**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accuracy of assessments, coordination of care with a wound care clinic, and ensure recommended interventions were followed for one (R18) of four residents reviewed for pressure ulcers, resulting in R18 being sent to the hospital from the wound care clinic for surgical debridement and intravenous (IV) antibiotics of an infected Unstageable (full-thickness skin and tissue loss in which the wound bed is obscured by slough or eschar) Pressure Ulcer. Findings include: On 10/14/24 at 9:26 AM, R18 was observed sitting up in bed eating breakfast. A low air loss mattress (group 2 mattress) was observed on R18's bed and a ROHO (individual air cells) cushion was observed in R18's wheelchair. R18 was asked if they had any wounds. R18's spouse explained R18 had a bad wound on their bottom and they were going to a wound care clinic for it. Review of the clinical record revealed R18 was admitted into the facility on 8/16/23 and readmitted [DATE] with diagnoses that included: acute and chronic respiratory failure, cervical disc disorder and atrial fibrillation. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition and required substantial/maximal assistance of staff for mobility in bed. The MDS assessment also indicated R18 had two facility acquired Stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcers. Review of R18's wound assessments documentation revealed: A Skin & Wound Evaluation dated 7/17/24 read in part, .Type: Pressure - Kennedy terminal ulcer (skin failure during the final weeks of life) .Stage: Stage 1: Non-blanchable erythema (redness) of intact skin .Location: Sacrum, Lateral .In-House Acquired .Exact Date: 7/17/24 . A Wound Evaluation dated 7/17/24 read in part, #18 - Pressure - Kennedy terminal ulcer - Stage 1 .Sacrum - Lateral . The evaluation also included a picture of R18's wound. A Skin & Wound Evaluation dated 8/31/24 read in part, .Type: Pressure - Kennedy terminal ulcer . Stage 2: Partial-thickness skin loss with exposed dermis .Progress: Resolved . A Wound Evaluation dated 8/31/24 read in part, .#18 - Pressure - Kennedy terminal ulcer - Stage 2 .Sacrum - Lateral . The evaluations included a picture that showed R18's wound that had an open wound, not a resolved wound. A Skin & Wound Evaluation dated 9/13/24 read in part, .Type: Pressure - Kennedy terminal ulcer .Stage: Unstageable: Obscured full-thickness skin and tissue loss . Location: Coccyx . In-House Acquired .Exact Date: (left blank) . A Wound Evaluation dated 9/13/24 read in part, .#21 - Pressure - Kennedy terminal ulcer - Unstageable .Coccyx . The picture showed the wound in the same place on R18's body as the previous sacrum evaluations. A Wound Evaluation dated 10/15/24 read in part, .#16 - Pressure - Unstageable .Coccyx . This evaluation was documented in a previously resolved wound thread however, the picture was consistent with R18's current wound. Review of R18's wound care consultation documentation available in the electronic clinical record included only two from 9/10/24 and 9/17/24, and revealed only treatment recommendations for R18's wounds. No consultation notes or description of R18's wound were included in the documentation. On 10/15/24 at 10:06 AM, the Director of Nursing (DON) was interviewed and asked about the apparent discrepancy in the documentation of R18's wounds. The DON explained she had not been at the facility when R18 acquired their wounds. The documentation and pictures of R18's wounds was reviewed with the DON. The DON agreed the wound labeled as Sacrum - Lateral and Coccyx and receiving the numbers 18, 21 and 16 were most likely the same wound. The DON was asked who had diagnosed R18's wound as a Kennedy terminal ulcer. The DON explained it is the doctor who diagnoses. When informed according to progress notes, R18's attending physician, Dr. S had last seen R18 on 7/10/24, the DON explained it must have been the Nurse Practitioner (NP R). The DON was asked about the lack of the wound care clinic's consultations and description of R18's wounds. The DON explained she would look into it. Multiple attempts beginning 10/15/24 at 12:31 PM were made to speak via phone or in person with Dr. S. No return call was made prior to the end of the survey. On 10/15/24 at 4:29 PM, a phone interview was conducted with Dr. P, the wound care clinic doctor. Dr. P was asked about R18's wounds. Dr. P explained R18's wounds had deteriorated significantly and were infected, they had sent R18 directly from the clinic to the Emergency Department (ED) from the clinic for surgical debridement and antibiotics .it had appeared the recommended interventions had not been done. Dr. P was asked if they had ever diagnoses R18's wounds as Kennedy terminal ulcers. Dr. P explained they had not. Dr. P was asked to provide the consultation notes for R18. Review of R18's wound care clinic consultation notes revealed: 9/10/24 .Note: The sacral wound cannot be examined today because the patient did not arrive seated in (their) Hoyer Lift (mechanical lift) sling. Therefore, the staff cannot safely transfer (them) for examination . 9/17/24 .Wound #4 Coccyx is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer .The patient's wounds have worsened despite offloading on a group 2 alternating low are loss pressure reducing surface. (in bold type) (They) is a candidate for a group 3 air-fluidized bed (powered support surface that circulates air through ceramic beads to reduce pressure, friction and shear). The prognosis for healing is extremely poor unless offloading can be optimized . 10/1/24 .The coccygeal ulcer has further worsened due to suboptimal offloading .A group 3 air-fluidized bed is strongly recommended. The prognosis for healing is extremely poor unless offloading can be optimized .Offloading: .Sleep on group 2 alternating low air loss pressure reducing surface and turn q2 (every 2 hours) hours alternating between sides until group 3 air-fluidized bed procured . 10/15/24 .The coccygeal wound has further deteriorated .suggesting inconsistent adherence to the offloading directives Nor, as far as I can tell, have my strong recommendation for a group 3 air-fluidized bed been pursued. The prognosis for healing is extremely poor unless offloading can be optimized .Wound #4 (coccyx) .New circumferential undermining .Except for a narrow peripheral rim of inflamed, red subcutaneous tissue, the wound surface is entirely obscured by grossly necrotic (dead) tissue undergoing liquefactive necrosis. No viable tissue is visible .Large amount of serosanguineous (blood and serum fluid) drainage with strong malodor. The wound is grossly infected .I disagree with the classification of the ulcer as a terminal Kennedy ulcer .the patient is not imminently or actively dying; however, given the current condition of the wound, he is at high risk for sepsis and death without urgent intervention, including hospital admission, IV (intravenous) antibiotic therapy, and aggressive debridement . Review of R18's progress notes revealed a Plan of Care Note dated 10/15/24 at 8:26 PM that read in part, .wound care provider was admitting guest to (local) hospital for debridement of (their) coccyx wound . Further review of R18's progress notes revealed: A Skilled Charting note dated 9/17/24 at 3:19 PM read in part, .Guest encouraged to turn and reposition. Guest favors laying on back . A Plan of Care Note dated 9/26/24 at 7:31 PM read in part, .Staff continues to encourage guest to turn and reposition frequently, guest does decline, states 'I don't like laying on my sides.' Guest prefers laying on (their) back . *It should be noted turning and repositioning is not necessary when using a group 3 air-fluidized bed. On 10/16/24 at 10:49 AM, NP R was interviewed and asked if they had diagnosed R18's wounds as Kennedy terminal ulcers. NP R explained they had agreed with the nurse's assessment, that it was a collaboration with nursing. NP R was asked if they were monitoring R18's wounds. NP R explained since R18 went to a wound care clinic, they did not monitor the wounds, they deferred to the doctor at the clinic. On 10/16/24 at 1:33 PM, the Administrator was interviewed and asked if they had ever been notified that the doctor at R18's wound care clinic had recommended R18 have an air-fluidized bed. The Administrator explained it had never been brought to their attention. On 10/16/24 at 12:49 PM, Licensed Practical Nurse (LPN) Q, who had taken the picture of R18's wound on 10/15/24, was interviewed and asked if there had been drainage and an odor when she changed the dressing on R18's coccyx. LPN Q explained there was drainage and an odor. Further review of the Wound Evaluation of R18's coccyx dated 10/15/24 read in part, .EXUDATE (drainage): Amount: Light; Type: Serous (serum); Odor noted after cleansing: None . On 10/16/24 at 1:54 PM, the DON was informed of the findings from the wound care clinic consultation notes and asked why the consultation notes had not been requested after each visit to the wound clinic since the clinic's doctor was the one who was managing the resident's wound. The DON had no explanation. Review of a facility policy titled, Prevention of Pressure Ulcers revised 10/2010 read in part, .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognize, evaluated, reported to the practitioner, physician, and family, and addressed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: MI00146401 and MI00146531 This citation had two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review the facility failed to provide adequate supervision for one Resident (R903) of two Residents reviewed for accidents resulting in an unbeknownst exit of a cognitively impaired, wheelchair bound resident from the facility and a fall with injury. Findings include: A record review revealed that R903 was admitted to the facility on [DATE] after a hospitalization, for skilled nursing and rehabilitation services. R903 was recently hospitalized and readmitted back to the facility on 7/25/24. R903's admitting diagnoses included Schizophrenia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), Parkinson's disease, end stage renal disease, (on hemodialysis) with history of falls and syncopal (fainting) episodes. R903 had a guardian who handled R903's medical, legal, and financial decisions. Based on the Brief Interview for Mental Status (BIMS), R903 had a score of 11/15, indicative of moderate cognitive impairment. R903 needed limited staff assistance with their Activities of Daily Living (ADLs) such as dressing, bathing etc. A complaint received by the State Agency revealed that a resident fell of their wheelchair in the middle of the road at 9 PM and the facility staff were unaware that R903 was outside of the facility. The facility's front doors were locked and resident was observed on the ground with their wheelchair by a visitor who had notified the facility staff. An initial observation was completed on 8/27/24 at approximately 11:05 AM. R903 was observed sitting in their wheelchair, in the room doorway. When this surveyor asked to meet with the R903, they were trying to back up into the room from the doorway and reported that they may need help and started backing up in their wheelchair. R903 took approximately two minutes to back into their room with verbal cues from the surveyor to back up the wheelchair. R903 had a dressing on the left lateral (outside) elbow area. R903 reported that they had pain on their left hip/groin area. When the surveyor asked how severe their pain was, R903 stated 10/10 and added I have never had this kind of pain. R903 added they were getting pain medication that was just started a few days ago. They had pain medication this morning and it was not helping and they needed something more. LPN C was notified by the surveyor. R903 was queried if the pain started after their fall, they reported that it started days after the fall and they did not remember the time frame. R903 was queried if they had seen a physician, R903 reported that a woman, not a doctor, not sure about the time frame, who was going to order an ultrasound (test) for the pain. LPN C' who was assigned to care for R903 came in; R903 reported that their pain was 10/10 and nurse reported that it was too soon to get another dose of Tramadol and they would get them a Tylenol. R903 was queried about their fall. R903 reported that they fell outside of the facility in the parking lot area. R903 confirmed that they were outside the building and there were no staff members with them. R903 stated, I scrapped my left arm, not sure if they hit their head. R903 reported that the Emergency Medical Services (EMS) came and they did not want to go to hospital. When asked about the details of the incident, R903 reported that they were in their wheelchair and thought they might have dozed off and fell. When queried further about the specifics of the fall, they reported that they did not remember. R903 added that they were not allowed to go out on their own anymore after the fall. R903 reported that they had a guardian for a few years who handled their businesses and they were able to provide the name of their guardian. R903 had asked the surveyor to check on the test that was ordered for them. Later that day a follow up observation was completed at approximately 1:40 PM. R903 was in their room and they reported that their left hip/groin pain was little better than the morning and stated it was 7/10 and they did not go to dialysis because of pain. R903 was queried about the fall time, approximately 8:30 PM (based on the visitor and staff witnesses) and how they had left through the main entrance door that was set to lock at 6 PM and if they knew the code to unlock the front door. R903 reported that they did not know the code and thought they went outside before the doors were locked (6 PM), but they were not sure. They added that they were not sure how long they were sitting outside before they fell out of their wheelchair. On 8/28/24 at approximately 10:05 AM, R903 was observed in their bed and x-ray technician was in the room. This surveyor met with R903 in their room after. R903 reported that they had an x-ray of their hip. They added that they still had left hip/pain, it was 6/10 and they had constant pain. R903 also added that they were in pain all weekend (last weekend) and they had asked the staff to get some medication for pain; they had been getting the tramadol for the last few days. R903 reported that they were not able to take their shower last night because of their pain. Review of R903's Electronic Medical Record (EMR) revealed a nursing progress note dated 8/8/24 at 20:30 read in part, At approximately 2030, guest was observed outside of the facility, on the ground. Guest stated that she was sitting in her wheelchair when she tipped over, with her wheelchair falling on top of her. Guest stated that she did hit her head on the ground. Guest has a new skin tear on the back of the left forearm writer called EMS to transport guest to hospital due to possible head injury .EMS refusing to take her to hospital stating she can make her own decisions. Director of Nursing (DON) and on call provider notified. Writer attempted to call guest's guardian but could not get in touch with her. Incoming nurse will reattempt during business hours . Further review of nursing progress note revealed a note titled skilled charting' dated 8/9/24 at 9:59 read in part, Transfer and ambulation 1-person assist (PA) with 2-wheeled walker. BIMS of 11, moderate cognitive impairment .Intervention: Offer resident to sit outside in front while waiting for dialysis. Resident can sit outside in front on patio on non-dialysis days and in the afternoon/evening. Root cause: poor trunk control. Inter Disciplinary Team (IDT) reviewed incident, root cause analysis, and new intervention and agree with plan of care. Review of R903's progress notes revealed a care transition (social services) note dated 7/26/24 that read in part, guest has a guardian named 'name of guardian omitted' .BIMS score 11/15 indicating cognition is moderately impaired .plan is for guest to remain Long Term Care (LTC) at 'name of the facility' omitted . Further review of progress notes did not reveal any evidence of follow-up evaluation by a physician or practitioner note after the fall incident on 8/8/24. There was no evidence that there were follow-up radiology/other diagnostic tests were ordered despite the nature of the incident: an unwitnessed fall incident outside of facility, with R903 reporting of hitting their head, R903's cognitive impairment and nursing observation/assessment that warranted a 911 call. Further review of the EMR revealed a physician progress note dated 7/19/24, (prior to recent admission to hospital). The surveyor confirmed with the DON on 8/27/24 that all physician documents were entered in EMR except for a practitioner visit note from 8/26/24. Review of R903's Electronic Medical Record (EMR) revealed physician orders that included: hemodialysis on Monday, Wednesday and Friday and a scheduled pick up at 11:30 AM; vital signs twice daily dated 7/25/24; acetaminophen tablet 325 milligrams (mg) - 2 tablets by mouth every 4 hours as needed for pain dated 7/25/24; and tramadol HCL 50 mg - 1 tablet every 6 hours as needed for pain. Review of R903's care plan revealed that R903 was at risk for falls due their diagnoses and co-morbidities with their physical and cognitive limitations. Review of physical therapy Discharge summary dated [DATE] revealed that R903 needed minimal staff assistance with their wheelchair mobility in a corridor or similar space. Resident's functional wheelchair mobility on outside terrain, patios and or sidewalk were not assessed or addressed. Standing balance at discharge indicated that R903 was a high risk for falls and they needed staff supervision with their transfers. A request was sent via e-mail on 8/27/24 at 12:48 PM and verbally to the DON and Administrator to provide the incident/accident report and investigation/facility follow-up for R903's incident/accident from 8/8/24. The facility provided an incident report completed on 8/9/24 that revealed the predisposing factors for the incident were impaired memory and weakness/fainted. The section under statements read no statements. Section under agencies people notified read that R903' s guardian was notified on 8/8/24 at 20:45. There was no investigation and root cause analysis of an unbeknownst exit of a cognitively impaired, wheelchair bound resident from the facility into a secluded area of the parking lot and sustained an unwitnessed fall with skin tear that was brought to the attention of facility staff by a visitor (at 8:30 PM). On 8/27/24 at approximately 2:15 PM Regional Nurse Consultant (RC) A was queried about the investigation file for R903's incident from 8/8/24 as the DON was out of facility. RC A reported that they just found out about the incident and they would check with the DON and Administrator. On 8/27/24 at approximately, 2:35 PM facility Administrator was queried about the incident and investigation report. They reported that they were not involved in investigating the incident. They were notified of R903's fall and the DON completed the fall investigation. They did not provide any further explanation. An interview with the visitor who observed R903 in the parking lot was completed on 8/27/24 at approximately 3:45 PM. The visitor reported that they were leaving the facility with their spouse after visiting a family member it was approximately 8:45 PM. They observed R903 lying on the ground with their wheelchair on top of R903 and they were unsure if that was resident or a visitor. They reported that they had asked R903 if they had hit their head and R903 responded yes. The visitor added that R903 had gash on her arm and it was bleeding. The visitor reported the facility front door was locked when they had left. Their spouse went in and alerted the staff member while they had stayed with R903. There were two nurses who came and assisted the resident. The visitor added that staff members thanked them the next day for and bringing the incident to their attention and helping with the situation. An interview with Licensed Practical Nurse (LPN) B was completed on 8/27/24 at approximately 1:45 PM. They were queried if they remembered about R903's incident on 8/8/24. LPN B reported that they remembered the incident. They had finished their shift and they were charting on the receptionist's computer near the main entrance. A family member came to the facility between 8:30 and 8:45 PM and reported that a resident was hurt and they were on the ground and needed help. When queried how the family member had entered the facility, LPN B reported that the door was locked the family member was regular visitor and they had the code to enter and they had to use the code to exit the building. LPN C who was also at the desk, was completing their charting after their shift. They both went out and saw R903 on the ground in back. LPN B confirmed that there was no one outside and the area where R903 was not visible from the inside. LPN B stated, We assessed [R903] notified [LPN F] (who was assigned to care for R903 on that shift). When they had reported that R903 was outside on the ground LPN F was not aware that R903 was outside the facility. They had called 911. This surveyor asked LPN B to show the area where they had found R903. This surveyor walked with LPN B from the front entrance to approximately three hundred feet away towards the secluded area (West side parking). There was turn on a sidewalk with an incline closer the [NAME] end parking where R903 was located, on the road next to sidewalk. The location of incident was also confirmed by the visitor. The surveyor queried if this was safe area for a wheelchair bound resident with impaired cognition to be alone at 8:30 PM, LPN B stated, No. An interview was completed with LPN C on 8/27/24 at approximately 2 PM. LPN C also witnessed the incident and assisted LPN B on 8/8/24. LPN C was also the nurse who worked on R903's unit on the morning shift (7 AM - 7 PM). When queried if they remembered the incident and they reported that they did. It was between 8:30 - 8:45 PM a family member came in when they were at the receptionist desk charting after their shift. The family member reported that there was someone one on the ground outside in a wheelchair and they were not sure if that was resident or visitor. They went to check with LPN B and observed R903 on the road next to sidewalk walk and they had notified LPN A who was nurse assigned to R903's unit. LPN A was not aware that R903 was outside of the facility. When they had asked R903 what happened, the Resident reported that they were trying to go around the curve and their wheelchair tipped over. They had assisted with the situation, EMS was called and R903 did not want to go to hospital and the DON spoke with EMS. This surveyor queried LPN C when they had last seen R903 and they reported that R903 was in the room when they had signed off from their shift. The surveyor queried about their signoff process, LPN C reported that they were supposed to see the resident when doing the recap with the oncoming nurse. This surveyor asked if R903 was allowed to go out on their own, LPN C reported that the Resident used to sit outside in the front prior to the fall. When queried how did they monitor when they were sitting outside and what was their process, LPN C reported that they did not have any issues prior; the receptionist left around 8 PM and they would let the charge nurse know if a Resident was sitting outside. It must be noted that the area where R903 was observed was not visible from the front entrance, unless someone did a walk through to the west side of the facility or had parked on this end and walked towards their car. Calls were made to Certified Nurse Assistant (CNA) who was assigned to R903 on 8/8/24 and they were not returned prior to survey exit. An interview with Maintenance Director (DM) D was completed on 8/27/24 at approximately 2:20 PM. DM D was queried about the main door lock time frames and the process. They reported that the doors were set to lock between 6 PM - 7 AM. If anyone needed to exit outside these times frame, the instructions are posted. If they needed to exit, staff were assisting them. DM D was queried about the camera and monitoring. They reported that they had camera in the hallways, but not outside. This surveyor went to check the cameras with DM D at approximately 2:30 PM. DM D had to get the assistance from the Administrator. At approximately 2:35 PM, the Administrator came in. This surveyor explained that they wanted to check the front door camera for 8/8/24 and Administrator reported that they did not have any cameras monitoring the front (main) entrance. An interview was conducted with Receptionist (RE) E on 8/27/28 at approximately 2:50 PM. Receptionist E reported that they had worked till 5 PM and they had two other staff members who took turns to cover the weekends and afternoons, till 8 PM. They had reported that the front door locks at 6 PM to 7 AM. They were queried about the facility process on who is allowed to sit outside and how they were monitoring. RE E reported that they checked with the resident if they had let their nurse know and if they were their own person they had let them sit outside and they were not monitoring the residents. They added if they had wander guard they were not allowed. An initial interview was conducted with the DON on 8/27/24 at approximately 3 PM. The DON was queried about the incident and why they did not investigate. The DON reported that they were notified of the incident by the charge nurse, that it happened right outside the door and it did not need an investigation so they had just completed a fall investigation and did not provide any further explanation. An interview was completed with R903's guardian on 8/27/24 at approximately 3:25 PM. The guardian was queried about the incident on 8/8/24. They had checked the call notes and checked with their assistant and reported that they did not receive any calls about the incident. When explained the incident the guardian asked, What was she doing at 8:45 PM in the parking lot?. They added that residents should not be in an area where employees cannot monitor them. They added that they never gave permission and R903 was not safe to be outside unsupervised. They noted that should have been notified of this incident. If it is after hours, staff could leave a voicemail and they should receive a call back for this incident. An interview was completed with the Administrator on 8/27/24 at approximately 5 PM. The Administrator was notified of the concerns with supervision for R903, how they had exited and the unknown timeframe they were outside the facility, the fall outside the facility with no investigation, and not notifying the guardian. The Administrator reported that they understood the concerns. An interview was completed with LPN F who was assigned to R903's unit at the time of the incident on 8/28/24 at approximately 6:55 AM. LPN F was queried about R903's incident. They reported that their shift started at 7 PM and they regularly worked that unit and they were familiar with the residents. LPN F added that they received the report from LPN C that R903 was in their room, but they did not physically see the resident after their shift started. They were getting ready to gather supplies and start to pass the medications. At approximately 8:30 PM they were alerted by LPN B that R903 was observed outside the facility on the floor. It must be noted that R903 was on the front end of the unit (1st room) and LPN F failed to explain how they had not seen the Resident for over an hour and a half since the start of their shift. They added that they went outside and LPN C was with R903. They reported that they had called 911 and R903 did not want to go to hospital so EMS did not take the resident. They added that R903 had periods of confusion and had a guardian, also the resident reported that they might have hit their head and the fall was unwitnessed. They did not want to take any chances and had called EMS. They added that they had communicated with the DON and had called the guardian and left a brief message. They had notified the oncoming nurse to call the guardian during business hours. The surveyor queried if R903 was safe at the location without staff supervision/assistance at that time, LPN F' stated nobody would be safe at the location. When queried about the time frame they reported that they did not know. When this surveyor asked what could have prevented the event, LPN F reported better communication between the nursing staff, walking rounds while receiving report at the start of their shift and communication between the receptionist and nursing staff would have prevented the incident. A follow-up interview with the DON was completed on 8/28/24 at approximately 11:35 AM. The DON reported that they were notified that R903 had a fall from the wheelchair as it tipped, right outside the main entrance and that is why they had not completed any investigation. The DON was queried if they had seen where R903 was on the ground and they reported they had not. The DON agreed to see the location. This surveyor and DON went to see the area where R903 was located. This surveyor queried if that area was safe for R903 to be unsupervised at 8:30 PM? The DON agreed it was not safe. The DON was queried how the facility determined that a Resident was safe to be outside unsupervised? The DON reported that it was based on cognitive assessment and their physical functioning. This surveyor queried about R903's cognitive impairment and physical limitations and how they were safe. The DON reported that R903 usually sat at the main entrance by the door. When they were queried R903 was supervised, they reported that the receptionist and care transition staff can monitor from their desk/office. When queried further how the receptionist could visually see through the walls and vestibule in the front and what happened if they left the desk/office? No further explanation was provided. When queried further about the process, The DON reported that the best practice'' for both nurses and CNAs was to do walking rounds during shift change. They reported that they understood the concerns. Review of facility provided document titled Elopements with a revision date of December 2008 read in part, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries. b. Notify the Attending Physician. c. Notify the resident's legal representative (sponsor) of the incident. d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record . The facility's elopement policy that was revised approximately 15 years ago did not address facility process on identification and assessment of at-risk residents, facility process to provide supervision in the facility premises such sitting outside the front door, patio etc. DPS #2: Based on interview and record review the facility failed to provide a thorough root cause analysis after fall(s) and provide resident specific intervention(s)/supervision for one (R902) of two Residents reviewed for falls. Findings include: A complaint received by the State Agency reveled that R902 had multiple falls after admission to facility and the facility failed to provide appropriate interventions. A review of the medical record revealed that R902 was a long-term resident of the facility, admitted to the facility on [DATE]. R902's admitting diagnoses included: Fracture of left Femur (after fall in the hospital), sepsis, heart failure, dementia, anxiety and history of stroke. Based on the MDS (minimum data set) assessment dated [DATE], R902 had a BIMS of 6/15, indicative of severe cognitive impairment. An initial observation was completed on 8/27/24 at approximately 10:30 AM. R902 was observed sitting up in their wheelchair. A family member was in the room. The right side of the bed was against the wall. R902 had nightstand that was partially blocking the bathroom doorway. When the surveyor queried about how the family member reported that they had placed it (the night stand) the night before so R902 would not attempt to go bathroom on their own. The Family member also reported that R902 had to wait longer for assistance when they needed to be changed, especially on weekends and later in the afternoons. They added that R902 was soiled and was changed around 11 AM yesterday after they had come in and had requested the staff to assist. An interview was completed with the complainant on 8/26/24 at approximately 4 PM. The complainant reported that R902 was a high fall risk when they admitted to the facility. R902 did not have the supervision and timely assistance with toileting; had multiple falls in the last few weeks. Review of R902's hospital Discharge summary dated [DATE] reveled that R902 had a fall in the hospital on 5/25/24 and had fracture of left femur (thigh bone) and had surgery and they were unable to bear weight on left leg and they were admitted to the facility for skilled nursing and rehabilitation services. Review of R902's Electronic Medical record (EMR) revealed that R902 had a recent room and unit change on 8/26/24. Prior to this, R902 was in a different unit in room [ROOM NUMBER], which was on the farther down, closer to the end of the hallway. Review of progress notes revealed a Care Transitions note dated 7/3/24 at 12:53, that read, reached out to family via e-mail and phone call regarding transferring guest to semi-private room on LTC (Long-Term Care) side A follow up note dated 7/3/24 at 13:06 read, Received notice from family that we can move guest to semi-private room on LTC side. No concerns at this time. Based on resident census record R902 was moved to room [ROOM NUMBER], a room closer towards the end of hallway. Facility was requested to provide the Incident & Accident (I&A) reports for R902 from July through current date and was received via e-mail. Review of I&A reports and progress notes revealed the following: R902 was high risk for falls, related to their recent fall history, co-morbidities with impaired cognition and functional mobility related to recent fracture of femur. R902 had falls on: 5/30/24, 6/14/24, 7/11/24, 7/15/24, 8/4/24, and 8/16/24. Review of I&A reports and investigative summaries revealed R902 had 3 falls between 8PM and 10:15 PM and 3 falls between 3 AM and 6 AM. R902 had 3 falls related to incontinence episodes and R902 attempting to get out of bed. Review of investigative summary for 5 out 6 falls for a resident with severe cognitive impairment revealed the root cause analysis as poor safety awareness for 5 out 6 falls and for other fall it read poor impulse control r/t (related to) cognition and an intervention dated 8/16/24 read, re-orientate resident to environment during rounds. Review of care plan included the following interventions: check for incontinence episode around 3 AM dated 5/30/24, offer toileting before and after meals dated 6/28/24, and check for incontinence episode during early morning rounds. An interview with the DON was completed on 8/28/24 at approximately 12:25 PM. The DON was queried about the falls for R902 and their root cause analysis that read poor safety awareness for R902, how that was a root cause for a resident with severe cognitive impairment and history of falls. The DON reported that R902 had multiple falls related to her restlessness due to incontinence episodes and they were working con improving their root cause analysis process with someone from corporate. The DON was queried if it was appropriate to have the high fall risk resident with recent fall and femur fracture to be farther at the end of the hallway and how re-orientation is an appropriate intervention. The DON reported that they understood the concerns and they were working on it. Review of facility provided document titled Falls and Fall Risk, Managing with a revision date of December 2007 (revised approximately 16 years ago) read in part, Based on previous evaluations and current data, the staff will identify interventions related to resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00125980 and has two deficient practice statements (DPS). DPS #1 Based on interview and record review the facility failed to follow the care plan and properly transfer one (R73) of three residents reviewed for accidents resulting in the resident suffering a laceration that required nine sutures to the right leg. Findings include: Review of the medical record revealed R73 was admitted to the facility on [DATE] with diagnoses that included: surgical aftercare following surgery on the genitourinary system, chronic kidney disease stage 3 and asthma. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of a progress note dated 1/1/22 at 12:40 PM, documented in part . 2 nurses assisted the guest to the restroom. Guest use the grab bars to pull herself up from the toilet to a standing position, guest was then wiped a brief pulled up. Guest sat herself down in wheelchair and stated ouch as both nurses looked down the guest leg was bleeding. Area clean and pressure dressing applied . family and DON (Director of Nursing) notified, guest sent to E.R for further evaluation . Review of an After Visit Summary dated 1/1/22 documented in part, . Reason for Visit Laceration . Suture removal anticipated in 10-14 days . Review of a Risk for falls careplan documented the intervention, Resident transfers via 2 person assist using slide board intitiated on 12/23/2021. Review of the careplan titled, The resident has potential/actual impairment to skin integrity r/t chronic venous insufficiency, risk for falls revealed an intervetion of, Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date initiated, 12/23/2021. Review of a facility incident report dated 1/1/22 at 11:58 AM, documented in part . Incident Location: Resident's Room . Person Preparing Report: (staff member name) . Nursing Description . 2 nurses assisted the guest to the restroom. Guest use the grab bars to pull herself up from the toilet to a standing position, guest was then wiped and brief pulled up. Guest sat herself down in wheelchair and stated ouch as both nursed looked down the guest leg was bleeding . Resident Description . I was doing so good using the toilet the two nurses were helping me and when I sat down in my wheelchair my leg was caught inside of the wheelchair and I was bleeding . Occurred during a 2-person transfer . Witnesses (Graduate Nurse - GN HH and Registered Nurse - RN D names) . were documented in the witness area. Review of a progress note dated 1/4/22 at 6:38 PM, documented in part, . Dressing removed to assess site under dressing noted 9 sutures no s/s of infection . Review of an Incident Note dated 1/5/22 at 6:07 PM, documented in part, . on 1/1/2022 at approx. 11:58 AM resident acquired a laceration to RLE (Right Lower Extremity) while sitting in wheelchair post toileting. Resident stated she bumped her leg on wheelchair causing the laceration . Upon returning form ER, resident now has sutures closing laceration . This note was documented by the DON. On 9/20/22 at 12:20 PM, GN HH was interviewed via telephone. When asked about the incident with R73, GN HH stated in part . I remember we were toileting her and I just heard her say ouch. We thought it was because she had trouble transferring. Her leg got caught . When asked how R73's leg got caught in their wheelchair if they had two nurses assisting with the transfer, GN HH replied they were not certain of R73's transfer status at the time and no one (that was present) knew if R73 was a one- or two-person transfer. GN HH then explained how R73 was not their resident or RN D resident but they were helping the other staff out because the facility was short staffed that day. When asked if they (GN HH' and RN D) was touching the resident at the time of the transfer, GN HH replied they (themselves and RN D) was in the restroom but they weren't physically touching the resident at the time of transfer. GN HH was then asked why they weren't physically touching the resident to help, and GN HH stated again they were unsure of R73's transfer status. GN HH then stated R73 reached for the grab bar and we kept hearing ouch, we turned and saw her leg bleeding. When asked if anyone ever followed up with them or asked for a statement regarding the incident GN HH stated No. On 9/20/22 at 1:22 PM, RN D was interviewed regarding the incident with R73. RN D was observed looking into the medical record and looking at R73's record and stated they remember vaguely. RN D explained a graduate nurse came and asked if they could help transfer (R73 name). RN D stated in part, . I was right behind the chair, she lifted up using the bar and sat down. We were there but we didn't touch her . When asked RN D stated they believed R73 was a two person assist. When asked if it was the facility's protocol to just observe a resident that required two people to assist them with a transfer, RN D then stated No, but I cannot remember. When asked if anyone followed up with them after the incident or asked for a statement, RN D stated they did not remember if anyone ever followed up with them. When asked what made the laceration to R73's leg, RN D stated the only thing we can think is the inside of the wheelchair is the foot pedal hook . When asked if the two people that are supposed to assist the resident back into their wheelchair, are supposed to make sure that all foot pedals and hooks are in the correct position prior to the resident transfer or assisting the resident back into their wheelchair safely, RN D stated they really couldn't remember. On 9/20/22 at 1:22 PM, the DON was interviewed regarding the transfer of R73 and asked to provide any additional documentation that they have regarding the incident. The DON begin to state how there were two staff members touching and assisting the resident with the transfer, but according to the facility's risk management the resident didn't give the nurses a chance to assist when R73 grabbed the bar then sat back down in their wheelchair. The DON was then asked who completed the investigation and the DON stated they did. The DON was asked if they took statements from the two nurses that was present at the time of the incident and the DON stated No. The DON was then asked to provide the investigation that they conducted for this incident for review. Shortly after the DON returned and stated they did talk to both of the nurses at the time of the incident and there was a risk investigation completed. The DON then stated the resident got up themselves without waiting for the staff. The DON was again asked to provide the statements obtained from the nurses and to provide the complete investigation. The DON then stated how could the surveyor expect for the staff to remember the incident from January (2022) and how could the investigation be based off of what they are saying from what they remember. The DON was again asked to provide for review the investigation that was completed at the time of the incident with the witness statements obtained. No further documentation was provided by the end of survey. DPS#2 Based on observation, interview and record review, the facility failed to thoroughly assess and timely investigate a laceration for one (R18) of three residents reviewed for skin conditions. Findings include: On 9/18/22 at 9:58 AM, R18 was observed lying in bed, a dressing was observed on her left lateral forearm, just below the elbow. R18 was asked why she had a dressing. R18 did not know. Review of the clinical record revealed R18 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included: Parkinson's disease, dementia, and schizoaffective disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R18 had severely impaired cognition and was totally dependent on staff for all activities of daily living (ADL's). Review of R18's September 2022 Medication Administration Record revealed an order for, Aquacell foam to LUE (left upper extremity). Change Daily, in the morning for Aquacell foam to LUE with a start date of 9/12/22 and discontinued on 9/16/22. Review of a Skin & Wound Evaluation dated 9/11/22 by Licensed Practical Nurse (LPN) M read in part, .Type: Laceration . Location: (blank) . Exact Date: 9/11/22 . Length: 1.3 cm (centimeters) . Width: 0.7 cm . Notes: (blank) . Enter name of resident/responsible party notified: (name entered was R18's family member, not R18's Guardian) . Review of R18's progress notes revealed no documentation of R18 obtaining a laceration on 9/11/22. Review of a weekly Skin & Wound Evaluation dated 9/19/22 read in part, .Type: Laceration . Location: Left Outer Forearm . On 9/19/22 at 9:36 AM, the facility was asked for investigations for R18. On 9/19/22 at 11:06 AM, Clinical Support A explained there were no investigations for R18. On 9/19/22 at 11:25 AM, LPN M was interviewed and asked about R18's laceration on her left forearm. LPN M explained no one knew how R18 got the laceration, they could not figure it out. When asked what she did, LPN M explained she cleaned the wound, took a picture, called the doctor, and got an order for a dressing, and called R18's Hospice. LPN M was asked if she had contacted R18's Guardian, LPN M explained she had called the first emergency contact, which was the family member. LPN M was asked if she had written a progress note, or started an incident report. LPN M explained she had not done either. On 9/19/22 at 4:05 PM, the Director of Nursing (DON) brought an investigation of R18 laceration. It contained two handwritten statements: One from Certified Nursing Assistant (CNA) V that read in part, I went into (R18's) room . and noticed a cut/scratch on the side of her upper right arm (bicep area). I noticed a lot of smeared and dried blood on her arm and on her blanket. She was laying on her left side and I noticed the side table very close to the bed . dated 9/11/22 and signed by CNA V. One from LPN M that read in part, CNA notified writer that resident was observed with blood on her left arm, very scant amount. Resident gets up in geri-chair daily. Resident was within arms way of the bedside table. Assessed and appears that the resident hit the bedside table and was leaning towards the left. Bedside table moved at this time . dated 9/11/22 and signed by LPN M. On 9/19/22 at 4:19 PM, LPN M was asked when she had written the statement. LPN M explained she had written the statement that day, 9/19/22. When asked why it was dated 9/11/22, LPN M explained the DON had told her to write that date.