**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide four of four residents (#3, #4, #5, and #12) out of 12 sample residents, with the necessary treatment and services to manage pressure injuries and minimize pressure injury risks. RESIDENT #3 Record review and interview revealed Resident #3 was hospitalized seven times and readmitted to the facility six times between January and June 2024. During this time, the resident developed pressure injuries to his sacrum, ischium, left and right heels, left ankle, and scrotum which ranged from stage 2 (partial thickness skin loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), as well as osteomyelitis (inflammation of the bone due to infection) of the sacral wound. Record review revealed the facility failed to assess the resident's pressure injuries on his readmission to the facility from the hospital on at least five occasions (1/18, 3/7, 3/19, 4/29, and 5/20/24) and failed to obtain and implement treatment orders timely. -In January, upon the resident's readmission on [DATE], nursing documented open wounds to the resident's right and left clavicle and coccyx per interview with the director of nursing (DON). However, the wounds were not assessed and no treatment orders were obtained until the following week. Further, the resident's skin assessments on 1/19, 1/20, and 1/21/24 incorrectly documented no skin issues. -In March, upon the resident's first readmission on [DATE], nursing documented a stage 2 sacral wound and an unstageable right heel wound, but the wounds were not assessed and no treatment orders for the wounds were obtained. Upon the resident's second readmission on [DATE], the resident's wounds were described as right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. There was no documentation of dressing changes and no wound treatment orders until 3/27/24. Per record review and interview, in March, the resident was in the facility for 13 days (3/7 - 3/12/24 and 3/19 - 3/27/24) without treatment orders for wounds on his sacrum, and right and left heels. On 4/1/24, the resident was readmitted to the hospital with a diagnosis of osteomyelitis of the sacral wound. The resident was hospitalized for almost a month. In April, upon the resident's readmission on [DATE], there were treatment orders for his sacrum, heels, and new ischial wound and documentation of treatments, but no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24. In May, upon the resident's readmission on [DATE], the readmission nursing assessment documented ankle stage 3, right heel unstageable, left heel stage 3, sacral stage 4, right gluteal fold unstageable, and scrotum stage 2. The assessment documented the initiation of a wound vacuum for the sacral wound but no new wound orders. There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. The facility's repeated failures to assess Resident #3's wounds on readmission, monitor the wounds, and ensure timely treatment orders created the likelihood of serious harm to Resident #3, as well as other current and future residents at risk for pressure injuries if the facility's failures were not immediately corrected. RESIDENTS #5, #12, AND #4 Further record review and interview revealed additional failures in the facility's management of residents' pressure injuries. Specifically, the facility failed to ensure: -Resident #5's wounds were assessed on admission, the resident was accurately assessed for risk of pressure injury development, and timely pressure prevention interventions and treatment were put in place; -Resident #4, who had four pressure injuries from stage 3 (full-thickness tissue loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), had an air mattress that was inflated appropriately to prevent increased pressure; and, -Resident #12's pressure injuries were assessed on admission and treatment was ordered timely and provided. Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy Record review and interview revealed Resident #3 was hospitalized seven times and readmitted to the facility six times between January and June 2024. During this time, the resident developed pressure injuries to his sacrum, ischium, left and right heels, left ankle, and scrotum which ranged from stage 2 (partial thickness skin loss) to stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), as well as osteomyelitis (inflammation of the bone due to infection) of the sacral wound. Record review revealed the facility failed to assess the resident's pressure injuries on his readmission to the facility from the hospital on at least five occasions (1/18, 3/7, 3/19, 4/29, and 5/20/24) and failed to obtain and implement treatment orders timely. -In January, upon the resident's readmission on [DATE], nursing documented open wounds to the resident's right and left clavicle and coccyx per interview with the director of nursing (DON). However, the wounds were not assessed and no treatment orders for the wounds were obtained until the following week. Assessments 1/19, 1/20, and 1/21/24 incorrectly documented no skin issues. -In March, upon the resident's first readmission on [DATE], nursing documented a stage 2 sacral wound and an unstageable right heel wound, but the wounds were not assessed and no treatment orders for the wounds were obtained. Upon the resident's second readmission on [DATE], the resident's wounds were described as right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. There was no documentation of dressing changes and no wound treatment orders until 3/27/24. Per record review and interview, in March, the resident was in the facility for 13 days (3/7 - 3/12/24 and 3/19 - 3/27/24) without treatment orders for wounds on his sacrum, right and left heels. On 4/1/24, the resident was readmitted to the hospital with a diagnosis of osteomyelitis of the sacral wound. The resident was hospitalized for almost a month. In April, upon the resident's readmission on [DATE], there were treatment orders for his sacrum, heels, and new ischial wound, but no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24 for severe sepsis. In May, upon the resident's readmission on [DATE], the readmission nursing assessment documented ankle stage 3, right heel unstageable, left heel stage 3, sacral stage 4, right gluteal fold unstageable, and scrotum stage 2. The assessment documented the initiation of a wound vacuum for the sacral wound but no new wound treatment orders. There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. The facility's repeated failures to assess Resident #3's wounds on readmission, monitor the wounds, and timely obtain and implement treatment orders created the likelihood of serious harm to Resident #3, as well as other current and future residents at risk for pressure injuries if the facility's failures were not immediately corrected. B. Facility notice of immediate jeopardy On 6/18/24 at 3:42 p.m., the nursing home administrator (NHA) was informed of the findings of immediate jeopardy under F686, Pressure Injuries. C. Facility plan to remove immediate jeopardy The facility plan to remove immediate jeopardy read: The identified Resident (#3) is currently at the hospital; therefore, no individualized plan of correction is indicated. This Resident will not be returning to the community. The community has identified two other Residents with pressure injuries. The director of nursing (DON) completed pressure injury assessments on these 2 Residents and updated the plans of care as indicated. Current treatment orders were verified and treatment was completed as ordered. On 6/19/2024, a community-wide audit of all residents was completed by the DON or designee to obtain a baseline on current skin concerns in the community. Any identified area was corrected upon discovery. On 6/19/2024, the DON completed an audit to ensure all treatments, supplies, and equipment were readily available for pressure injury treatments. Additionally, the Director of Clinical Operations completed an audit of all air mattresses and support surfaces to ensure proper use in accordance with (the) manufacturer's recommendations or resident preferences. All identified areas were corrected upon discovery. Beginning 6/18/2024, the DON or designee initiated education with nursing staff regarding proper identification, documentation, and monitoring of pressure ulcers, as well as implementing interventions to prevent breakdown and completion of treatments as ordered for resident's skin injuries. Education to be provided to agency staff prior to the next scheduled shift. Beginning 6/19/2024, (the) DON or designee (is) to complete wound rounds weekly and ensure documentation is inputted in (the) electronic health record weekly. Beginning 6/19/2024, DON or designee (is) to complete wound dressing change observations and complete chart review two times a week for one month, then weekly for two months wound documentation for two residents to ensure that orders in place and are being followed as written, that staff is following appropriate infection control practices, that the physician is notified as needed, and that documentation is consistent throughout the chart. Identified concerns to be addressed with staff. Beginning 6/19/2024, (the) Nurse consultant or designee (is) to complete (a) monthly review of (the) resident's wound documentation to ensure that it is consistent with documentation from the wound physician and that the physician is being contacted as necessary for the wound. Identified concerns to be addressed with DON/designee. Beginning 6/19/2024, any residents admitted to the facility or returning from the hospital will be assessed for any area of skin breakdown. Any areas identified requiring treatment will have orders verified or obtained and wound care appointments will be transcribed and overseen by nurse leadership. A review to include an additional skin check will be completed. DON or designee to report on wound data monthly in the quality assurance performance improvement QAPI meeting. Identified concerns to be tracked and trended as needed. D. Removal of immediate jeopardy The facility plan was accepted by the state survey agency on 6/19/24 at 12:48 p.m., based on the systemic changes outlined in the plan to ensure pressure injuries would be assessed, monitored, and treated, and oversight planned to ensure compliance. The immediate jeopardy situation was removed; however, the deficient practice remained at level G, isolated, actual harm. II. PRESSURE INJURIES - CLASSIFICATION OF INJURIES AND FACILITY EXPECTATIONS A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 6/23/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Facility expectations in the management of pressure injuries and pressure injury risks. 1. Facility policy The facility's Pressure Injury Policy, dated 3/10/23, was received from the regional director of clinical services (RDCS) on 6/20/24 at 2:12 p.m. The policy read, in pertinent part: Purpose: To assess and implement interventions as appropriate to reduce the likelihood of (the) development of pressure injuries and that a resident who has a pressure injury receives appropriate care and services to promote healing and to prevent additional pressure injuries. Assessment: Using a standardized Braden Risk Assessment Tool, assess a resident's pressure injury risks upon admission. Conduct a thorough skin assessment. The facility will complete this assessment upon admission and weekly thereafter unless otherwise indicated. Daily monitoring with accompanying documentation. Protecting against the effects of pressure, friction, and shear. Reduce pressure over bony prominences by offloading and positioning. Evaluate the need for a pressure-reducing mattress or overlay. The facility will initiate and follow treatment modalities as ordered by the primary physician. 2. Staff interviews a. The DON and the regional director of clinical services (RDCS) were interviewed on 6/18/24 at 9:28 a.m. The DON said she expected a wound assessment would be completed within the first few hours after the resident was admitted . She said the assessment should include general size, color, and whether there was drainage or signs of infection. The DON said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. The DON said measurements should be obtained each week by the wound team with measurements and a description of the resident's wounds, even if the resident is being seen by an outside wound clinic. The DON said nursing staff should monitor and assess the resident's wounds as dressing changes are performed. Treatments and dressing changes should be documented on the treatment administration record (TAR) b. Licensed practical nurse (LPN) #1 was interviewed on 6/20/24 at 12:55 p.m. LPN #1 said the skin assessment should be done the same day as the resident's admission. LPN #1 said she prioritized this and completed it within an hour of admission. LPN #1 said if there was something abnormal, she reported the observations to the registered nurse (RN) for a thorough assessment and the RN would call the physician. c. Registered nurse (RN) #1 was interviewed on 6/20/24 at 1:00 p.m. RN #1 said she assessed residents' skin condition at admission and readmission and tried to complete the assessment within an hour of admission. RN #1 said if a resident's skin condition was abnormal, she would measure and document a description of the wounds and contact the physician to obtain orders the same day. III. RESIDENT #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), the resident's diagnoses included leukemia, diabetes, kidney disease, and cerebrovascular disease (conditions affecting blood vessels and flow in the brain). The 3/25/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. It documented that the resident was at risk for the development of pressure injury and had three unhealed, unstageable pressure ulcers. Resident #3 required a pressure-reducing device for his chair and bed, nutrition interventions to manage skin problems, and pressure injury care, including the application of ointments/medications. Resident #3 required partial assistance with eating and was dependent on staff for repositioning in bed, transferring, and bathing. B. Record review and interviews revealed Resident #3 developed six wounds. The facility failed to provide the resident with the necessary care and services to prevent the pressure wounds from developing and worsening. Specifically, the facility failed repeatedly to assess Resident #3's wounds on readmission, monitor the wounds, and timely obtain and implement treatment orders as expected. 1. January - February 2024 a. The resident was hospitalized 1/5 - 1/8/24 for sepsis. On 1/8/24, Resident #3 was readmitted to the facility. On 1/9/24, the wound physician's progress note revealed Resident #3 had developed a non-pressure wound on the left buttock, described as moisture-associated skin damage (MASD) partial thickness which measured 1.3 cm by 1.3 cm by 0.1 cm. Treatment orders to use a foam silicone border every two days were initiated. b. The resident was hospitalized 1/14 - 1/18/24 for urinary retention On 1/18/24, Resident #3 was readmitted to the facility. The hospital physician's note revealed Resident #3 had a neck/collar area pressure injury which started at the nursing facility on 1/12/24 from his cervical collar. (The note did not mention a non-pressure wound on the left buttock noted 1/8/24.) Assessment failures: Record review revealed no assessment of Resident #3's wounds upon readmission to the facility on 1/18/24. See facility policy above. In an interview on 6/18/24 at 9:28 a.m. with the DON and the regional director of clinical services (RDCS), the DON confirmed the 1/18/24 nursing assessment documented three open wounds (left clavicle, right clavicle, and coccyx) but there was no documentation these wounds were assessed. Moreover, the RDCS said the nurse on 1/19/24 and 1/20/24 documented the resident's skin was intact and the DON said an assessment completed on 1/21/24 documented no skin issues. Treatment failures: The resident's record revealed no treatment orders until 1/23/24. See facility expectations above. In the interview on 6/18/24 at 9:28 a.m., the DON said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. c. Documentation of the presence of additional wounds 1/31/24, 2/6/24, 2/13/24 On 1/31/24, the wound physician's progress note revealed: -Non-pressure wound left buttock, partial thickness, MASD, 0.8 cm by 0.3 cm by 0.1 cm. -Non-pressure wound left neck, full thickness, 5.5 cm by 1.2 cm by 0.3 cm. -Pressure wound of right heel, full thickness, unstageable, 2.2 cm by 2.2 cm x non-measurable depth. The heel wound was noted to be greater than 13 days in duration. However, the 1/25/24 wound notes did not reveal a heel wound. On 2/6/24, the wound physician's progress note revealed: -Non-pressure wound left buttock had resolved. -Non-pressure wound left neck healing and measured 3.0 cm by 0.7 cm by 0.3 cm. -Non-pressure wound of right heel resolved. On 2/13/24, the wound physician's progress note revealed: -Non-pressure wound left neck full thickness, cauterization procedure for abnormal granulation tissue. -Non-pressure wound left ischium full thickness, measured 3.9 cm by 2.0 cm by 0.1 cm. -Pressure wound right heel, undetermined thickness, unstageable measured 1.1 cm by 1.5 cm by non-measurable. 2. March 2024 a. The resident was hospitalized from 2/14 to 3/7/24, for a urinary tract infection and surgical revision. He was readmitted to the facility on [DATE] until 3/12/24 when he was hospitalized again until 3/19/24 for urinary retention and suprapublic catheter placement. The resident was readmitted to the facility on 3/19 until 4/1/24 when he returned to the hospital. Failures on readmission 3/7/24 and 3/19/24. Assessment failures 3/7 to 3/12/24 and 3/19 to 3/27/24: The nursing admission assessment on readmission 3/7/24 at 5:50 p.m. revealed a stage 2 sacrum wound and an unstageable right heel wound. The nursing assessment on readmission on [DATE] revealed a right thigh skin tear, right heel stage 3, left heel deep tissue injury, and sacrum macerated and red. See facility policy above. In an interview on 6/18/24 at 9:28 a.m. with the DON and the regional director of clinical services (RDCS), the DON confirmed there was no description of the resident's wounds on his readmission from 3/7/24 to 3/12/24. Further record review revealed no description of the resident's wounds on readmission from 3/19/24 to 3/27/24 when Resident #3 was seen by the wound physician (see below). On 3/30/24, nursing notes at 4:03 p.m. and on 3/31/24 at 5:42 a.m. described the resident's coccyx wound as having odor. However, there was no documentation of an assessment or follow-up. Treatment failures 3/7 to 3/12/24 and 3/19 to 3/27/24: Record review revealed no wound treatment orders during the resident's first readmission in March. Further, record review revealed no treatment orders during the resident's second readmission on 3/19 until 3/27/24 when the resident was seen by the wound physician. See facility expectations above. In the interview on 6/18/24 at 9:28 a.m., the DON confirmed there were no wound treatment orders from the resident's readmission from 3/7/24 to 3/12/24 and no wound treatment orders from his readmission from 3/19 until 3/27/24. She said nurses were responsible for obtaining orders before the wound physician rounds. She said the nurse should check for any orders sent with the resident from the hospital and the nurse should call the doctor for orders if the resident had a wound and no orders existed. In addition, a review of the treatment administration record (TAR) revealed it did not have documentation of dressing changes from 3/19 to 3/26/24. See facility expectations above. The DON said in the interview on 6/18/24 at 9:28 a.m., that all treatments and dressing changes should be documented on the TAR. c. Documentation of wounds 3/27/24 The wound physician's progress note included the following description: sacrum, unstageable due to necrosis 10 centimeters (cm) x 11 cm x 0.1 cm depth; right heel unstageable 2.0 cm x 3.0 cm, depth not measurable; and left heel unstageable 2.5 cm x 3.0 cm, depth not measurable. The physician also identified a non-pressure wound (moisture-associated skin damage) greater than seven days on the resident's scrotum 3.0 x 2.0 x 0.1 which was not previously identified by the facility. 3. April 2024 a. The resident was hospitalized from [DATE] to 4/29/24 for pressure ulcers and osteomyelitis of the sacral wound. The hospital admission history and physical revealed a computerized tomography (CT) on 4/1/24 demonstrated coccygeal osteomyelitis (from sacral ulcer) as the primary infectious source. Failures on readmission to the facility 4/29/24: Record review revealed there were treatment orders for his sacrum, heels, and new ischial wound, but there was no evidence the wounds were assessed and monitored before he returned to the hospital on 5/15/24. The DON in the interview on 6/18/24 at 9:28 a.m. said the resident was being seen by an outside wound clinic after 4/30/24; however, she said the resident should have continued to be seen by the wound team weekly at the facility. The DON said measurements should have been obtained each week by the wound team with a description of the resident's wounds at the facility. The DON said nursing staff should have monitored and assessed the resident's wounds as dressing changes were performed. On 5/6/24, Resident #3's outside facility wound clinic visit physician progress note revealed the following: sacral pressure injury stage 4; left ischial pressure injury, unstageable; left heel pressure injury, unstageable; right heel pressure injury, unstageable; left ankle pressure injury, unstageable and left foot (metatarsal) pressure injury, unstageable. 4. May - June 2024 a. The resident was hospitalized on [DATE] for severe sepsis and readmitted to the facility on [DATE]. He was readmitted to the hospital on [DATE] and remains hospitalized . The resident's readmission nursing assessment on 5/20/24 documented: ankle stage 3; right heel unstageable; left heel stage 3; sacral stage 4; right gluteal fold unstageable; and scrotum stage 2. The assessment also documented the initiation of a wound vacuum (wound vac) for the sacral wound. Treatment orders were resumed from the resident's previous admission without new orders. Failures on readmission to the facility from 5/20/24 to 6/13/24: Assessment failures: There was no monitoring or description of the wounds by nursing staff before the resident's readmission to the hospital on 6/13/24. See above. The DON in the interview on 6/18/24 at 9:28 a.m. said the resident was being seen by an outside wound clinic after 4/30/24. However, she said the resident should have continued to be seen by the wound team weekly at the facility. The DON said measurements should have been obtained each week by the wound team with a description of the resident's wounds at the facility. The DON said nursing staff should have monitored and assessed the resident's wounds as dressing changes were performed. The outside wound clinic RN (WCRN) was interviewed on 6/18/24 at 1:00 p.m. The WCRN said Resident #3 was seen at the clinic by the wound physician once per week and was last seen at the clinic on 6/5/24. She said Resident #3's wounds were: sacral, stage 4; left heel, stage 3, right heel, unstageable; left ankle, stage 3, and ischial, stage 4. The WCRN said if there were gaps in the treatment of the wounds, it could have led to the worsening of Resident #3's wounds. Treatment failures: The WCRN said the wound vacuum (initiated on 5/20/24) was not on the resident when he arrived for the visit on 6/5/24. The WCRN said the facility sent the wound vac machine the week prior, however, it was not working and was out of batteries. Certified nurse aide (CNA) #3 was interviewed on 6/20/24 at 12:36 p.m. CNA #3 said she sometimes noticed residents' bandages that needed replacement and she told the nurse when this occurred. CNA #3 said she bathed Resident #3 on 6/11/24 and his dressings were labeled with the date of the last dressing change on 6/7/24. CNA #3 said she notified the nurse and the DON that Resident #3's dressings had not been changed. The DON and RDCS were interviewed a second time on 6/20/24 at 1:16 p.m. The DON said a CNA told her Resident #3's dressings had not been changed for several days last week. The DON said she did not remember the name of the CNA, the nurse, or the dates. The DON said she told the nurse and the dressing was changed. The DON said she told all staff that dressings needed to be changed as ordered. She said she provided education and began monitoring staff for dressing change completion but she did not have documentation of the education provided or the monitoring she had completed. The DON said she did not know if Resident #3's wounds had progressed before his hospitalization on 6/13/24. The RDCS said there was no documentation describing the wounds after the missed dressing changes. IV. Resident #5 A. Resident status Resident #5, less than age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included infection of the right upper extremity stump, sacrum pressure ulcer, diabetes mellitus, and left and right above-the-knee amputation. According to the 4/23/24 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. Transfers did not occur according to the assessment. Resident #5 required substantial to maximum assistance with bed mobility and supervision with personal hygiene. She was dependent on staff for toileting. The assessment documented Resident #5 had a pressure injury to the sacrum. It further documented the resident's pressure injury was unstageable and pressure injury care and treatment were in place. The assessment documented the resident was frequently incontinent. B. Record Review On 4/19/24 the Nursing Admit Data Collection Tool documented the resident had pressure injuries to the right and left gluteal folds. There was no further description of the wounds. The Braden assessment, dated 4/22/24, documented the resident was not at risk for pressure injuries. The assessment documented the resident had no sensory impairment, was rarely moist, chairfast, had slightly limited mobility, adequate nutrition, and had no problems with friction. -However, the resident had current pressure injuries as documented on 4/19/24 and had diabetes mellitus. Further, she required substantial assistance with bed mobi

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #71 1. Resident status Resident #71, under the age of 65, was admitted on [DATE]. According to the July 2022 CPOs, diagnosis included chronic obstructive pulmonary disease (COPD), morbid obesity, diabetes mellitus type two, bipolar disorder, schizoaffective disorder (hallucinations and delusions), anxiety, abnormal posture, and anxiety. The 6/28/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance of two people with bed mobility, transfers, personal hygiene and supervision for eating. 2. Observations and resident interview Resident #71 was interviewed on 7/19/22 at 11:51 a.m. She said a nurse and a CNA were transferring her using the mechanical lift over the weekend. The CNA told the nurse that the mechanical lift was malfunctioning and not to move the lift. She said the nurse moved the lift and it was unsteady. Resident #71 said the mechanical lift wheels were under her bed and would not move. She said this caused the mechanical lift to become unsteady and it tipped, causing her to fall into the wall. The resident pointed out a gash on the wall next to her bed from the mechanical lift and an indent from where she hit her head. The resident had a bump on the left side of her head. Resident #71 was interviewed again on 7/21/22 at 11:18 a.m. She said her head was still tender when touched, but the bump was resolving. She said the staff told her she would be alright and did not check her head for any injury after the resident hit her head when the lift fell into the wall. Resident #71 said the facility continued to use the mechanical lift that malfunctioned until 7/20/22. The resident said no further issues occurred after the event. 3. Record Review The activities of daily living (ADL) care plan, initiated on 8/25/16 and revised on 2/23/22, documented Resident #71 required assistance with ADLs related to diagnosis of obesity, asthma, diabetes mellitus type two and anxiety. The interventions included, in pertinent part, that the resident required a mechanical lift with two person assistance for all transfers. 4. Incident on 7/17/22 The 7/17/22 change in condition assessment documented the resident bumped the left side of her head on the grab bar that was lined with stuffed animals next to her bed. No changes were observed to her mental or functional status. The assessment documented that the resident reported she had no complaints of pain. There were no injuries noted. The physician was notified and no new orders were obtained. The 7/17/22 nursing progress note documented that the CNAs were transferring the resident from her wheelchair to her bed using a mechanical lift. The mechanical lift tipped and the resident bumped her head on the grab bar next to her bed that was lined with stuffed animals. The note documented the resident said, no it is ok, it is nothing. 5. Staff interviews confirmed the facility failed to implement neurological checks after the resident hit her head, failed to educate staff on transferring the resident, and failed to remove the mechanical lift from use for several days after the incident. The director of maintenance (DOM) was interviewed on 7/21/22 at 12:35 p.m. He said he was notified on 7/20/22 (three days after the incident) that the mechanical lift had malfunctioned. He said he removed the mechanical lift from use and requested an outside company to service the lift. The ADON was interviewed on 7/21/22 at 1:23 p.m. She said she was notified the mechanical lift had malfunctioned on the day when nursing staff transferred Resident #71. The ADON said nursing staff should have initiated neurological checks, since Resident #71 hit her head. She confirmed the facility failed to initiate neurological checks. The ADON said she was going to begin an investigation immediately on the incident on 7/17/22. The ADON was interviewed again at 3:07 p.m. She confirmed Resident #71 had a hematoma (bump) to the back of the left side of her head and complained of pain to the touch. -The ADON said she had the nursing staff initiate neurological checks immediately and contacted the physician. -The ADON said the facility had not completed education with the nursing staff on safe resident transfers, after the incident with Resident #71, but she would begin this immediately. -The ADON said the mechanical lift should have been removed from use and inspected immediately after the incident on 7/17/22. The INHA was interviewed on 7/21/22 at 4:25 p.m. The INHA said neurological checks should be initiated when a resident hits their head or has an unwitnessed fall. The INHA did not comment on the status of the mechanical lift that was said to have been malfunctioning. C. Resident #21 1. Resident status Resident #21, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2022 CPOs, diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left side (limited movement of the left side following a stroke), heart failure, obesity, repeated falls, epilepsy (seizure disorder) and chronic pain. The 4/20/22 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required extensive assistance of two people for bed mobility, transfers, toileting and extensive assistance of one person for dressing and personal hygiene. The MDS assessment indicated the resident had not had any recent falls. 2. Record review The activities of daily living (ADL) care plan, initiated on 2/14/2019, documented Resident #21 had a self-care performance deficit related to diagnosis of dementia, left sided weakness, limited range of motion, pain and history of a stroke. The interventions included, in pertinent part, providing a transfer pole for assistance with transfers and providing one staff member to assist with transfers via a stand pivot transfer with a gait belt and transfer pole. The fall risk care plan, initiated on 2/5/19 and revised on 9/27/19, documented Resident #21 was at high risk for falls related to a history of falls with major injury, history of a stroke with left sided weakness, incontinence, new admission, psychoactive drug use, vision and hearing problems, and difficulty walking related to a hip and foot fracture. The interventions included, in pertinent part, keeping the resident's call light within reach, encouraging the resident to keep his bed in a low position and discontinuing the resident's transfer pole and transferring the resident via a mechanical lift (5/19/22). 3. Fall incident on 5/28/22 - unwitnessed by staff The 5/18/22 incident note documented that the resident was attempting to self transfer from his wheelchair to his bed when he lost his balance and fell. The resident's roommate witnessed the fall. Neurological checks were initiated and no injuries were sustained from the fall. The 5/18/22 incident report documented the resident was found on the floor by a certified nurse aide (CNA). The resident reported he attempted to pull himself into bed from his wheelchair, but fell to the floor. The 5/18/22 interdisciplinary (IDT) post fall assessment documented that the resident had an unwitnessed fall on 5/18/22 without injury. The intervention was to remove the transfer pole from the resident's room and staff were to use a hoyer lift (mechanical lift) for all transfers. The 5/26/22 IDT note documented the resident was reviewed for a recent witnessed fall on 5/18/22 with no injury. The IDT determined the resident was no longer safe to transfer with a transfer pole and needed to be transferred via a hoyer (mechanical lift). The transfer pole was to be removed. 4. Observations revealed the resident's transfer pole had not been removed On 7/18/22 at 11:07 a.m. Resident #21 was lying in bed. His bed was approximately three feet off the ground and there was a transfer pole next to his bed. On 7/20/22 at 10:28 a.m. Resident #21 was lying in bed. His bed was approximately three feet off the ground and there was a transfer] pole next to his bed. On 7/21/22 at 11:16 a.m. the director of maintenance (DOM) removed the transfer pole from Resident #21's room, because the director of therapy (DOR) recommended the discontinued use (see interview below). 5. Staff interviews The DOR was interviewed on 7/21/22 at 10:53 a.m He said the resident had been on therapy services from 4/14/22 to 5/12/22. He said during this time, the therapy team had verbally recommended the transfer pole to be discontinued. The DOR said the resident still had a transfer pole in his room, which could lead to additional falls. He said the resident was not strong enough to use the transfer pole safely. Certified nurse aide (CNA) #9 was interviewed on 7/21/22 at 11:26 a.m. She said fall interventions were communicated verbally between staff. She said she was not aware of any specific fall interventions for the resident. Licensed practical nurse (LPN) #1 was interviewed on 7/21/22 at 1:33 p.m. She said Resident #21 had fall mats in place next to his bed. She said Resident #21 often fell when he was trying to self transfer himself using the transfer pole in his room. She said person-centered fall interventions should be documented in the resident's care plan. The interim nursing home administrator (INHA) was interviewed on 7/21/22 at 2:45 p.m. She said the IDT reviewed a resident after a fall. She said the IDT was responsible for assessing the resident after each fall and implementing a new person-centered intervention to prevent further falls. The INHA said the care plan should contain person-centered fall interventions. D. Resident #130 1. Resident status Resident #130, age [AGE], was admitted on [DATE]. According to the July 2022 CPOs, diagnoses included fecal impaction, gastrostomy status (feeding tube), dysphagia (difficulty swallowing), cognitive communication deficit, hyponatremia (low sodium) and severe protein-calorie malnutrition. The 4/27/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of 11 out of 15. He required extensive assistance of one person for bed mobility, transfers, dressing, eating, personal hygiene and total dependence of one person for toileting. The MDS assessment indicated the resident had a fall within two to six months prior to admission to the facility. 2. Observations On 7/20/22 at 2:30 p.m. Resident #130 was lying in bed with regular socks on his feet. On 7/21/22 at 10:05 a.m. Resident #130 was lying in bed with regular socks on his feet. 3. Record review The ADL care plan, initiated on 5/1/22 and reviewed on 7/18/22, documented Resident #130 had an ADL self-care performance deficit related to atrial fibrillation (a-fib, abnormal heart beat), muscle weakness and chronic obstructive pulmonary disease (COPD, difficulty breathing). The care plan documented that the resident utilized a wheelchair for longer distances and used a walker in his room with staff. The interventions included: providing the resident an air mattress, encouraging the resident to participate in tasks, ensuring the resident has effective pain management prior to ADLs, providing cueing with tasks as needed and providing extensive assistance with one staff member for all ADLs. The cognitive care plan, initiated on 5/4/22, documented Resident #130 had impaired cognitive function or impaired thought process related to diagnosis of cognitive communication deficit and short term memory loss. The interventions included: administering medications as ordered, asking yes/no questions to determine resident needs, communicating with the resident regarding his capabilities, using the resident's preferred name and identifying oneself prior to providing care, keeping the resident's routine consistent, segmenting tasks to support short term memory deficits by breaking tasks into one step at a time, presenting one thought at a time and reporting changes in cognitive function. The fall care plan, initiated on 6/3/22, documented Resident #130 had a fall with minor injury related to poor balance, unsteady gait, weakness and a history of falls. The interventions included: continuing interventions on the at-risk care plan, encouraging the resident to ask for assistance, ensuring the resident had non-skid socks on, placing on the fall prevention program, observing for injury after the resident sustained a fall and educating the staff on using a gait belt when transferring the resident. -The facility failed to develop a fall risk care plan upon admission when the resident was assessed as a high fall risk. The 4/22/22 admission fall risk assessment identified the resident as a high fall risk. The 6/2/22 fall risk assessment identified the resident as a low fall risk. The 7/17/22 fall risk assessment identified the resident as a high fall risk. 4. Fall incidents a. 6/2/22- witnessed The 6/2/22 change of condition assessment documented Resident #130 sustained a skin tear during a fall. The 6/2/22 incident report documented the resident had an assisted fall in the shower and sustained a skin tear to his right forearm. The 6/2/22 nursing progress note documented a certified nurse aide (CNA) was assisting a resident from the shower chair to his wheelchair when his legs gave out. The CNA assisted the resident to a sitting position on the floor and called for assistance. The resident was assessed and sustained a skin tear to his right forearm. The resident's representative and the physician were notified of the fall. The 6/3/22 IDT post fall review assessment documented the resident sustained a witnessed fall on 6/2/22. The resident required first aid after he sustained a skin tear to his right forearm. The intervention was to educate staff to use the gait belt with transfers. The 6/9/22 IDT progress note documented that the resident had a recent assisted fall in the shower. The intervention was to educate staff on using a gait belt when transferring the resident. -On 7/21/22 a request was made for education regarding using a gait belt with transfers. The facility did not provide documentation of the education provided to the staff during the survey process which exited on 7/21/22. b. 7/17/22 - unwitnessed The 7/17/22 change of condition assessment documented that the resident sustained a fall and appeared very confused. The 7/17/22 incident report documented the resident was found on the floor lying on his back, yelling for help. The 7/17/22 nursing progress note documented Resident #130 called for help. Upon entering the room, the nursing staff found the resident sitting on the floor. The progress note documented that the resident reported he was attempting to walk over to his wife when he lost his balance and fell. The resident complained of pain to his bottom. The resident was assisted back to bed and continued to attempt to self-transfer. The physician was notified and ordered an x-ray of the resident's bottom. Neurological checks were started. The nurse attempted to call the resident's representative to notify her of the fall. The IDT post fall assessment documented that the resident sustained an unwitnessed fall on 7/16/22. The interventions included providing frequent rounding to check for needs and encouraging Resident #130 to wear non-skid socks. -During observations the resident was not wearing non-skin socks (see observations above). 5. Staff interviews CNA #10 was interviewed on 7/21/22 at 1:21 p.m She said fall interventions for residents were communicated verbally through the staff. She said she was not aware Resident #130 had any recent falls or specific fall interventions implemented. The assistant director of nursing (ADON) was interviewed on 7/21/22 at 1:23 p.m. She confirmed the facility recommended educating nursing staff on using the gait belt when transferring Resident #130 after he sustained a fall on 6/2/22. The ADON was not sure if the training occurred and said she would look into the status of the training. -The facility did not provide the training conducted after Resident #130 sustained a fall on 5/2/22 during the survey process which exited on 7/21/22, as requested. The INHA was interviewed on 7/21/22 at 2:45 p.m. She said the intervention the facility implemented of encouraging the resident to wear non-skid sock was not appropriate. She said the facility should have assessed the resident's gait prior to recommending non-skid socks as they could have been more detrimental to the resident's fall risk. II. The facility also failed to provide care for four residents (#1, #71, #21, and #130) in a manner to prevent falls and to identify post-fall decline. A. Resident #1 1. Resident #1, age [AGE], was admitted on [DATE]. According to the July 2022 computerized physician orders (CPO), the diagnoses included history of falling, repeated falls and unspecified dementia without behavioral disturbance. The 7/3/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 11 out of 15. He required extensive assistance of one person with bed mobility, transfers, toileting and dressing. It indicated the resident sustained one fall with no injury since the previous assessment period. 2. Record review The fall care plan, initiated on 5/10/22, documented the resident sustained an actual fall with no injury. The interventions included encouraging the resident to ask for assistance, offering and assisting the resident with toileting frequently, reminding the resident to lock the brakes on his wheelchair before transferring and educating the resident to use the call light to ask for assistance. The 5/10/22 nursing progress note documented that the resident was found on the floor after sliding from his wheelchair. The 5/10/22 fall investigation documented the resident had an unwitnessed fall and was found on the floor beside his bed and wheelchair. The resident slid out of the wheelchair because he forgot to lock it. The 5/10/22 neurological check was documented as completed at 4 on 4:35 p.m. -The resident's medical record did not reveal any further documentation that showed neurological checks had been completed in increments for 72 hours for the fall the resident sustained on 5/10/22. -The facility was unable to provide additional documentation to show neurological checks had been completed during the survey process. 3. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/21/22 at 10:45 a.m. She said neurological checks were started when a resident fell and hit their head or sustained an unwitnessed fall. She said neurological checks were documented on a form and should be completed for 72 hours at documented intervals. The assistant director of nursing (ADON) was interviewed on 7/21/22 at 3:10 p.m. She said neurological checks should be initiated if a resident sustained a fall and hit their head or had an unwitnessed fall. She said neurological checks should be started immediately following the fall and should be documented on a written neurological form for every 72 hours in the documented time intervals. The interim nursing home administrator (INHA) was interviewed on 7/21/22 at 2:00 p.m. She said she was unable to locate documentation that neurological checks had been completed for Resident #1 for the unwitnessed fall on 5/10/22. Based on observations, interviews, and record review, the facility failed to ensure seven residents (#55, #45, #5, #1, #71, #21, and #130), out of a total sample of 47 residents, received adequate supervision and assistive devices to prevent accidents. Specifically: The facility failed to take steps to ensure the safety of three residents identified at risk for elopement and/or to require a WanderGuard (#55, #45, and #5) after Resident #55 eloped from the facility. Specifically: -Resident #55 eloped from the facility undetected on 7/10/22, and was discovered a block away from the facility by the police. Resident #55 wore a WanderGuard device, an electronic monitoring system that triggered should he exit the facility through a door armed with the WanderGuard system. Yet, on 7/10/22, the facility investigation revealed no alarm was heard by staff when the resident exited the facility. -The facility failed to take steps following Resident #55's elopement to review, revise and sufficiently educate staff on how to protect Resident #55 as well as Residents #45 and #5, who, like Resident #55, wore a WanderGuard device. While Resident #55's care plans were updated and his WanderGuard device replaced, there was no evidence the facility thoroughly investigated the incident to uncover and address why no alarm was heard, and to review the facility's use and reliance on the WanderGuard system to prevent resident elopements. Staff interviews revealed staff lacked knowledge of which residents and how many residents had a WanderGuard device, how to check whether the WanderGuard device was functioning properly, and which facility doors were armed with the WanderGuard system; facility leadership and floor staff were unaware all exit doors were not armed with the WanderGuard system. The facility's failure to take an immediate and comprehensive review of the facility's WanderGuard system and its response to Resident #55's elopement on 7/10/22 put Resident #55, as well as Residents #45 and #5, at risk for serious harm if immediate corrections were not implemented. The facility also failed to provide care for four residents (#1, #71, #21, and #130) in a manner to prevent falls and to identify post-fall decline. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Review of the elopement investigation from 7/10/22 for Resident #55, observations conducted from 7/18/22 through 7/19/22, and staff interviews, revealed the facility failed to provide Residents #55, #45 and #5 with a safe environment and adequate supervision to avoid preventable accidents. Specifically, the facility failed to take immediate and comprehensive steps following Resident #55's elopement on 7/10/22, to review, revise and sufficiently educate staff on how to protect Resident #55, as well as Residents #45 and #5, who, like Resident #55, had been identified as an elopement risk and/or wore a WanderGuard device. While Resident #55's care plans were updated and his WanderGuard device replaced, there was no evidence the facility thoroughly investigated the incident to uncover and address why no alarm was heard, and to review its use of the WanderGuard system. Staff interviews revealed staff lacked knowledge of which residents and how many residents had a WanderGuard device, how to check whether the WanderGuard device was functioning properly, and which facility doors were armed with the WanderGuard system; facility leadership and floor staff were unaware all exit doors were not armed with the WanderGuard system. B. Facility notice of immediate jeopardy On 7/19/22 at 4:10 p.m. the nursing home administrator (NHA) and regional clinical resource (RCR) #1 and #2 were notified that the facility's failure to provide residents with a safe environment and adequate supervision to avoid preventable accidents created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 7/20/22 at 2:30 p.m. the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: The facility would complete elopement assessments on all residents in the facility by 7/22/22. Any resident who would be identified as high-risk with a desire to leave the facility would be placed on 15 minute checks. The unit manager would be assigned to complete the 15 minute checks log on each shift. The director of nursing (DON) or other designee would audit the 15 minute check logs. The DON or designee would review and update care plans for those residents identified as at risk of elopement. Wander/Elopement binders would be placed at each nurse's station as well as the front lobby to include any residents deemed at risk with an updated picture, face sheet, and the elopement and wandering residents policy. Binders would be placed by 7/22/22. WanderGuard would be checked daily and documented on the treatment administration record by the unit manager or other designee to ensure functioning and placement. The DON or other designee would audit for compliance. The DON or other designee would provide education to all staff on 7/19/22 on the Wanderguard system. Training would include how the WanderGuard activates, how to check the functioning of the WanderGuard, checking the placement of the WanderGuard, and documentation for the WanderGuard. Training would also include education on 15 minute checks for all residents deemed at risk for elopement. Training would also include education on the location of the wanderer/elopement binders and the contents of the binder. Education would also be provided on the elopements and wandering residents policy. This would include how to properly respond if an alarm goes off and what to do if a resident elopes from the facility. The education would continue until all staff were educated by 7/22/22. On 7/19/22 the maintenance director tested the doors with the WanderGuard system as well as egress exit doors to ensure proper functioning. All exit doors were currently functioning properly. The maintenance director would complete daily checks of all WanderGuard and egress exit doors for proper functioning. The NHA or designee would audit the daily checks for compliance. D. Removal of Immediate Jeopardy The above plan was accepted and, based on the facility plans above, the immediate jeopardy was removed on 7/20/22 at 2:38 p.m. However, deficient practice remained at an E level. II. The facility failed to ensure the safety of three residents identified at risk for elopement/ and or requiring a WanderGuard monitoring device (#55, #45 and #5). A. Facility policy and procedure The Elopements and Wandering Residents policy and procedure, undated, was provided by the NHA on 7/21/22 at 1:33 p.m. It read, in pertinent part, Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. B. Resident #55 - wanderer and elopement risk 1. Resident status Resident #55, age [AGE], was admitted on [DATE] and resided in the facility's east unit. According to the July 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, altered mental status, and depression. The 6/8/22 minimum data set (MDS) assessment indicated the resident had a severe cognitive impairment with a brief interview for a mental status score of three out of 15. It indicated the resident had daily wandering and the wandering placed the resident at significant risk of getting to a potentially dangerous place. It indicated the resident required supervision for locomotion on and off the unit and needed extensive assistance for dressing, toileting, and personal hygiene. The 6/20/22 wandering/elopement risk assessment indicated the resident scored 14 which represented a high risk for wandering. It indicated Resident #55 could not follow directions, could not communicate, was ambulatory, had a history of wandering, had a medical diagnosis of dementia and diagnosis impacting mobility, and indicated wandering in the past month. It indicated Resident #55 could be redirected but was occasionally resistant. 2. Review of 7/10/22 incident On 7/19/22 at 12:00 p.m. the NHA provided the investigation of the resident's elopement on 7/10/22. The investigation included the final report, a change of condition completed for the resident, and the service order completed on the facility exit doors. The final report revealed the following: -Law enforcement called the facility on 7/10/22 at 5:42 p.m. and asked the receptionist if the resident lived at the facility. Law enforcement stated they found the resident one block away from the building. They brought the resident back to the facility uninjured. The report indicated the level of oversight that was provided at the time of the incident was routine skilled nursing facility care. It indicated the facility became aware of the incident at 5:42 p.m. Observations of camera footage noted the resident in the back parking lot of the building at 5:16 p.m. -The facility confirmed all exit doors were operational and the WanderGuard system was checked by an outside security system company and was found to be functioning correctly. Staff that were interviewed said they did not hear alarm sounds in the building at the time of the elopement. The report indicated the WanderGuard alarm would need to be manually shut off at a keypad once engaged. -Staff reported the resident was in the dining room at 4:45 p.m. and was escorted to his unit shortly after. The report indicated the receptionist did not see the resident at the front of the building and staff did not see the resident on the west unit which indicated the east doors were the suspect. The report indicated the resident was fitted for a new WanderGuard device, placed on one to one supervision, and the 6/2/22 wander/elopement assessment and care plan were reviewed and deemed current. -The conclusion of the report indicated it was substantiated that the resident left the facility unattended and was located by law enforcement. 3. Record review - steps taken after the resident's elopement on 7/10/22 A change in condition form was completed on 7/10/22 following his elopement. It indicated no mental or functional status changes were observed. It indicated increased physical aggression and agitation following the event. A progress note completed on 7/10/22 at 8:08 p.m. read a new WanderGuard device was placed on the resident's right ankle. It read the DON and the maintenance director checked the functioning of the device. Resident #55's care plan was revised 7/11 and 7/12/22: -The elopement care plan, revised 7/12/22, indicated the resident was an elopement risk and wanderer. Interventions included WanderGuard to the left leg, checks of placement and functioning of safety monitoring device every shift, distraction from wandering with pleasant diversions, structured activities, food, conversation, television, or books, and observation of location at regular and frequent intervals with documentation of wandering behavior and attempted diversion interventions. -The behavior care plan, initiated 7/11/22, indicated Resident #55 was an elopement risk. Inter[TRUNCATED]