**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This intake pertains to Intake MI00138670. Based on interview and record review, the facility failed to timely implement interventions or properly treat an existing pressure injury for one resident (R700) out of three reviewed for wounds, resulting in the hospitalization for debridement of the wound. Findings Include: A review of an Intake called into the State Agency noted the following, .Complainant states that facility neglected to properly treat the bedsore .complainant states the bedsore got progressively worse and the size of a grapefruit. Complainant states on [date] the resident was sent to the hospital for debridement . A review of the medical record revealed that R700 admitted into the facility on 5/12/2023 with the following diagnoses, Multiple Sclerosis and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating a slightly impaired cognition. R700 also required extensive two-person assist with bed mobility and transfers. Further review of the admission skin assessment noted the following, Site: Sacrum Description: Open Area. A review of the admission progress note noted the following, Date: 5/12/2023 at 6:51 PM .Resident has an open area to coccyx. A review of the physician orders revealed that an order to treat the wound was not entered until 5/16/2023 (4 days later). Further review of the progress notes revealed that R700 was seen by the wound care team on 5/23/2023 (11 days later). The progress note revealed the following, .Sacral unstageable (Slough or eschar-dead skin- obscures the wound bed)-this area measures 3.5 x 2.1 cm (centimeters) with no determinable depth. Edges are attached and there is no eschar (necrotic tissue), tunneling, or undermining, or odor. This area can be cleaned with normal saline, and santyl applied to the area. Wound should be covered with a dry dressing. A review of the physician orders revealed the following order, Start Date: 5/17/2023 .Iodsorb External Gel 0.9% .Apply to Sacrum topically every 48 hours for Sacral Ulcer. Start Date:6/5/2023 .Santyl External Ointment 250 Unit/GM .Apply to sacrum topically everyday shift for sacral ulcer. Review of the Treatment Administration Record (TAR) revealed blank spaces that indicate the treatment was not documented and/ or completed on the following days, 6/7 and 6/13. Further review of the progress notes revealed the following, Date:6/5/2023 .On exam today patient is alert. Family and nursing report concerns for worsening wound to buttocks. Date:6/6/2023 .Sacral Unstageable-this area measures 5.6 x 3.2 cm with no determinable depth .This area can be cleaned with normal saline, and Dakins wet to dry applied to the area. Wound should be covered with a dry dressing. Review of the physician orders did not reveal an Dakins wet to dry wound care order. Date: 6/12/2023 .Nursing reports significant purulent, malodorous drainage of dressings-they are currently fully saturated and due to be changed per schedule. Wound appears to have significant tunneling depth significantly increased since last assessment by wound care . Additional review of the physician orders revealed the following, Revision Date:6/13/2023 .Transfer to hospital for surgical debridement of buttocks wound. On 1/3/2024 at 12:34 PM, an interview was conducted with Wound Care Nurse (WCN) C. WCN C stated that when a resident is admitted into the facility with a wound, then a treatment order should be entered immediately. WCN C stated that they created a template for the nurses to use or they can call the physician and obtain an order. WCN C was queried as to why the orders were not changed to the recommendations provided by the wound care provider. WCN C stated that they spoke about the orders at bedside with the provider and decided to go with other treatments. A review of a facility policy titled, Skin Management revealed the following, .4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140941 Based on interview and record review, the facility failed to provide two-person assistance during care for one resident (R712) out of one reviewed for falls, resulting in a fall from bed and death. Findings Include: A review of an incident and accident report dated [DATE] revealed the following, Nursing Description: CENA (Certified Nursing Assistant) was in Resident's room to provide care. While CENA was at the sink [they] heard a loud thump. CENA went back to Resident's bed and saw that [R712] was lying on the floor. CENA informed Writer that Resident was on the floor. Writer observed Resident lying on the floor on [their] right side on the left side of [their] bed with [their] head slightly under the bed frame. Writer asked Resident did [they] roll out of bed on [their] own, Resident stated yes with a head shake. Prior to fall, Resident was last seen at approximately at 2:00 am lying in [their] bed sleeping with call light within reach. Resident Description: Writer asked Resident did [they] roll out of bed on [their] own, [R712] stated yes with a head shake. CENA and roommate heard the thump. Writer asked Resident if [they] had hit [their] head, [R712] stated no. A review of the medical record revealed that R712 admitted into the facility with the following diagnoses, Dementia and Hemiplegia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R712 also required extensive two person assist with bed mobility and transfers per the most recent functional mobility Minimum Data Set Assessment set. Further review of the care plan revealed the following intervention, Bed Mobility: Resident requires 2-person assistance to reposition and turn in bed. Date Initiated: [DATE]. A review of the progress notes revealed the following, Date [DATE] at 2:00 PM .At 8:57AM upon assessment resident was observed unresponsive to voice, touch, and pain. Writer initiated a code blue 911 was called. EMS (Emergency Medical Services) on scene and policemen responsible party was notified. Resident was pronounced deceased at 9:14 AM picked up at 1:35 PM by medical examiner. A review of Autopsy Report revealed the following notes from the Medical Examiner, .it is my opinion that [R712] dies secondary to multiple pulmonary fat emboli, with contributory blunt force injuries of the head, neck, chest, and upper back. It is unclear how these injuries were sustained. On [DATE] at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to if R712 was supposed to be a two person assist during care. The DON stated that R712 was supposed to be a two person assist during care. The DON stated that the certified nursing assistant had been wrote up and education had been given to all staff, as well as more. A review of a facility policy titled, Fall Management, noted the following, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included, Description of deficient practice, In-depth analysis how the defiency practice occured: Certified Nursing Assistant failed to provide care including bed mobility for a resident that requires a 2 person assist. How facility identified resident affected and residents having potential to be affected by the same deficient practice:Like residents are those who require 2 person assist for bed mobility. Corrective action taken for residents affected: Like residents plan of care has been audited to ensure number of personal assists is accurate. Like residents have been audited to ensure staff are following the bed mobility plan of care. Measures of systemic changes made to ensure that deficient practice will not occur and affect others: NUrsing staff educated on assist cena's with residents who require 2 person assist. Nursing stadd educated on following [NAME]. How facility monitors its corrective actions to ensure same decifient practice is corrected and will not recur: The Director fo Nursing and the Nursing Home Administrator wll review 10 residents who require 2 person assist including bed mobility are completed properly for 4 weeks then monthly for 2 months. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00132609 Based on interview and record review the facility failed to provide adequate supervision and secure all facility doors for one resident at risk for elopement (R905) of three residents reviewed for elopement, resulting in the resident exiting out of an unlocked unalarmed kitchen door and ambulating to an adjacent neighborhood and sustaining lacerations to the left side of their face and body. Findings include: On 11/30/22 at 9:35 AM, unidentified family member I was contacted regarding an alleged incident which occurred involving R905 on 10/30/22. Family member I stated, I was told by the facility that [Resident] got out an unlocked side door of the facility and was found by [police], they had fallen and cut their face. I just don't want this to happen to anyone else. On 11/30/22 at 9:59 AM, an incident and accident report (I/A) involving R905 dated 10/30/22 7:00 AM, was reviewed and revealed the following, During morning rounds [Nurse I] noticed that [Resident] was not in their room. Code search initiated. At approximately 7:30 AM, [police] called and notified that resident was being taken to [hospital] for evaluation. On 11/30/22 at 10:05 AM, the Accuweather.com website revealed that the temperature on 10/30/22 reached a high of 65 degrees Fahrenheit and a low of 39 degrees Fahrenheit. On 11/30/22 at 10:32 AM, a review of a police report dated 10/30/22 indicated that R905 was located in a neighborhood close to the facility and was observed to have Injuries to the left side of their body. The police report further indicated that R905 was taken to the hospital via EMS (emergency medical services) for further evaluation. On 11/30/22 at 11:45 AM, a review of R905's most recent, Risk for Elopement assessment dated [DATE] revealed that R905 was, At Risk for elopement. On 11/30/22 at 11:49 AM, a review of R905's elopement risk care plan revealed the following, Focus: [R905] is at risk for exit seeking behavior R/T (related to) history of attempts to leave facility .Date Initiated: 10/13/2022 Revision on: 10/25/2022. Goal: [R905] will not leave facility unattended through the review date. Date Initiated: 10/13/2022 Revision on: 10/25/2022 Target Date: 11/2/2022. Interventions: Approach [R905] in a slow calm manner and redirect away from exit doors as needed. Date Initiated: 10/13/2022 Revision on: 10/25/2022. Distract [R905] when wandering in to inappropriate areas by offering pleasant diversion, structured activities, food, conversation, etc., Date Initiated: 10/13/2022 Revision on: 10/25/2022. On 11/30/22 at 12:34 PM, a review of R905's electronic medical record (EMR) revealed that R905 was originally admitted to the facility on [DATE] with diagnoses that included, Unspecified displaced fracture of surgical neck of left humorous (upper left arm), BiPolar disorder, and Unspecified psychosis. R905's most recent minimum data set assessment (MDS) dated [DATE], indicated that R905 had a moderately impaired cognition and required extensive assistance with all activities of daily living (ADLs) other than eating. R905 was discharged from the facility on 10/30/22. On 11/30/22 at 2:15 PM, Nurse I was interviewed by phone and asked about the incident involving R905 which occurred on 10/30/22. Nurse I stated, It was right around shift change. [R905] wasn't in their room. I had been redirecting [R905] back to their room a few times that night. Nurse I indicated that they had been told that [R905] exited out a door through the kitchen. Nurse I stated, When I was on the phone talking to the Director of Nursing (DON) regarding the incident, the [police] called and stated they had found the resident. Nurse I was asked where the resident was found and indicated that they were unsure. Nurse I was asked at what time on 10/30/22 they last saw the resident in the facility. Nurse I indicated that they were unsure when they last saw R905. On 11/30/22 at 3:10 PM, certified nursing assistant (CNA) D was interviewed and asked about the incident involving R905 which occurred on 10/30/22. CNA D stated, I was in my assigned hallway and not too far away from [R905's] room. Around 3:30 AM, [R905] exited their room and I assisted them back to their room and into bed. I began my rounds/changes around 4:00 AM, and the resident was out of my sight. I didn't see [R905] after that. CNA D was asked if they knew where R905 was found. CNA D stated, No. On 12/1/22 at 9:30 AM, unit nurse manager (UNM) H was interviewed regarding the incident involving R905 which occurred on 10/30/22. UNM H indicated that they were the on call manager on the night of the incident. UNM H stated, I came into the facility along with the DON and Administrator (NHA), by the time I got in, the police had called and indicated that they had found the resident and the resident was being transported to [Hospital] for an evaluation. We completed an elopement code drill and have done inservice training since the incident occurred. On 12/1/22 at 10:00 AM, food services director (FSD) K was interviewed regarding the elopement incident involving R905. FSD K verified that the kitchen door was left unlocked on 10/30/22. FSD K indicated that although they were not exactly sure what exact door [R905] exited through, FSD K acknowledged that there had been a door in the kitchen that was unalarmed that could have been exited through. FSD K stated, All doors are locked now, the door in the kitchen has a screamer alarm (alarm that makes a loud noise) on it now, and the door leading into the kitchen has a log sheet now which staff sign to verify that the door was locked and sign in the morning to verify that the door was locked when they arrive for their shift. On 12/1/22 at 12:15 PM, the NHA was interviewed and asked what their expectations were for staff to prevent resident elopement. The NHA stated, Expectation for staff are to be aware of your residents and to engage them in activities and keep them occupied as much as possible. On 12/1/22 at 12:47 PM, a facility policy titled Elopement Policy Last Revised 4/26/2022 stated the following, Policy: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .8. Rounds of all residents are made at the beginning of the shift, at mealtimes, and at the end of the shift at a minimum by direct care staff and licensed nurses. CNA or nurse can achieve this through medication administration pass, mealtime passes, and during care rounds Upon return of the resident to the facility, the Director of Nursing or charge nurse should: f. Investigate how the resident exited and make recommendations on safety measures to the Safety Team Committee; and g. Update the resident's care plan and care guide with preventive interventions for elopement. On 11/30/22 at 9:00 AM, the facility provided documentation to address the incident which occurred on 10/30/22. A summary of this plan indicated the following, October 30, 2022: Past Non-Compliance (PNC). Date: 10/30/22: Description of deficient practice: Facility failed to prevent a resident, who requires supervision, from going outside the facility doors independently. The resident was able to enter the Dietary Kitchen and exited the facility through a door in the kitchen that did not have an alarming system in place. A QAPI/RCA meeting was held to review the Elopement on 10/30/22. How facility identified resident affected and residents having potential to be affected by the same deficient practice. The Administrative Nurses reviewed the residents in the facility last Elopement Risk Assessment to identify the residents who at risk for elopement. Corrective action taken for the resident affected: Resident was assessed at the hospital The Resident Chart was reviewed Upon readmission the resident will be re-assessed for Elopement Risk The Elopement care plan was reviewed and revised as needed Wander Guard device was device checked and was functioning properly Resident room placement was reviewed Measures of systemic changes made to ensure the deficient practice will not occur and affect others. A QAPI Meeting was held to review the elopement, staffing and door alarms on 10/30/22. Rounds were made on all doors in the facility that exit to the outside to validate alarms are functioning, if the door is not alarmed a screamer door alarm was placed on that door. The entrance door to the Dietary Department will be checked by 2 staff members to validate the door is locked at the end of the day. Administrative Nurses and or the Social Worker reviewed the residents identified at risk for elopement to validate the last risk for elopement evaluation was accurate, the orders for the wander guard are in PCC, the care plans for elopement are up to date and the wander guard is in place and functioning. The Elopement policy was reviewed and deemed appropriate. Re-education on the elopement policy began on 10/30/22. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The Maintenance Staff or designee will complete rounds on all doors in the facility that exit to the outside to validate alarms are functioning 7 days a week for 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. Maintenance Staff or designee will make rounds to validate the entrance door the Dietary Kitchen is locked on off shits weekly x 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. The Licensed Nurses or designee will make frequent random rounds on the residents identified at Risk for Elopement on the Midnight weekly x 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations.