE]% [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner meal refused [DATE]: Breakfast meal refused, Lunch ,d+[DATE]%, Dinner meal refused (per clinical documentation) [DATE]: Breakfast meal refused, Lunch meal refused, Dinner ,d+[DATE]% [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner ,d+[DATE]% [DATE]: Breakfast ,d+[DATE]%, Lunch meal refused; Dinner meal refused [DATE]: Breakfast ,d+[DATE]%, Lunch ,d+[DATE]%, Dinner meal refused [DATE]: Breakfast meal refused, Lunch meal refused, Dinner ,d+[DATE]% [DATE]: Breakfast meal refused, Lunch meal refused, Dinner not applicable On [DATE] at 10:42 AM, when the facility's Registered Dietitian (RD) and Dietetic Technician (DT) were queried about when they should be notified about a change in a resident's intake, they stated when there was a marked decline. The RD and DT were queried about interventions they would recommend if contacted that a resident had not eaten and drank well in ,d+[DATE] days. They stated that it would trigger a need for dehydration labs such as a complete metabolic panel. The RD and DT added that Grand Rounds are held on each unit usually five days a week and that's where nursing has the opportunity to discuss what's going on with residents. A review of R201's care plans documented the following: -Focus: Resident has a behavior problem, at times he will wander out of his room and pretend he is sleeping standing up, falling while standing up, sitting while standing up, in a car or that he is on a skateboard. He will slowly start to fall backwards or to the side when he knows someone is close to catch him; dated [DATE]. Interventions included: Provide resident with 1:1 (staff to resident ratio) when he is in behavior mode. -Focus: Resident uses [CONDITION(S)] medications related to behavior management; dated [DATE]. Interventions included: Monitor for side effect of medication and follow policy .[MEDICATION(S)] .anorexia . behavior changes Focus: The resident uses antidepressant medication related to major depressive disorder; dated [DATE]. Interventions included: Observe for and report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; appetite loss Focus: At risk for dehydration and alteration in nutrition status as evidence by: fluctuating intake by mouth; psych medication use with potential for fluctuation in weight; dated [DATE]. Interventions included: Offer substitutions for refused items. Focus: Resident is at risk for alteration in comfort related to depression, dementia with [CONDITION(S)], gastroesophageal reflux disease, [CONDITION(S)], [CONDITION(S)] fibrillation; dated [DATE]. Interventions included: Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Focus: Resident is at risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions; dated [DATE]. Interventions included: Observe for changes in mental status caused by situational stressors and report to physician as appropriate. There was no available documentation that R201 had been provided a 1:1 (staff to resident ratio), offered substitutions for refused meal items, and that his primary care physician had been notified prior to [DATE] about documented increased behaviors, appetite loss, resistance to care, and decrease in functional ability. Further progress notes for R201 were as follows: -[DATE] at 11:39 AM: (Physician E) in. Lab orders received included CMP (comprehensive metabolic panel provides a check of kidney function and electrolyte and fluid balance). Labs put in for tomorrow morning. -[DATE] at 6:55 PM: At approximately 4 PM Resident receiving [MEDICATION(S)] via hypodermoclysis (subcutaneous infusion of fluids; a useful hydration technique for dehydrated adult patients) second liter running. CNAs providing care due to resident pulling [CONDITION(S)] bag off and stool all over body and bed. CNA went to roll resident and her finger was stuck by hypodermoclysis needle. Resident had pulled it out and staff was unaware. New site started LLQ (left lower quadrant). 2nd bag almost complete. At approximately 5:30 PM Resident having periods of lethargy. Vital signs within normal limits, pulse oximetry within normal limits. (Physician E) notified of labs: blood urea [MEDICATION(S)] 149 (normal range ,d+[DATE]), creatinine 5.82 (normal range 0.,d+[DATE].30), sodium 157 (normal range ,d+[DATE]) drawn on [DATE]. Resident is yes to hospital. New order received to send to (local hospital) per (Physician E). Resident transferred out at 6:30 PM. -[DATE] Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . -Additional lab data obtained on [DATE] documented glomerular filtration rate 9 (normal >60mg/min) and chloride 112 (normal range ,d+[DATE]) -R201's annual physical dated [DATE] assessment and plan documented in part the following: Chronic kidney disease. Monitor renal function. Avoid nephrotoxic medications. Encourage hydration. Severe protein-calorie malnutrition. Monitor oral intake. Nutrition following. Encourage oral intake. On [DATE] at 2:15 PM, a review of the clinical record for R201 was conducted with Unit Manager L and the DON. When queried if R201's behaviors had become worse in [DATE], Unit Manager L said, Yes. When R201's food intake was reviewed, Unit Manager L stated there was a decline in his intake after [DATE]. Unit Manager L added, He went from consuming an average of ,d+[DATE]% to zero-25%. When Unit Manager L was queried if she had recognized R201's decrease in appetite, what would she have done, she said, I would notify the physician; talk to the physician about labs; and talk with psych services; I would notify speech therapist and the diet technician. When queried about the reason she would notify the speech therapist and dietetic technician, Unit Manager L said, Speech therapist to rule out chewing difficulties related to cognitive change and the diet technician to get recommendations for supplement and changes to his diet. R201's clinical record review did not document that the speech therapist or dietetic technician had been notified. The chart review documented that the physician ordered labs on [DATE]. The labs ordered were not stipulated STAT as the labs were put in for tomorrow morning. Unit Manager L stated the physician was notified on [DATE] about R201's change in condition. When queried if it were acceptable that staff waited four days before contacting the physician, Unit Manager L said, No, a lot of things could happen; labs could be off; the resident could be dehydrated. If you're not eating, behaviors can get worse. When queried if timely notification occurred to the physician, the DON said, From the time he stopped eating, no. On [DATE] at 4:15 PM, when the DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, she said, I don't think so. Per review of the facility's documents on Changes in Resident's Condition or Status dated [DATE] and Changes in Status, Identifying and Communicating, Long-Term Care, dated [DATE]: -This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. -A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). -In a long-term care setting, identifying and addressing any change in a resident's status from baseline is important. A resident is more likely to return to baseline status and avoid complications when early recognition and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -Early recognition, assessment, and intervention assist in providing necessary care, which can decrease the need for transfer to an acute care facility or emergency department. -Every health care team member is responsible for communicating a resident's change in status from baseline. -Nurses are responsible for communicating a resident's change in status, including the assessment findings, to the practitioner.

This citation pertains to Intake number MI 83. Based on observation, interview and record review the facility failed to provide adequate supervision for one sampled resident (R#704) from a total sample of three residents reviewed for accidents resulting in an unprovoked altercation and the potential for further altercations. Findings include: On 4/4/19 at 10:39 AM, R#704 was observed wandering unsupervised near the Orange Court Nursing Unit. At 12:56 PM, R#704 was observed wandering unsupervised near the Social Services office. Review of a facility provided 24 hour State Agency reported incident documented; On 4/1/19 (R#704) wandered down to the therapy gym room. Started hitting another resident (R#705) in the face and grabbed her arm causing a skin tear. Staff had difficulty redirecting resident (#704) but were able to walk with him back to the unit. 30 minute checks (check the whereabouts of the resident) were initiated. A statement from Physical Therapy Assistant (PTA A) documented, R#704 walked up to R#705 who was on the (brand name of equipment) bike. R#704 started punching R#705 multiple times in the face and grabbed her arm causing it to bleed. Staff approached R#704 immediately and tried to redirect. R#704 was walked back to unit with therapist and Assistant Director of Nursing (Nurse B) was called immediately. Record review revealed that R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was severely impaired. Review of progress notes dated 3/15/19 thru 4/3/19 revealed the following: -Admission Social Service (SS) note 3/15/19; .He was admitted to the facility receiving [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (treatment for [REDACTED]. Per his Son, he has been taking [MEDICATION NAME] for about a year now, started by his neurologist for aggression . -Nurses note (NN) 3/19/19; .He is attempting to stand up and is ambulating (walking) without any assistance from his room to the middle of hallway, very hard to redirect to stay in common area. He was combative with redirection from staff and his wife called and resident was given the chance to speak with wife and it appeared that his behavior became worse and was more resistive and combative with staff after talking to his wife . -NN 3/22/19; .During shift resident is up ambulating and wandering hallway. Attempts to redirect are difficult as resident is resistant and due to language barrier (Arabic speaking). -NN 3/25/19; .Resident has been ambulating unassisted on the unit all morning. Observed going in and out of other resident's rooms. -NN 3/26/19; .Ambulating independently and wanders on and off the unit. Wanders in and out of other resident's rooms. Found attempting to open an emergency door x 1 and went up front to the lobby x 1. Resident was wearing his roommate's shoes and sweater. The Certified Nurse Assistant (CNA I) attempted to redirect the resident and get the sweater and resident hit the CNA . -NN 3/27/19; Resident is alert with confusion and is up ambulating through out the unit and his gait (walking) is slow and steady and he is wandering through out the unit this shift and into other resident's rooms and was in another resident's room and urinated on the floor and was sitting on another resident's bed and was redirected to the dinning room for dinner . -NN 3/30/19; .resident continues to receive both Physical Therapy (PT) and Occupational Therapy (OT) services and is ambulating both on and off the unit and is easily redirected back to the unit. He is wandering into other residents rooms and need redirection to common area . -NN 3/31/19; Resident attempting to go out exit doors several times, redirected by staff. resident ambulating to other units and going into other resident rooms. Going through other resident's closets and upsetting other resident's and family members .Resident not easily redirected, becomes agitated and swinging at staff. -NN 4/1/19 (previously noted Facility Reported Incident); Resident wandered down to the therapy room. Started hitting another resident in the face and grabbed her arm causing a skin tear. Staff had difficulty redirecting resident but were able to walk him back to the unit .30 minute checks initiated. -SS note 4/1/19; Resident was unable to respond to questions regarding incident .Resident continues to wander . -NN 4/2/19; Resident up and wandering all night, walking around in the day room and all over the facility, difficult to redirect at times, continue half hour checks x 24 hours, no attempts to hit anyone noted or reported thus far this shift . -SS note 4/3/19; .Resident was observed today on Village Nursing Unit entering room [ROOM NUMBER] and beginning to sit in a chair in that room .redirected him out and walked him back to Blue Court Nursing Unit (were resident resides) . attempt to talk to resident while walking he only responded ok. Review of a 3/15/19 care plan titled (Name of resident) uses [MEDICAL CONDITION] medications related to behavior management, [DIAGNOSES REDACTED]. Record review revealed a Risk for mood or behavior .He has a noted history of aggression prior to hospitalization . (R#704) has tendency for impulsive and unpredictable behavior, becoming aggressive towards staff and others, striking out unprovoked care plan dated 3/15/19 had an intervention of, Monitor (resident's name) closely while in common areas. A wandering/elopement care plan was not developed until 4/3/19 (12 days after the wandering behavior was documented in a nurse note and one day after a resident altercation), with an intervention of Frequent monitoring (determine resident whereabouts throughout the shift). On 4/4/19 at 2:00 PM, Certified Nurse Assistant (CNA I) was interviewed and stated, About a week ago, he was in the shower room and I was trying to take his sweater off and he started grabbing at me and scratched my arms. On 4/4/19 at 2:10 PM, during an interview with Nurse D was interviewed and stated, He was just brought back over from Orange Court (another Nursing Unit) just a few minutes ago. He wanders all over. We bring him to activities and he sits down for about 2 minutes and he's right back up and off again. It's hard to stay on top of him. On 4/4/19 at 2:30 PM, during an interview with the facility's Director of Nursing (DON) she was asked how she was ensuring the safety of the other vulnerable residents in the facility from a resident that has a history of aggressive behavior, strikes out unprovoked and is wandering through building in and out of other resident rooms, to which she responded, We don't always know if or when he becomes aggressive. We think it's when he becomes over stimulated. A lot of the times he's just walking around freely and not creating a problem. The staff redirect him and brings him back to his unit. We had psych (psychiatry services) see him and they just adjusted his medication. When we have an opening (bed availability) on the closed unit, we will move him there. The DON did not say what additional interventions were implemented to protect the other residents during the interim time (while awaiting medication adjustment to reach therapeutic levels and room change). Review of the facility's policy titled, Unsafe Wandering and Elopement dated 12/13/18 documented, .Wandering may become unsafe when a resident becomes overly tired or enters an area that is physically hazardous or that contains potential safety hazards (e.g. chemicals, tools, and equipment, etc.). Entering into another resident's room may lead to an altercation or contact with hazardous items. Unsafe wandering can be associated with an increased risk for falls and injuries. Review of the facility's policy titled, Protection of Residents: Reducing the Threat of Abuse and Neglect dated 2/2018 documented, Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals.