**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level require more than one deficienct practice statement. A. Based on observation, interview, and record review the facility failed to ensure a resident with dementia and a diffuse traumatic brain injury was adequately supervised to prevent elopements and failed to develop and implement new interventions to prevent elopements for 1 (R22) of 2 residents reviewed for supervision in a sample of 42. This failure resulted in R22 exiting the facility multiple times without staff knowledge, including on an unknown date in October or November of 2024 in which R22 walked approximately 0.8 miles from the facility down a busy street and across a busy highway in town, and was later located by facility staff walking around a business parking lot. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy situation identified to have begun on 06/15/2024, when R22 exited the facility without supervision and the facility failed to investigate the incident and failed to implement new interventions to prevent R22 from eloping. V1 (Administrator) was notified of the Immediate Jeopardy on 2/4/25 at 3:13 PM. The surveyor confirmed by observations, interview, and record review, the immediacy was removed on 02/4/2025, the facility remains out of compliance at a severity level two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: a) R22's admission Record with a print date of 1/30/25 documents R22 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, diffuse traumatic brain injury, major depressive disorder, anxiety disorder, and insomnia. R22's MDS (Minimum Data Set) dated 11/7/24 documents R22 has a moderate cognitive impairment. This same MDS documents under Section E-Behavior, R22 has a behavior of wandering and the wandering placed R22 at significant risk of getting to a potentially dangerous place. R22's Elopement/Wandering risk assessments dated 2/9/24, 5/7/24, 8/8/24, and 11/6/24 document R22 is at risk for elopement. R22's Progress Notes document the following: 2/10/24 8:43 AM, At approximately 0843 (8:43 AM) this writer was informed that resident was outside. Resident was escorted back inside facility. Resident came inside willingly. Full facility count was initiated, and it was confirmed that only this resident was outside. A head to toe assessment completed with no new skin issues noted or reported at this time, vital signs assessed, stable and recorded in EHR (Electronic Health Record). Resident was wearing Tie Dye shirt with grey sweat pants, non-skid footwear and a reflective vest, Administrator, DON (Director of Nursing), and MD (Physician) notified with NNO (no new orders) at this time Outside temp (temperature) 42 degrees, clear and sunny, Resident is currently in his room resting. Signed by V44 (Former DON/Director of Nurses) 6/15/24 9:31 AM, (R22) found in the parking lot by staff on arrival to facility. (R22) brought in by said staff and informed this nurse. Resident is well appearing. No scratches, no bruises, no injuries observed. Resident seen by this nurse approximately 30 minutes prior. Residents nurse and administrator notified. Signed by V45 (RN/Registered Nurse) 6/24/24 3:46 PM, Resident elopes through north hall emergency exit door. 2 staff ran to door upon alarms. The resident had already gotten to church parking lot by the time staff reached the resident. Signed by V45 (RN) 7/13/24 11:58 AM, Resident exited facility and was returned safely by staff. Head to toe assessment performed. All body systems are at baseline. No trauma to skin. All vitals WNL (within normal limits). Resident given ice water and re-educated that he needs staff to accompany him when going outside. Resident currently in his room being assisted with breakfast meal. Call light within reach. Signed by V45 (RN) 10/27/24 9:04 AM, Resident exits the building today. His 101 (sic) sitter was right behind him when he exited. Resident was redirected into the building safely. Skin assessment performed. No skin integrity issues present. Signed by V45 (RN) 11/21/24 8:52 AM, Resident exited the building and was returned safely by staff. Skin assessed. No injuries and skin intact. Provider notified. Vitals WNL. Signed by V45 (RN) This surveyor attempted to contact V45 (RN) who no longer works at the facility on 1/29/25 at 1:20 PM and again on 2/3/25 at 9:31 AM, with no answer. This surveyor requested a return call with each attempt and no return call was received. On 1/28/25 at 8:23 AM, R22 walked into the beauty shop where the surveyors were working. There was no staff present with R22 at this time. R22 then left the beauty shop by himself and walked to the south hall where an unknown staff member saw R22 wandering around and took R22 to the front of the building by the reception desk. The unknown receptionist gave R22 a donut and then an unknown staff member walking in the door put on a mask and took R22 with her to his hall. R22's Progress Notes document on 1/29/25 at 7:14 AM, At approximately 0707 (7:07 AM) this writer was informed that resident was outside. Resident was escorted back inside facility by staff. Resident came inside willingly. Full facility count was initiated, and it was confirmed that only this resident was outside. A head to toe assessment completed with no new skin issues noted or reported at this time, vital signs assessed, stable and recorded in EHR. Resident wearing blue shirt with blue sweat pants, non-skid footwear and a reflective vest, Administrator, DON, and MD notified with NNO at this time. Outside temp 40 degrees, clear and sunny. Resident is currently in his room resting in his bed. Signed by V23 (RN/Registered Nurse) On 1/29/25 at 12:19 PM, when asked if she did investigations on elopements, V1 stated she did not think she had any official documentation. V1 stated the tracking and trending they do for R22's elopements include reviewing the care plan and discussing them in the daily QA (quality assurance) meetings. The facility Daily QA (Quality Assurance) Meeting Notes included multiple pages and handwritten dates with no year documented on some of them. The QA Meeting notes document the following under Resident Behaviors. 6/17/24 (R22) out of facility door alarm sounding, seen by staff member, returned without incident 6/25 (initials of R22): North R (right) staff to alarm. 7/15 (initials of R22) South left, staff responded to alarm running, staff caught. 10/28 (initials of R22) North R (right) with 1:1 . 11/22 Admin Add on Notes: (initials of R22): South, turned around with no difficulty. On 1/29/25 at 9:15 AM, V6 (Certified Nursing Assistant/CNA) stated she came to work at 7:00 AM on 1/29/25 and was told R22 had left the facility. V6 stated she didn't know details about what happened. V6 stated she had been told V21 (CNA) was outside and happened to notice R22 in the parking lot. V6 stated it is hard to keep up with R22 while providing care to the other residents. V6 stated R22 has a 1:1 staff member because he likes to get out and she thinks someone is always with R22. V6 stated R22 also wears a safety vest like construction workers wear (reflective) to make R22 more visible. On 1/29/25 at 10:19 AM, V21 (CNA) stated she got to the facility around 7:05 AM on 1/29/25 and saw R22 running around the parking lot. V21 stated R22 was wearing pants, shirts, socks, and had a blanket. V21 stated the doors were not alarming and they were trying to find out which door R22 went out. V21 stated R22 got out of the facility a month or two ago and was walking down the road toward the stop sign by a (2 lane highway). V21 stated she didn't have any other information about that time. According to the website Google.com/maps, (road referenced) is approximately 0.3 miles from the facility. On 1/29/25 at 11:08 AM, V22 (CNA) stated she was responsible for R22 on night shift beginning on 1/28/25 and clocked out at 7:20 AM on 1/29/25. V22 stated she was giving report to the oncoming shift at 7:00 AM and R22 was doing laps around the facility. V22 stated R22 went into a room where they were covid testing staff around 7:10 AM. V22 stated R22 wasn't in his room when she did the walk through with the day shift staff relieving her, but she had just seen him walking around. V22 stated she wasn't aware he was found outside the facility, in the parking lot, until after she clocked out. V22 stated there were no door alarms sounding when she left. V22 stated if R22 had exited through any other hall exit door she wouldn't have heard the alarm. V22 stated she was not aware of R22 exiting the facility without staff supervision any other time. V22 stated R22 doesn't have a 1:1 staff on night shift because they don't have enough staff to provide it. V22 stated most of the time they have enough staff to keep R22 safe and meet the needs of the other residents. V22 stated R22 wears the safety vest at night in case he does elope. On 1/29/25 at 11:24 AM, V23 (RN) stated she works 12-hour night shift (7 PM to 7 AM). V23 stated on the morning of 1/29/25, she was giving report to day shift (V4 LPN/Licensed Practical Nurse) a little after 7:10 AM, when she was notified R22 had exited the facility and was in the driveway/parking lot. V23 stated she didn't hear a door alarm sound. V23 stated she looked at R22 to make sure he didn't have any injuries. V23 stated R22 had eloped before but it had been a while since he had. V23 stated R22 wears a reflective vest they take off when they put his pajamas on at night. V23 stated she had been told they couldn't use the wander guard system since it was considered a restraint. On 1/29/25 at 2:07 PM, V4 (LPN) stated she arrived at the facility around 6:30 AM on 1/29/25. V4 stated she was told R22 had eloped, and administration was checking to see which door he exited and checking the panels to see what alarms were going off. V4 did not have any other information related to this elopement. On 1/29/25 at 10:03 AM, V27 (CNA) stated he wasn't aware R22 eloped on the morning of 1/29/25. V27 stated R22 has a sitter with him, the doors are alarmed, and R22 won't leave the facility. V27 stated R22 has a tracker on his ankle, and they can track him if he would leave. V27 stated anyone who sees R22 should redirect him back to his area. V27 stated if R22 starts walking the sitter follows him but once he takes his medications, he is chill. On 1/29/25 at 11:36 AM, V12 (Maintenance Director) stated he was aware R22 had eloped on 1/29/25 and had already checked all the doors to make sure they were working correctly, and they were. V12 stated he makes daily rounds and hadn't had any door locks/alarms not working. At 11:41 AM on this same date, this surveyor walked with V12 to the exit door located near the beauty shop. V12 opened the door, and it alarmed as it should. This surveyor walked with V12 to see if the alarm could be heard on the halls the residents reside on and/or near the nurse's station. The alarm was no longer able to be heard after turning the corner and prior to reaching the nurse's station and/or resident room areas on the south hall. This surveyor and V12 walked toward the north hall and the alarm sound was no longer able to be heard near the entrance door of the dining room which is prior to the north hall nurse's station and resident room areas. V12 also confirmed he could not hear the alarms. When asked if they couldn't hear the alarms how would staff know someone had exited the facility, V12 stated, he knows they have a 1:1 staff sitting with R22, he wears a reflective vest, and V1 (Administrator) has something on her phone with R22's GPS (Global Positioning System) location. On 1/29/25 at 1:56 PM, V16 (CNA) stated she was not aware R22 had eloped on the morning of 1/29/25. V16 stated she wasn't sure what R22's interventions were to prevent elopement. V16 stated R22 has a consistent one to one staff from 8:00 AM to 3:00 PM but after 3:00 PM he pretty much does his own thing, especially if they are short staffed. On 1/29/25 at 9:28 PM, V24 (CNA) stated R22 doesn't have a 1:1 staff with him on night shift. V24 stated they watch him the best they can. V24 stated it is easy to watch him through the night it's in the morning when they are trying to get people up that is it harder. V24 stated R22 is very smart and has the concept of holding the door until it opens. V24 stated he wears the safety vest so people can see him if he gets out. V24 stated she was working when R22 eloped on 1/29/25 but he wasn't one of her assignments. V24 stated none of the alarms sounded. When asked if she could hear the alarms V24 stated, Not very well. V24 stated R22 is supposed to always have the safety vest on. On 1/29/25 at 9:38 PM, V18 (CNA) stated R22 has a staff member sitting with him throughout the day but not on nights. On 1/29/25 at 4:30 PM, V1 (Administrator) provided this surveyor with the facility undated Self-Identified Quality Assurance Plan of Correction documents, Problem Identified: Exit from facility. Resident did not leave grounds, resident not harmed or emotional upset. Returned to facility without difficulty. 1. Corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice? (R22 initials) was immediately returned to the facility without complication and placed on 1:1 supervision .3. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? Facility immediately checked all exit doors for alarm function. All alarms functioning and require a key to shut them off. Facility immediately did a resident head count to assure all residents accounted for. All residents were accounted for. Facility interviewed all staff, and no one answered an alarm and shut it off. Facility has educated all staff on duty and will educate all staff who haven't previously been educated for the next three days about monitoring door closure behind them when they come in the facility or when they leave the facility to make sure door closes securely and properly. Facility placed (R22's initials) on 1:1 supervision and will continue until re-evaluate by the IDT (Interdisciplinary Team) to decide if is safe to remove the supervision. Facility contacted the sister and will send referrals to all TBI (Traumatic Brain Injury) facilities that can be located in the state of Illinois. Facility has ordered additional door exit alarms for the three doors that are the furthest from the nurse's station as added precaution. Facility has ordered Stop Sign door guards to be applied at each exit door with the exception of the front lobby door where visitors and staff enter and exit many times a day. Staff will be educated to not remove the door guards. 4. How will you monitor the corrective action (s) to ensure the deficient practice will not recur .Admin (administrator), DON, and/or designees will do random observations of at least one staff member entering and exiting the facility a minimum of 5 times per week for 4 weeks. Admin, DON, and/or designees will do random observations of Stop Sign door guards properly applied to each exit door a minimum of 5 times per week for 4 weeks. Results of the observations will be discussed in the Quarterly QA (Quality Assurance) Meeting times 2 with educational needs discussed as need by the Facility Administrator, DON, and or designee. Completion Date: 1/29/25. The untitled document dated 1/29/25 attached to this plan of correction documents 1/29/25 After investigation, IDT concluded that resident (R22) followed an employee out of a door. During investigation all door alarms were checked and functioning properly on 1/29/25. In addition, door alarms are checked daily by maintenance or designee. IDT identified QAPI (Quality Assurance and Performance Improvement) and implemented staff in-servicing immediately. On 1/30/25 at 12:02 PM, V28 (Family Member) stated the facility hadn't communicated with her at all recently. When asked how long it had been since the facility had called her with an update, V28 stated it had been a couple of months since she heard anything from them. V28 stated she was R22's surrogate mom and she was the only one they would contact regarding R22's condition and care. V28 stated she was told awhile back (date unknown) R22 had attempted to escape the facility. V28 stated that is the only elopement she was made aware of. V28 stated she hadn't been contacted by the facility at all the past few days. V28 stated she is concerned with the care R22 is getting because she is the one who always looks after him and she hadn't been getting any communication from the facility. On 1/30/25 at 1:15 PM, V1 (Administrator) stated they have a tracking tag on R22 so if he exits the facility, they call her or the Director of Nursing and they track where R22 is located. V1 stated they don't have a wander guard system because it would be expensive to implement in the building. V1 stated V31 (Social Services Director) was the staff member who contacted V28 (Family Member) after R22's elopement on 1/29/25. On 1/30/25 at 2:00 PM, V31 (Social Services Director) stated R22 eloped once while she was at the facility. V31 stated he made it to the facility parking lot. V31 stated he just gets out and the facility staff get him and bring him back in. V31 stated he doesn't make it very far. When asked if she called V28 (Family Member) to discuss possible placement in a TBI (Traumatic Brain Injury) facility after he eloped on 1/29/25, V31 stated she had not spoken with her and hadn't sent out any referrals. V31 stated she tries to call everyone's power of attorneys who are on her advocate list and V28 had never returned her calls. V31 stated, she (V28) is [NAME] (missing in action). V31 stated she had worked at the facility since 12/2023 and had never had contact with V28. V31 stated she had left a number for V28 to return calls and she had never called her back. When asked if she had attempted to contact V28 after R22 eloped on 1/29/25, V31 stated, No, I haven't tried to call her yet. On 1/30/25 at 10:04 AM, V7 (CNA) stated she had provided care for R22, and he elopes at times. V7 stated they can't hear the door alarms when they go off and R22 moves fast. V7 stated R22 got close to the next town one time and that is when they implemented the reflective vest. V7 stated they also put an air tag on his ankle. V7 stated R22 usually walks to the church located next to the facility. On 1/30/25 at 10:41 AM, R46, who is alert to person, place, and time, stated sometimes R22 will run out of the door. R46 stated R22 looks for food all the time, will take whatever he finds, and eat it. R46 stated R22 has made it out the door, run across the street, and made it into people's houses. R46 stated this occurred about a month and a half ago. R46 stated he also went towards the stop sign located at the corner of Old Murphysboro Road and Tower Road. On 1/30/25 at 1:32 PM, V29 (Medical Records/CNA) stated she had been working when R22 had eloped in the past. V29 stated R22 wanders and has a staff member who sits with him. V29 stated they try to have one 24 hours a day, but it doesn't always work that way. V29 stated R22 isn't afraid to just walk out the door. V29 stated she wasn't working when R22 made it to the next town or into neighboring houses but had heard about it and believes it was more than a year ago that it occurred. On 1/30/25 at 3:07 PM, V32 (CNA) stated R22 usually had a staff member sitting with him from 8 AM to 1 PM or 3 PM. V32 stated when R22 doesn't have a sitter the other aids can't always keep an eye on him. V32 stated most of the time R22 stays in his room. V32 stated the farthest R22 got was down Tower Road toward Old Murphysboro Road. V32 stated one time (date unknown) he did make it to the gym located close to the intersection of Old Murphysboro Road and New Route 13 (4 lane highway). V32 stated she was busy providing care to another resident that day and she thought V33 (CNA Supervisor) was the one who picked R22 up. V32 stated R22 didn't have a staff member sitting with him that day. V32 stated the front door was alarming and they were able to hear it. V32 stated R22 wasn't injured or upset when he returned to the facility. V32 stated she had heard R22 had gotten into the houses across the street from the facility but that was before she started working at the facility in 2023. On 1/30/25 at 3:16 PM, V33 (CNA Supervisor) stated she was working when R22 had eloped in the past. V33 stated R22 usually elopes at shift change when they are getting the residents up in the morning. V33 stated R22 made it to the gym located at the corner of Old Murphysboro Road and New Route 13. V33 stated it occurred around 7:00 AM. V33 was unable to recall the exact date but stated it was in October or November of 2024. V33 stated on that day, she saw R22 make a lap around the unit and when R22 starts wandering, they redirect him back to his room. V33 stated she happened to hear the alarm go off and she knew she needed to look for him. V33 stated she got in her car, and she went one way and other staff went another way. V33 stated she found him wandering around the gym parking lot (located at the intersection of Old Murphysboro Road and New Route 13), with a cup in his hand. V33 stated she got R22 in the car and took him back to the facility. V33 stated another time R22 left, he made it onto Old Murphysboro Road and was found near the funeral home (located 2 miles from the facility). V33 stated R22 had the reflective vest on and that happened a long time ago (unable to provide a date). V33 stated if it's quiet enough they can hear the alarms on the doors. According to the website Google.com/maps, the gym is located 0.8 miles from the facility and would take the average person 16 minutes to walk from the facility to the gym. On 2/3/25 at 10:02 AM, V43 (CNA) stated he remembered R22 exiting the facility without staff. V43 stated R22 likes to go through his bathroom into the adjoining room and out that room's door. V43 stated they immediately mobilized a search party and found him about 15 minutes later. V43 stated he believed it was V33 (CNA Supervisor) who located him that time. V43 was not able to remember the date it occurred but believed it was 2-3 months ago. V43 stated he knew R22 had eloped two other times and was trying to get into someone's residence and someone's car but that was probably two years ago. V43 wasn't sure if R22 had a 1:1 present with those elopements. V43 stated it is very hard to do 1:1 with him if no one is assigned to him. V43 stated it is very hard to keep track of him. On 2/6/25 at 10:22 AM, V51 (CNA) stated she was working when R22 eloped once. V51 stated she believed it was in December of 2024 but couldn't remember the exact date. V51 stated staff heard the alarm on the laundry room door, and all went to see why it was alarming. V51 stated R22 was found in a neighbor's yard by V45 (RN). V51 stated R22 didn't have staff with him and when they located him, he was trying to wrap himself in a blanket. V51 stated she didn't think he was gone long because the neighbors called the facility and believed it happened around 8:00 AM. On 2/6/25 at 9:40 AM, V50 (CNA) stated she was working when R22 eloped in the past. V50 stated she couldn't remember the exact date, but she knows the elopements occurred in 2024. V50 stated it happened twice. V50 stated one of the times (date unknown) she was in or near the dining room when a resident told her the door alarm was sounding on R22's unit. V50 stated as she went around the corner onto the unit, she could hear the alarm and see the door was cracked. V50 stated she spotted R22 across the main busy street, walking on the sidewalk, towards the stop sign located at the intersection of Tower Road and Old Murphysboro Road. V50 stated R22 was alone with no staff with him. V50 stated she yelled his name, and he kept walking. V50 stated she caught up to him close to the intersection, turned him around, brought him back to the facility, and notified nursing. V50 stated the other time she walked to the nurse's station on the north hall and heard the door alarm sounding. V50 stated she quickly walked to the door and when she looked out, she saw R22 outside without staff, walking toward the stop sign. V50 stated she caught up to him close to the intersection. V50 stated she didn't remember the date of these occurrences, but they were both in 2024. On 1/30/25 at 3:51 PM, V44 (Former Director of Nurses) stated she worked at the facility from 2/24/23 to 1/10/25. V44 stated R22 did leave the facility when she was working and he either went out the front door or out the door at the end of his hall and staff were with him. V44 stated when R22 doesn't have a sitter everyone keeps an eye on him. V44 stated they try to keep him away from the beauty shop hall since that door is the farthest away and hardest to hear. V44 stated she doesn't recall R22 ever making it to the gym located on Murphysboro Road and New Route 13. R22's current Care Plan documents a Focus area of (R22) is an elopement risk/wanderer AEB (as evidenced by) Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities of others. Date Initiated: 05/24/2022. The interventions documented for this Focus Area are, 1:1 sitter x (times) 72 hours. Medication review and adjustments made as ordered. Date Initiated: 06/01/2022 .Hydroxyzine as ordered for anxiety and restless behaviors. Date Initiated: 08/18/2023 .Allow him to sleep longer in the morning and offer snack upon waking up. Date Initiated: 08/21/2022 . Medications times changed, no meds to be given before 9 a.m. Date Initiated: 8/21/2022 .offer a more substantial snack such as peanut butter and jelly or appropriate substitute at bedtime. Date Initiated: 08/21/2022 Offer snack upon waking, Date Initiated: 08/21/2022 .Safety device monitor to right ankle-check for placement every shift and notify management (DON/Director of Nurses, ADON/Assistant Director of Nurses, Administrator) if it is not in place. Date Initiated: 8/11/2023 .Assess for fall risk. Date Initiated: 5/24/2022 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Likes to listen to music. Date Initiated: 05/24/2022. Documents wandering behavior and attempted diversional interventions in behavior log. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist: Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/24/2022. Monitor for fatigue and weight loss. Date Initiated: 05/24/2022. Safety vest on at night. Date Initiated: 12/11/2024. R22's Care Plan/Behavior Tracking Record was reviewed from 1/2024 to 2/3/2025 and documents under Problem Statement, (R22) will wander putting his health and safety at risk. The Goal is documented as, (R22) will be easily redirected in the next review. With Interventions documented as, 1. Point in the direction you would like (R22) to go. 2. Get (R22) snacks/drink. 3. Redirect. 4. Refer to nursing as needed. These same records document R22 wandered 9 days in 1/2024, 6 days in 2/2024, 28 days in 3/2024, 16 days in 4/2024, 22 days in 5/2024, 28 days in 6/2024, 23 days in 7/2024, 30 days in 8/2024, 22 days in 9/2024, 17 days in 10/2024, 30 days in 11/2024, 26 days in 12/2024, 10 days in 1/2025, 2/1, 2/2, and 2/3. Each day R22 wandered has multiple episodes of wandering documented. The facility was unable to provide any behavior tracking specific to elopements. On 01/29/25 at 12:32 PM, V8 (MDS Coordinator) stated she was responsible for updating and implementing interventions on resident care plans. V8 stated R22 didn't have any new interventions implemented to prevent elopements in the year 2024. V8 stated she didn't implement any new interventions because R22 was never out of eyesight of staff. V8 stated she just implemented new interventions when she was directed to by the Administrator and Director of Nursing. When asked what their usual routine was if someone had a new event occur, V8 stated they discuss it in meetings and implement an intervention to try to decrease risk. When asked why they didn't do that each time R22 eloped, V8 stated, I couldn't tell you. V8 stated she didn't remember any details about R22's elopements and she didn't believe any notes were taken when they met. This surveyor reviewed the care plan interventions documented on R22's current care plan and asked V8 if R22 had eloped in December 2024 and if not why was there a new intervention of the safety vest documented on 12/11/2024. V8 stated she would have to check on it. On 1/29/25 at 1:48 PM, V8 (MDS Coordinator) stated the intervention of the vest was implemented before 12/11/24 it just wasn't documented on R22's care plan. V8 stated it was found when the previous regional nurse was doing a review of R22's record and she added it to the care plan. V8 stated she wasn't sure when they implemented the safety vest intervention. On 2/3/25 at 2:07 PM, V1 (Administrator) stated she was not able to locate any other documentation on R22's elopements for the year 2024. V1 stated the IDT (Interdisciplinary Team) had not met yet to determine if R22 was safe to not have a 1:1, 24 hours a day. V1 stated R22 was currently on 1:1, 24 hours a day. When asked why he wasn't on it on the night when I called and spoke with staff V1 stated, Ok. When did you call. This surveyor responded with 1/29/25 and asked again if he had 1:1, 24 hours a day. V1 stated, We are working on it. When asked what that meant, V1 stated, We are working to schedule 1:1, 24 hours a day. When asked does he currently have 1:1 supervision 24 hours a day, V1 stated, I will have to check with the person who does scheduling. This surveyor reviewed with V1 that V31 (Social Services Director) had stated she did not talk with V28 (Family Member) after the elopement on 1/29/25 and had not spoken with her since she started working at the facility. V1 stated they reached out to V28 and V28 didn't answer so they kept calling until they got a hold of her. V1 stated they spoke with V28 on 2/3/25. When asked if she could remember what happened each time R22's progress notes document an elopement, V1 stated possibly after reviewing everything. This surveyor reviewed with V1, the interviews documenting R22 was found at the gym located 0.8 miles from the facility and V1 stated she was not aware of that. This surveyor asked V1 if they should notify the family and physician with each elopement and V1 stated, I would have to check. When asked if she could say why there were no new interventions implemented after each elopement for the year 2024, V1 stated, I cannot. When asked if there should have been new interventions implemented, V1 stated, I am not sure. I will need to check. On 2/4/25 at 8:46 AM, V1 (Administrator) stated she couldn't remember the exact date the 1:1 staff supervision on day shift started for R22, but she believed it was in July or August of 2023. V1 stated they didn't implement that intervention to prevent elopements but had implemented it to keep R22 from taking other residents' food out of their rooms and they didn't set it up to have to be consistent with the time frames that R22 had 1:1 staff but they tried to have them during meal hours. On 01/30/25 at 2:19 PM, V34 (Physician) stated he was not notified that R22 had eloped and did not feel that he was safe in the community alone. V34 stated he was aware R22 had a history of wandering and stealing food but does not recall any communication regarding him leaving the facility. The

Based on interview and record review, the facility failed to ensure physician's orders were followed, for 1 of 5 residents (R55) reviewed for significant medication errors in the sample of 30. This failure resulted in R55 missing three doses of long- acting insulin from 1/17/25 to 1/19/25, causing R55's blood sugars to be extremely elevated. This has the potential to lead to ketoacidosis which could result in coma and possible death. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy was identified to have begun on 01/17/25 at approximately 9:00 PM when the facility was unable to provide R55's scheduled long-acting insulin and did not notify the physician. The facility also failed to administer R55's long-acting insulin as ordered on 01/18/25 and 01/19/25. V1 (Administrator) and V2 (Director of Nursing), were notified of the Immediate Jeopardy on 02/04/25 at 3:13 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 02/04/25, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings include: R55's admission record documents an admission date of 01/17/25 and list the following diagnoses in part; vascular dementia, mild with psychotic disturbances and type 2 diabetes mellitus. R55's MDS (Minimum Data Set) dated 01/24/25, documents a BIMS (Brief Interview for Mental Status) of 11, indicating that R55 is moderately cognitively impaired. Section I-active diagnoses documents an active diagnosis of diabetes mellitus. R55's care plan documents an initiation date of 01/28/25 for a focus area that states R55 is at risk for complications r/t (related to) dm (diabetes mellitus). R55's Physician's Order Sheet (POS) documents an order with an order date and a start date of 01/17/25 for Toujeo Solostar Subcutaneous Solution pen-injector 300 Units/ML, (Insulin Glargine) (long-acting insulin), Inject 70 units at bedtime for diabetes mellitus. R55's Physician's Order Sheet (POS) documents an order with a start date of 01/18/25 for Blood glucose per fingerstick as needed for signs/symptoms of hyperglycemia/hypoglycemia. On 01/27/25 at 10:03am, V36 (Family member) stated that they continued to ask the nurse about R55's meds the first couple of days of being in the facility because she wasn't getting all of them or her insulin, they continued to be told they were still working on it. V36 stated staff reported they were still working on her admission through Sunday. V36 stated R55 was not getting her blood sugar checked at meals either. V36 stated that R55 had her blood sugar checked four times a day at the hospital and she had continuous monitoring at home. On 01/29/25 at 12:01pm, V37 (Family member) stated R55 was admitted on Friday 01/17/25 in the evening, and it was a struggle all weekend getting her medications. V37 said that they asked the nurses several times from Friday to approximately Sunday or Monday for R55's medications and insulin's and they kept saying that they were working on getting her admitted still. V37 stated they asked staff several times to check R55's blood sugar around mealtime, which is what she did at home and at the hospital, but no one did. R55's progress notes document that on 01/17/25 and 01/19/25 Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin) was not administered due to awaiting pharmacy delivery. R55's January 2025 Medication Administration Record (MAR) documents a blood glucose finger stick was started and administered by V42 (Registered Nurse/RN) on 01/18/25 and documents a blood sugar of 308. R55's January 2025 MAR documents no signatures on 01/17/25 or 01/19/25 for Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin), indicating it was not administered. R55's January 2025 MAR documents a signature on 01/18/25 for Toujeo Solostar Subcutaneous Solution pen-injector (Insulin Glargine) (long-acting insulin) indicating that it was administered by V46 (Registered Nurse/RN), and a blood sugar of 411. V46 was unavailable for interview to explain how she was able to administer a medication that was not available in the facility or why she documented in the MAR a blood sugar of 411 and did not contact the physician. On 01/30/25 at 09:58am, V41 (Pharmacy medical records) reviewed medication orders for R55. V41 stated a new order was received from the facility for long-acting insulin on 1/17/25. V41 stated an emergency order was called to the backup pharmacy (a local pharmacy) on 1/17/25. V41 stated the order was never picked up by facility. V41 stated on 1/19/25, a nurse from the facility called to ask about it and the pharmacy informed them it was to be delivered later that evening or there was an emergency order called in to the backup pharmacy and they stated they will wait for the delivery. V41 confirmed the long-acting insulin was delivered on 01/19/25. V41 stated the facility would not be able to access their supply without contacting the pharmacy for a code to open the bin the medication was in. On 02/03/25 at 03:43pm, V2 (DON) stated that discharge orders from residents admitted from the hospital are to be put into the computer system as soon as possible, copied and then faxed to the pharmacy. V2 stated if they are not faxed by 8pm, they will not be received that day. V2 stated some medications, including insulin's are kept in the emergency kit in the medication room. V2 stated if they are not in there, they should contact the pharmacy and see if they can bring them on an emergency run or from the backup pharmacy (local pharmacy). V2 stated if it comes from the backup pharmacy, she believes they deliver it. V2 stated she was not aware that R55 missed multiple doses of long-acting insulin before she reviewed her admission packet on 1/20/25 or 1/21/25. V2 stated at that time she contacted V34 (Physician) to see if he wanted R55 to have sliding scale insulin. V2 stated that her process for new admission orders is that two nurses independently review the orders and then she will review the admission packet also. V2 stated she would have expected V34 be contacted with any missed doses of insulin or blood sugars above 300. On 02/03/25 at 12:03pm, V42 (RN) stated the process for admitting new residents with medications, is that the admitting nurse puts the orders in, and if they are not finished by the next shift, the oncoming nurse should finish them. V42 stated if she put an order in for an as needed (PRN) blood glucose fingerstick for R55, it was because it was either on her discharge sheet or ordered by the doctor. V42 stated that she did not notify the doctor of a blood sugar of 308 for R55 because they are not required to. V42 stated if they need medications, they call the pharmacy, if they cannot get them then they should notify the doctor. V42 stated on 01/19/25 when she was taking care of R55, her meds were still not available in the facility and she did not notify the physician. On 02/03/25 at 12:19pm, V4 (License Practical Nurse/LPN) stated when a new admit comes, they get discharge orders and the nurse that receives the resident is to put them in. V4 stated they are then checked by a second nurse and then by V2 (DON). V4 stated this is a new process that was put in place by V2 since she started a few weeks ago. V4 stated the process for obtaining medications is to call the pharmacy and order the medication, see if it is in the emergency supply and then the backup pharmacy. V4 stated she was not sure who's responsibility it was to get meds from the backup pharmacy, but she has seen them come via door dash from a local pharmacy before. V4 stated residents should not miss a dose of insulin and if that were to happen, the doctor should be notified. V2 stated she did R55's admission but could not recall what the situation was with R55's medications when she was admitted . On 01/30/25 at 02:19pm, V34 (Physician) stated on 01/17/25 he was notified late at night about R55 having a drug allergy and order clarification for a medication. V34 stated he was not contacted again until 1/21/25. V34 reviewed his communication with the facility and stated he had not been contacted at all about R55's insulin not being available or blood sugar until 1/21/25. V34 stated he was contacted on 01/21/25 by V2 (Director of Nursing/DON) about orders for sliding scale insulin for R55. V34 stated yes and he directed them to call his office if they were not familiar with his standard sliding scale. V34 stated he would expect to be contacted about any resident, not just a new resident, with a blood sugar of 308 and 411, especially the 411. V34 stated his expectation would also be that they recheck R55's blood sugar after numbers like that. V34 could not say for sure what would have happened or the level of harm that could have happened because everyone responds differently, but that he had not been notified of any of it. V34 stated his expectation would be for R55 to not miss any doses of insulin, especially if there was a script waiting at a pharmacy in town the same day. V34 stated his expectation would be to be notified in those instances. On 02/03/25 at 02:45pm, V26 (LPN) stated she was working on 01/17/25. V26 stated she did not recall the situation with R55 and not receiving insulin. After a review of R55's medication administration record (MAR), V26 verified she did not administer R55's insulin and she recalled being told in report from the day shift nurse that the medication was on its way. V26 stated she could not recall if she notified the doctor or not but should have. On 02/10/25 at 07:51am, V50 (Pharmacy medical records) stated it is the responsibility of the pharmacy couriers to pick up medications filled at the backup pharmacy. V50 stated she had no documentation as to why R55's insulin was not picked up from the backup pharmacy or that anyone from the facility contacted them about R55 until 01/19/25. V50 stated the facility did not attempt to obtain the medication from the Emergency kit for R55. V50 stated when the facility calls in the order to the pharmacy, if it is the emergency kit (E-kit), the pharmacy technician would advise them to pull from E-kit if it were available there. V50 stated the pharmacy technician would then walk them through the process and grant them access to the medication. V50 stated judging by the fact that an order was sent to the backup pharmacy immediately, the medication may not have been available in the E-kit. V50 confirmed there was not R55's type of insulin available in the facility emergency kit from 01/17/25-01/20/25. V50 confirmed there was no correspondence between the facility and the pharmacy from 01/17/25 and 01/19/25 regarding R55's insulin. According to the Mayo Clinic website (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551), Diabetic ketoacidosis is a serious complication of diabetes. Under When to See a Doctor it documents Seek emergency care if: Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test .untreated diabetic ketoacidosis can lead to death. According to the Center for Disease Control (CDC) website (https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.html), Diabetic ketoacidosis (DKA) is serious and can be life-threatening. Under Causes it documents Very high blood sugar and low insulin levels lead to DKA. The two most common causes are: .2. Missing insulin shots, a clogged insulin pump, or the wrong insulin dose. Under Testing it documents Go to the emergency room or call 911 right away if you can't get in touch with your doctor and if you're having any of these signs: Your blood sugar stays at 300 mg/dL or above . A facility document titled Administering Medications with a revision date of December 2012 documents under policy statement, Medications shall be administered in a safe and timely manner, and as prescribed. The Immediate Jeopardy began on 01/17/25 and was removed on 02/04/25 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review. 1. 2/4/25 Facility has reviewed the following policies for education and implementation. -Medication Order Policy-Revision made to assure IDT review and reconcile all new admission medication orders within 24 hours of admission. 2. 2/4/25 at 5:30 PM DON educated by the Regional Clinical Director, on the following policies and procedures; Medication Order Policy. IDT to review all new admission medication orders within 24 hours. 3. 2/4/25 at 5:30 PM Staff education on the following policies and procedures by DON and Regional Clinical Director and/or IDT who received train the trainer training listed above. -Medication Order Policy -IDT to review all medication within 24 hours. -Alleged Completion date 2/4/2025 and ongoing prior to working next scheduled shift until 100% of employees are educated. -Clinical department new hires will be educated prior to starting any shifts by a member of the IDT that have been trained to provide the training. 4. 2/4/25 at 3:55 PM Nurses in serviced on Medication Order Policy including but not limited to medication reconciliation with hospital orders upon admission done by V2 (DON) and V39 (LPN). 5. 2/4/25 at 5:00PM IDT team in-serviced on revised Medication Order Policy with emphasis on all new admission orders should be reviewed within 24 hours completed by V8 (LPN, MDS/CP Coordinator) and V2 (DON) V39 (LPN) or clinical designee. 6. 2/4/25 at 5:35 PM. All resident medication order to medications on hand match back began by V3(Regional Director of Clinical Services), V2 (DON), V39 (LPN).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free from neglect when they failed to assess, treat, and implement interventions to prevent pressure ulcers, accurately assess for skin breakdown, discontinue psychotropic medications as ordered by the physician, and provide oral care for 1 of 5 (R12) residents reviewed for neglect in the sample of 19. This failure resulted in R12 being transferred to the local hospital on [DATE] for altered mental status and possible sepsis. Once at the hospital it was determined R12 had received Haldol and Clonazepam without a physician order from 11/23/24 until 12/01/24. R12 had developed 15 new wounds including a Stage 2 and Stage 3 to his buttocks, a Stage 2 to the left knee, and two deep tissue injuries to his bilateral heels. R12 also had a buildup of a hardened yellow/brown coating with cracking and fissures noted to be covering the tongue from lack of oral care. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/23/24 when the facility failed to 1. Assess R12's skin upon return from the hospital on [DATE], 2. Put treatment orders in place for the pressure ulcer identified throughout R12's hospital stay 3. Identify, assess, treat, and notify the physician of the new pressure areas identified on R12's 11/30/24 shower sheet, 4. Discontinue psychotropic medications as ordered on the hospital discharge instructions on 11/23/24, and 4. Provide oral care per current standards of practice. V1 (Administrator) was notified of the Immediate Jeopardy on 12/11/24 at 1:30 PM. The surveyor confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 12/11/2024, but the noncompliance remains at Level Two due to additional time needed to evaluate implementation and effectiveness of training. Findings Include: R12's admission Record with a print date of 12/5/24 documents R12 was admitted to the facility on [DATE] with diagnoses that include fracture of left femur, hypotension, diabetes, schizophrenia (diagnosis added on 11/07/24), bipolar disorder (added on 11/07/24) difficulty walking, and muscle weakness. R12's MDS (Minimum Data Set) dated 10/17/2024 documents R12 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. This same MDS documents R12 required partial to moderate assist for transfers, was independent for bed mobility, and was at risk for developing pressure ulcers. R12's local hospital records dated 12/01/24 documents R12 is more confused upon arrival to the hospital. R12's current Care Plan documents a Focus area of (R12) uses psychotropic medications (Escitalopram) r/t (related to) dx (diagnosis) depression, anxiety. Schizophrenia 10/9/24 Clonazepam for agitation, 10/27/24 Clonazepam increased, 10/29/24 Escitalopram decreased, 11/8/24 Haldol, Date Initiated: 05/03/2024. Interventions for this Focus area include, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/03/2024 . R12's facility Progress Notes document the following: 11/17/24 - At 0700 (7:00 AM) resident was observed to be unresponsive and weak. VS (vital signs): 97.1, 122, 32, sat (oxygen saturation) 70, bp (blood pressure) 139/75. No purposeful movement on the left side. Unable to assess pupils. Ambulance called and resident transferred to (local hospital) ER (emergency room). MD (physician) and POA (power of attorney) informed. 11/17/24 - Called for an update on the resident. Resident will be admitted IP (inpatient) for aspiration PNE (pneumonia). R12's local hospital record documents R12 was admitted to the local hospital on [DATE] and discharged back to the facility on [DATE]. R12's hospital record includes under Secondary Discharge Diagnosis, bed sore on buttock. This same hospital record documents under Hospital Course, .Patient advised to take Augmentin 875 for 3 days post discharge. He was also advised to stop taking Haldol and Clonazepam as the medications were held for the entirety of his admission and he had no psych issues . Under Active Issues Requiring Follow-up and Discharge Plan the hospital records document, .Please stop taking Haldol. Please stop taking Clonazepam . R12's facility Progress Note dated 11/23/24 documents, Resident's Haldol and Clonazepam discontinued by hospital at discharge. Antibiotic added Discharge medication list faxed to (name of pharmacy) and (V14/Physician) office. Provider notified of arrival. R12's facility Order Summary Report Active Orders as of 11/30/24 includes the following physician orders, Clonazepam 0.5 mg (milligrams) Give 0.5 mg by mouth three times a day for anxiety, with a start date of 10/27/24 and Haloperidol (Haldol) oral tablet 5 mg Give 5 mg by mouth three times a day related to schizophrenia, unspecified; bipolar disorder unspecified, with a start date of 11/08/24. There is no end or discontinue date documented for either physician order. R12's Progress Notes dated 11/24/24 at 2:57 PM signed by V18 (RN/Registered Nurse) documents, Clonazepam Tablet 0.5 MG, give 0.5 mg by mouth three times a day for anxiety Resident's medication was dc'd (discontinued) at the hospital. Reaching out for clarification on medication. R12's Medication Administration Record (MAR) dated 11/01/24 to 11/30/24 documents an order for Clonazepam 0.5 mg to be administered at 9:00 AM, 2:00 PM, and 9:00 PM. This MAR documents initials indicating Clonazepam 0.5 mg was administered at 9:00 PM on 11/23, 11/24, 11/26-11/30, at 9:00 AM 11/24-11/30/24 and at 2:00 PM 11/26-11/30/24. This same MAR documents the Clonazepam was held at 2:00 PM on 11/24 and 11/25/24. This indicates upon R12's return to the facility the Clonazepam was administered 20 times and held three times. This same MAR documents an order for Haldol 5 mg to be administered at 9:00 AM, 2:00 PM, and 9:00 PM with initials documented indicating R12 was administered Haldol at each dose time from 11/23/24 to 11/30/24. On 12/16/24 at 12:37 PM, V18 (Registered Nurse/RN) stated she was responsible for readmitting R12 to the facility after his return from the hospital on [DATE]. V18 stated she charted the Haldol and Clonazepam had been discontinued in the progress notes. V18 stated when she returned to work the next day, she noticed they were still active on R12's medication list so she held them waiting for clarification. V18 stated she spoke with the night shift nurse (V19/RN) who said she had taken care of it and the medications were reinstated so she assumed the physician had given an order to resume them. On 12/28/24 at 10:00 AM, V19 (RN) stated V18 was the day shift nurse when R12 returned from the hospital, and she (V19) was the oncoming night shift nurse. V19 stated V18 reported to her R12's medications were discontinued by the hospital. V19 stated R12 doesn't have any medications ordered on night shift other than Tylenol. V19 stated she did not call the physician to clarify the medication orders from the hospital discharge. V19 stated she wouldn't have had a reason to look at those medications and/or orders since R12 didn't take medications on her shift and V18 had reported to her they were discontinued. On 12/4/24 at 2:35 PM, V5 (CNA/Certified Nursing Assistant) stated mid-November, R12 stopped eating, started refusing care, and became a two person assist. V5 stated it was a change in R12's condition and it worsened when he came back from the hospital on [DATE]. V5 stated R12 would get up for meals before he went to the hospital and when he came back, he would barely eat and/or drink and even stopped yelling down the halls. V5 stated she reported this to an unknown nurse, and she thought the nurse assessed R12 and documented it. On 12/9/24 at 12:50 PM, V2 (DON/Director of Nurses) stated the Haldol and Clonazepam were started because R12 had extreme behaviors. V2 stated after it was discontinued at the hospital, she assumed V15 (Psychiatric Nurse Practitioner/Psych NP) had resumed the order when he returned to the facility and that was why he was still getting the medications. On 12/9/24 at 1:02 PM, V15 (Psych NP) stated the facility did not notify her R12 had been to the hospital and/or that the medication had been discontinued by the hospital physicians. V15 stated she looked back at her communication with the facility, and she got a message R12 needed a refill on his Clonazepam but was never notified by the facility the medication had been discontinued. V15 stated she hadn't seen R12 since 10/24/24 and her expectations would be that if a medication were discontinued while the resident was at the hospital it would stay discontinued when they returned to the facility. R12's Braden Scale dated 11/10/24 documents a score of 14, which indicates R12 is at moderate risk of skin breakdown. R12's Braden Scale dated 11/24/24 documents a score of 12, which indicates R12 is at high risk of skin breakdown. R12's current Care Plan documents a Focus area of (R12) is at risk for skin breakdown r/t (related to) requires assist with bed mobility, frequently incontinent of B & B (bowel and bladder). Has left side neglect. Date Initiated: 05/16/2024. This Focus area includes the following interventions, 10/30/24 cover spokes on left side of w/c (wheelchair) .8/27/24 Pad bed frame. This same focus area includes the following interventions initiated on 5/26/24, assist T & P (turn and position) at least every 2 hours and prn (as needed) Educate resident/family/caregivers of causative factors and measures to prevent skin injury Encourage good nutrition and hydration in order to promote healthier skin Follow facility protocols for treatment of injury .Keep skin clean and dry. Use lotion on dry skin . Monitor/document location, size and treatment of skin injury, if occurs. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (physician) Offer toileting/check every 2 hours and prn (as needed) provide peri-care as needed Pressure relief mattress on bed and cushion in w/c (wheelchair) as preventative . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . R12's Order Summary Report Active Orders as of 11/30/24 documents a physician order for weekly skin checks with no orders documented for treatments to specific areas of skin breakdown and/or orders for interventions to prevent skin breakdown from 11/23/24 to 12/01/24. R12's Progress notes document. 11/23/24 12:49, Report received from (name of local hospital). Resident will be arriving today by EMS (emergency medical services). Resident is a Mechanical soft diet with thin liquids by mouth. Family declined to have resident's code status changed to comfort measures and will remain full code with current plan of care with an addition of PO (oral) abx (antibiotic). 11/23/24 15:51, Resident arrives at this time via EMS. R12's Initial Skin Alteration Record signed by V18 (RN), dated 11/23/2024 documents under Site, Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound [NAME] found (sic) to BUE (bilateral upper extremities). Several bruises and skin tears present Comments- healing skin tears to left arm noted. no signs of infection observed. resident not in pain at this time. this nurse unable to complete a head to toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. Treatment Plan .Monitor skin tears . There are no measurements, assessments, or physician notification documented on this assessment. R12's medical record did not document any Initial Skin Alteration Records after 11/23/24. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she was working on 11/23/24 when R12 returned from the hospital. V18 stated she attempted to do a skin assessment, but he was resisting, and she didn't want to cause him distress. V18 stated she did see the dressings that had been applied at the hospital and looked under them and didn't see any open areas. V18 stated she meant to put an order in to remove and replace them every three days and just forgot to do it. When asked what interventions were implemented to prevent skin breakdown, V18 stated he had a pressure reducing mattress on his bed and a cushion in his chair. V18 stated they floated his heels and would try to reposition him hourly. R12's Weekly Skin Check dated 11/24/24 not signed until 12/04/24 by V18 (RN) documents under Site: Left antecubital- Resident refusing skin assessment, yelling to leave him alone. Able to assess visible skin. Resident pushing away this nurse when trying to assess. Wound found found (sic) to BUE. Several bruises and skin tears present Comments: healing skin tears to left arm noted, no signs of infection observed. resident no in pain at this time. This nurse unable to complete a head-to-toe assessment as resident was screaming no and resisting with physical pushing away of this nurse. will continue to monitor. This is the same narrative that was documented in R12's Initial Skin Alteration Record dated 11/23/24. On 12/9/24 at 9:59 PM, when asked if she completed the Weekly Skin Check dated 11/24/24, V19 (RN) stated R12 was sitting in his wheelchair, and she noticed the area on his arm was healed. V19 was asked if she assessed any other skin on R12 and she stated, No, I just looked at his arm. V19 stated they have another nurse who does all the treatments for south side. This surveyor reviewed with V19 that R12 wasn't located on that side and V19 stated she thought he was. This surveyor then asked V19 if she did a physical assessment of R12's skin from 11/23/24 until 12/01/24 and if she completed the 11/24/24 Weekly Skin Check and V19 stated, I don't remember. I usually just ask the CNA if the residents have any skin changes. On 12/9/24 at 12:50 PM, this surveyor reviewed the 11/23/24 initial skin assessment and the 11/24/24 weekly skin assessment with V2 (DON) and she stated the 11/24/24 assessment looks like it was copied and pasted from the 11/23/24 assessment. R12's Skin Monitoring: Comprehensive CNA Shower Review documents dark bruising to R12's left arm, heels as red, coccyx as dark red, a bandage to the inside of his inner right leg and a bandage on his left hip with V17's (CNA) signature dated 11/30/24. This Review documents V2 (DON's) signature with a date of 11/30/24 with no assessment of the new areas documented under Nurse Assessment. On 12/5/24 at 8:37 AM, V17 (CNA) stated R12's condition had declined when he returned from the hospital on [DATE]. V17 stated R12 wasn't eating, drinking, and/or communicating as well. V17 stated she gave R12 a bed bath on 11/30/24 and found a bandage on his left hip that was looking a little rough. V17 did not remember if there was a date on the bandage that would indicate when it was placed. V17 stated when she rolled R12 over she noticed R12's coccyx was dark red, and his right hip was splotchy in color. V17 stated she was concerned R12 was mottling and then she removed his socks and noted that both of his heels were dark red as well. V17 stated there was a bandage on R12's inner thigh that didn't look as bad as the one on his left hip, but she again didn't know if there was a date on it. V17 stated she didn't remove the bandages, so she didn't know what his skin looked like under them. V17 stated she documented the areas on the shower sheet and told V2 (Director of Nurses) who was working as her nurse that night. V17 stated she told V2 she was worried R12 was dying and that his family needed to be notified. V17 stated she also reported the change in R12's condition to the oncoming shift and her supervisor (V21/CNA Supervisor). V17 stated R12 was sent out to the hospital two days later so she assumed someone heard her concerns. When asked what interventions were in place to prevent the pressure injuries from worsening, V17 stated there was a pillow under his left hip that was always there because of previous skin issues but that was the only intervention in place. V17 stated R12 was clean and dry when she changed him and that he was dependent on staff for all care. On 12/5/24 at 1:48 PM, V21 (CNA Supervisor) stated V17 told her R12's skin looked bad, but she didn't remember the date this occurred. V21 stated she asked V17 if she had reported it to the nurse and V17 told her she reported it to V2 (DON). On 12/5/24 at 12:04 PM, V2 (DON) stated she didn't remember signing off on the 11/30/24 shower sheet that documented the new areas of skin breakdown for R12. V2 stated she was working the floor that day and was told she had to get skin assessments on all the residents. V2 stated she attempted to get other nurses to assist her with it and was not able to get anyone to assist. V2 stated V17 (CNA) helped her by doing skin assessments and documenting them on the shower sheets. V2 stated she knew R12 was declining, not getting out of bed, not eating, and not drinking. V2 stated, I am really pi**ed off at myself and the building because I had zero help except for the CNA's who can't make calls or write orders. It can't be just me. I don't have any help at all. When asked if she ever assessed R12's skin, V2 stated, No. V2 stated the skin assessments were done on Sunday 11/30/24 but she didn't sign them until Monday, December 01, 2024. V2 stated she wished V17 had told her on Friday, how bad R12's skin was. When asked to clarify if R12's skin was assessed on Friday 11/29 or Saturday 11/30, V2 stated they were working midnight shift, and she wasn't sure if it was before or after midnight. V2 stated it was miscommunicated and they missed it. V2 stated if she had done R12's skin assessment she would have notified the physician and obtained orders for treatments. V2 stated they recognized there was an issue and have put things in place to make it better. V2 stated they are checking each morning during clinical rounds to make sure skin assessments are being done. V2 stated R12 should have had a head-to-toe assessment on 11/23/24 when he returned from the hospital and again before he went back to the hospital on [DATE]. On 12/5/24 at 11:16 AM, V18 (Registered Nurse) stated she followed R12 closely even when she wasn't his nurse. V18 stated he wasn't eating well, and his oxygen dependence was increasing. V18 stated R12 didn't start showing skin breakdown until 11/30/24 and she was working on the other side that day. V18 stated she told his nurse she would be over there the next day and would look at him then. On 12/9/24 at 10:18 PM, V24 (CNA) stated she provided care to R12 between 11/23/24 and 12/01/24. V24 stated R12 was incontinent of bowel and bladder and was not able to turn and reposition himself. When asked what interventions were implemented to prevent pressure ulcers from developing, V24 stated they were turning and repositioning R12 and using pillows for support. V24 stated she was aware of the areas of skin breakdown on R12, and he had them for probably a couple of weeks. R12's facility Progress Notes document: 11/30/24 - 1907 (7:07 PM) Resident has a loss of appetite and motivation. Resident continues to take medication but not showing any improvement. This nurse will continue to monitor. Reported to nightshift nurse. If not showing improvement by mid shift tomorrow, will reach out to provider for further intervention. 12/01/24 - 14:06 (2:06 PM) Resident still not doing well and declining. Despite antibiotics, resident has not eaten in two days, has crackles throughout lung fields, febrile at 102.8 F (Fahrenheit), today extreme lethargy to the point where nursing judgement is that it is not safe to give PO (oral) medication. EMS (Emergency Medical Services) called for emergent send out for possible sepsis. Provider and POA (Power of Attorney) notified. Vital signs as follows: 154/64, pulse 138, respirations 28 and shallow with crackles and wheezes, Temp (temperature) 102.8, post Tylenol, O2 (oxygen) at 91 on 4 L (liters). 12/01/24 - 4:26 PM, (R12) admitted IP (in patient) for AMS (altered mental status) and sepsis r/t (related to) aspiration PNE (pneumonia). R12's local hospital records dated 12/01/24 documents Patient presents from the nursing home for altered mental status. He is somnolent. This hospital record documents under ED (Emergency Department) Triage notes, Per EMS, pt (patient) was recently discharged with pneumonia. Pt had a temp of 103.6 F, Tylenol was given at nursing home. Heart rate 130's and more confused this morning. Pt localizing to pain and shaking head to questions. Labored breathing. skin warm, Dry. mouth is extremely dry The physical exam dated 12/01/24 documents R12 is ill appearing and lethargic. Under Clinical Impression it documents, Altered mental Status, unspecified altered mental status type. Sepsis without acute organ dysfunction, due to unspecified organism Under Physical Exam R12's hospital record includes, .Skin: General skin is warm and dry. Comments: Sacral decubitus, multiple wounds left buttocks, left hip, heels, left arm - see photos R12's hospital records document under Wound Nurse Note, Wound care: Wound consult completed w/(with) dressings applied to the following POA Pis (present on admission pressure injuries): right medial heel: DTPI (deep tissue pressure injury) & (and) left lateral heel.: DTPI & coccyx: Stage 3 PI and Left buttock: Stage 2 PI and left lateral knee: Stage 2 PI; and skin tear located on the left elbow previously dressed per assigned RN (Registered Nurse). R12's hospital records document the following assessments of the pressure areas all dated 12/01/24. 1. DTPI right heel- measured 4.5 cm (centimeters) x 3.8 cm described as purple, painful, dry, intact, non-blanchable. 2. Pressure injury of left lateral heel measured 2 cm x 1.5 cm and described as non-blanchable, purple, dry, intact. 3. Stage 2 pressure injury left buttocks measured 0.6 cm x 0.7 cm x 0.1 cm and described as partial thickness, red moist, painful, blanchable with scant serous drainage. 4. Stage 3 pressure injury to midline coccyx measured at 1.5 cm x 0.9 cm x 0.2 cm and described as full thickness, moist, painful, with scant amount of serosanguinous drainage, and 5. Stage 2 pressure injury to left lateral knee measured at 0.9 cm x 0.5 cm x 0.1 cm and described as red, moist, with scant amount of serous drainage. Under Adult Neglect Assessment and Plan, R12's hospital record document, Patient has over 15 new wounds since last admission, he received Haldol and benzos (benzodiazepine) in the nursing home which were discontinued by our team at the time of the discharge (11/23/24), patient became somnolent due to this and stopped eating and was readmitted this time. Patient's son does not want him to go back to (name of facility) and is looking at other nursing home options. On 12/4/24 at 8:55 AM, V16 (Registered Nurse-hospital) stated he was familiar with R12. V16 stated R12 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. V16 stated R12 had three wounds when he left the hospital on [DATE] that had dressings on them. V16 stated when R12 returned to the hospital on [DATE], R12 had 15 wounds and still had the same dressings on the original three wounds that was on when he was discharged on 11/23/24. On 12/5/24 at 2:08 PM, V14 (Physician) reviewed R12's hospital records and stated the pressure areas on R12's hip deteriorated from 11/23/24 to 12/01/24. V14 stated the area on R12's trochanter increased in size from 11/23 to 12/01/24. When asked if the pressure ulcers/injuries were avoidable, V14 stated the areas on R12's heels would have been preventable. On 12/09/24 at 1:29 PM, V14 (Physician) stated if R12 was immobile from somnolence then it could precipitate him developing pressure ulcers. According to the Medical Dictionary located at the website Somnolency | definition of somnolency by Medical dictionary the definition of somnolent is 1. Drowsy; sleepy; having an inclination to sleep. 2. In a condition of incomplete sleep; semi-comatose. On 12/4/24 at 4:00 PM, V1 (Administrator) stated R12 had new areas identified on his 11/30/24 shower sheet. V1 stated there were no assessments, treatment orders, physician notification, or physician orders documented in R12's record related to the new areas. V1 stated her expectation would be for any new area of skin breakdown to be assessed and the physician notified for treatment orders. R12's hospital records with an admission date of 12/01/24 documents under Dehydration- Assessment & (and) Plan Note, Nursing staff reported pt (patient) has had decreased PO (oral) intake since last admission, especially for the last 2 days during (sic) pt has had only a few bites to eat. Pts oral mucus membrane appeared dry with yellow crusts on tongue and palate. R12's local hospital records with an admission date of 12/01/24 documents a photograph of R12's mouth that shows R12's tongue that is covered in a dry scaly cracking with fissures, with a thick residue that is yellow/white/brown in color. On 12/11/24 at 10:04 AM, V23 (RN/Hospital Shift Supervisor) stated when R12 was admitted to the hospital on [DATE] his mouth looked like the bottom of the Sahara dessert. On 12/4/24 at 2:35 PM, V5 (CNA) stated they offer oral care, but residents have the right to refuse it and they don't offer it to someone who is alert and oriented since they can ask for it if they want it. When asked if she provided anyone with oral care today (12/4/24) while she was working, V5 stated she did not. V5 stated one of the nurse's was wanting to set up a cart for them so oral care would be offered when the residents got up. When asked if she ever provided oral care for R12, V5 stated she didn't. V5 stated it was hard to provide care for R12 because he would refuse. On 12/5/24 at 11:16 AM, when asked about oral care, V18 (RN) stated it was an issue. V18 stated for Christmas she bought rolling carts and was going to have them put their morning care supplies on the cart. V18 stated she had a concern oral care wasn't being provided but it had been identified as an issue and a plan was in place to attempt to improve it. On 12/5/24 at 11:47 AM, V20 (Family Member) stated he had concerns about the care R12 was provided at the facility. V20 stated he was told by the nurse at the hospital R12's bandages/treatments were not changed after he left the hospital on [DATE] and the areas were worse. V20 stated he also had concerns R12 wasn't getting good oral care because every time he would go to the facility his lips were always dry and chapped and R12 was always thirsty. On 12/5/24 at 12:48 PM, V1 (Administrator) stated she had access to the pictures of R12's mouth that were taken at the local hospital during his emergency room evaluation on 12/01/24. V1 stated she was very disappointed with the way his mouth looked. When asked what her expectations were for oral care, V1 stated, I mean that it is to be done routinely. On 12/5/24 at 2:08 PM, V14 (Physician) V14 stated oral care is pretty darn important. V14 stated the stuff on his tongue could be food or cancer but he wasn't able to tell from the pictures and did not elaborate further on why oral care was important. On 12/18/24 at 3:00 PM, V39 (Physician) stated she provided care to R12 during his hospital stay beginning on 12/01/24. V39 stated R12 had been discharged from the hospital about a week (11/23/24) prior and when he returned to the hospital on [DATE], he had more pressure ulcers that had developed while at the facility. V39 stated when R12 was discharged from the hospital on [DATE] they had discontinued the Haldol and Clonazepam. V39 stated the facility continued to give R12 those medications. V39 stated those medications caused somnolence which in turn caused R12 to not eat and/or drink the way he should have. V39 stated this caused R12 to end up back in the hospital with dehydration. V39 stated R12 wasn't turned and repositioned while at the facility which led to R12 developing more pressure ulcers. V39 stated R12 was not provided oral care for probably 5-6 days leading to R12's tongue having the crusty build up on it that is evidenced in the photos that were taken at the hospital. V39 stated she considered these failures by the facility to be neglect. According to the National Library of Medicine found at A preventive care approach for oral health in nursing homes: a qualitative study of healthcare workers' experiences - PMC .Studies have reported that poor oral health affects older adults' wellbeing and is associated with issues pertaining to pain and problems with eating, swallowing and social interactions [3]. Impaired oral health can also have a negative impact on general health conditions such as cardiovascular disease and diabetes, and it can lead to malnutrition and aspiration pneumonia The facility Decubitus Care/Pressure Areas policy dated 9/2024 documents, The facility Decubitus Care/Pressure Areas policy dated September 2024 documents, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Procedure: Upon identification of skin breakdown, the following will be completed; 1) The pressure area will be assessed and documented. 2) Complete all areas of a wound assessment following NPUAP (National Pressure Ulcer Advisory Panel) guidelines i) Document size, stage, site, depth, drainage, color, odor, and treatment (once obtained from the physician) 3. Notify the physician for treatment orders 4. Documentation of the pressure area must occur upon identification and at least once each week 8) Initiate problem area on care plan. The facility Change in a Resident's Condition or Status policy dated 2021 documents, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The facility Adverse Consequences and Medication Errors policy dated 2023 includes, .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include: a. Omission .b. Unauthorized drug-a drug is administered without a physician's order . The facility Administering Medications policy dated January 2024 documents, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders, including any required time frame . The facility Abuse Prevention Policy dated 2022 documents, residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Purpose: .The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated Neglect is a facility's failure to