**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of hospital medical records, review of the emergency department record, review of the Abuse/Neglect policy and procedure, review of the Wound Treatment Management policy, review of the Skin Assessment policy, resident interview, Medical Director interview and staff interviews, the facility failed to ensure Resident #59, who was admitted to the facility on hospice care, was free from a situation of neglect when facility staff failed to provide ongoing wound assessments, care and services to prevent a significant decline in a wound, and notification to the physician when there was a decline in the wound. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm with negative health outcomes when emergency services were called for Resident #59 on 03/22/24 due to a deteriorating mental status and Hospice Nurse #215 checked the left leg wound and it was getting worse. Consequently, Resident #59 required an inpatient hospital admission from 03/22/24 to 03/29/24 for which Resident #59 was treated for an infected necrotic wound of the left lower extremity. Surgical debridement was required and occurred on 03/25/24 which resulted in a large skin flap on the lateral aspect of the wound to be removed. Cultures revealed polymicrobial, proteus, methicillin-resistant staphylococcus aureus (MRSA) and enterococcus organisms were present in the wound requiring prolonged oral and intravenous (IV) antibiotic therapy through 04/07/24. In addition, the facility failed to provide ongoing wound assessments for Resident #42, including weekly skin assessments with wound measurements and descriptions according to policy, that placed the resident at potential risk for more than minimal harm that was not Immediate Jeopardy. This affected two (#42 and #59) of three residents reviewed for abuse and neglect. The facility census was 85. On 04/04/24 at 12:38 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/22/24 when hospice Resident #59 was transferred to the hospital due to an altered mental status and was found to have an infected left lower extremity wound. Upon Resident #59's admission to the facility on [DATE] a blister to the left knee was noted, and there was no documented evidence of ongoing monitoring or documentation related to the blister or to a left lower leg wound contained within Resident #59's medical record. Subsequently, Resident #59 was admitted to the hospital on [DATE] for an infected necrotic wound of the left lower extremity requiring surgical intervention, ongoing wound treatments, and IV antibiotic therapy. The Immediate Jeopardy was removed on 04/04/24 when the facility implemented the following corrective actions: • On 04/04/24 at 2:09 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting and Immediate Jeopardy (IJ) Review was held with the Administrator, DON, and Medical Director #600 to review the facility polices for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, Change in Condition, Skin Assessment, and Completion of Wound Care. No policy changes were made as a result of the review. • On 04/04/24, the DON educated the nurse managers on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation and the need to report immediately any concerns, on skin assessments and wound monitoring including education on monitoring for weekly skin assessments being completed on all residents and individual wound monitoring for each individual wound a resident has. • On 04/04/24, the DON educated the facility nurses and nursing assistants on Skin Assessments being completed weekly on all residents and to document in the resident's medical record the location, appearance, and size of any skin condition, on Wound Management policies, including the management and documentation of a wound to include size, appearance, measurement and drainage, and the documentation of such wounds, and with any new skin conditions the unit managers are to be notified. Education on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, including how to identify and prevent situations of neglect, identification of change in condition, including how to timely identify situations when care cannot be or is not provided to residents in the facility and to know when to seek medical attention, and completion of wound care per orders. • On 04/04/24, the Administrator educated Staffing Coordinator #105, Director of Admissions #107, Business Office Manager #121, Human Resources Director #130, Social Services #131, Receptionist #133 and #213, the DON, Maintenance Supervisor #134 and Maintenance Helper #162, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #191, Director of Dining Services #190, Maintenance Director #603, Housekeeping Manager #148, Director of Recreation #104, Recreation Assistant #123, and Director of Rehabilitation #132 on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. • On 04/04/24, Director of Rehabilitation #132 educated one physical therapist, four occupational therapists, two speech therapists, four physical therapy assistants and two occupational therapy assistants on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. • On 04/04/24, Director of Dining Services #190 educated four cooks and one dietary aide on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. • On 04/04/24, Housekeeping Manager #148 educated six housekeeping and laundry staff on the policy for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property. • On 04/04/24, the DON, Registered Nurse Unit Manager #181 and Licensed Practical Nurse Unit Manager #214 completed head-to-toe body assessments on all 85 current residents to ensure no evidence of negligence in care resulting in skin impairments had occurred. No new skin or wound issues were noted and review of the medical record for skin and wound assessments had been completed and documented in the last seven days; however, Residents #06, #25 and #84 did not have skin assessments documented in the last seven days, so these records were updated to include the head-to-toe assessment completed on 04/04/24. • Beginning on 04/04/24, an ongoing audit four times a week for four weeks completed by the DON/Designee to ensure individual wounds have been assessed no less than weekly and any negative change in a wound will have physician notification. • Beginning 04/08/24, an ongoing audit will be completed by the Nurse Managers/Designee four to five times a week for four weeks to ensure skin assessments/observations are completed at least weekly, then randomly thereafter. • Interviews conducted on 04/08/24 from 6:47 A.M. to 9:10 A.M., with Occupational Therapist #101, Director of Dining Services #190, Housekeepers #104 and #113, Laundry #103, and Director of Recreations #164 verified education received on resident abuse and neglect with all staff able to verbalize the importance of reporting immediately any concerns related to resident abuse and neglect. Interviews with Licensed Practical Nurses (LPN) #110, #128, #140, #167 and #168, State Tested Nursing Assistants (STNA) #155, #170, #167 and #168, and Registered Nurses (RN) #138 and #179 verified they received education on monitoring of skin conditions and reporting as well as resident abuse and neglect. The nurses interviewed (RNs and LPNs) also verified education received on the completion and documentation of weekly skin assessments on all residents, wound assessments to include measurements, and with each dressing change a note in regard to a description of the wound needs to be made, and any changes in a resident's skin or wound needs to be reported immediately to the physician. Although the Immediate Jeopardy was removed on 04/04/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #59 revealed an admission date of 03/05/24 from the acute hospital. Resident #59 had diagnoses including anemia, sleep apnea, chronic obstructive pulmonary disease, chronic respiratory failure, morbid obesity, hypertension, atrial fibrillation, heart failure, anxiety disorder, depression, type II diabetes mellitus, chronic kidney disease, atherosclerosis of native artery left lower extremity with ulceration of calf, and cardiomyopathy. Review of the hospital record revealed Resident #59 had presented on 03/01/24 with a complaint of not feeling well and a main complaint of left thigh pain and swelling. Resident #59 reported to have experienced several falls, winded with activities of daily living (ADLS), and a concern for inability to care for self. Review of the wound documentation dated 03/04/24 at 11:12 A.M. (from the resident's hospitalization prior to admission) revealed Resident #59 had five wounds: A right pretibial wound that was bleeding a moderate amount with a pink/red wound bed, tissue around the wound was blanchable, red in color with fragile warm skin, the wound had defined edges and measured 2.8 centimeters (cm) long by 1.9 cm wide by 1.0 cm deep; a right distal pretibial wound with a small amount of drainage with a pale pink, red base with the surrounding tissue warm and intact with defined edges. The measurements for the right distal pretibial wound were 2.2 cm long by 1.2 cm wide by 0.1 cm deep; a left posterior elbow wound which appeared to be a ruptured blister with small amount of drainage, measurements were 6.2 cm long by 7.1 cm wide by 0.1 cm deep; a left lower posterior arm wound with a pink, red wound bed with a small amount of drainage, measurements 2.0 cm long by 3.2 cm wide by 0.1 cm deep; and a left anterior-medial knee wound identified as a fluid filled blister that measured 13.3 cm long by 0.8 cm wide by 0.1 cm deep, fluid filled blister. Review of the continuation of care paperwork for Resident #59 dated 03/05/24 and timed at 11:16 A.M., revealed the following treatment orders dated 03/06/24 for each of the wounds: left forearm, cleanse with saline, pat dry, apply skin prep to the wound edge, apply foam dressing, every three days; left posterior elbow, cleanse with saline, pat dry and apply skin barrier to wound edges, apply foam dressing, change every three days for wound healing; right distal pretibial, cleanse with normal saline, pat dry, apply skin barrier to wound edges, apply foam dressing, change every day shift every other day and as needed; right proximal pretibial, cleanse with saline, pat dry, apply barrier cream to around the wound, cover with calcium alginate and apply foam dressing, change every day shift every other day and as needed; and left medial knee blister, cleanse with saline, pat dry, cover with Adaptic gauze, cover with abdominal pad and secure with roll gauze. Change every other day shift and as needed. Review of the nursing admission assessment completed on 03/05/24 at 6:45 P.M., revealed Resident #59 had an unstageable vascular wound to the left lower extremity with measurements of 13.5 cm long by 1 cm wide; the assessment noted Resident #59 was unable to tolerate range of motion to the left lower leg due to pain and the leg had discoloration. The assessment also noted a stage II pressure ulcer to the right shin measuring 2.7 cm long by 1.8 cm wide by 0.9 cm deep, a right outer ankle blister 2.5 cm long by 2.0 cm wide, a left elbow pressure ulcer, stage II, measurements 6.3 cm long by 7.9 cm wide., and a left lower arm pressure ulcer, stage 1 with measurements 2 cm long by 3.2 cm wide. Review of admission orders for Resident #59 dated 03/06/24 included the left forearm to be cleansed with saline, patted dry, skin prep applied to the wound edge, and covered with foam dressing every three days, the left forearm was to be cleansed with saline, patted dry, skin prep to the wound edge, and covered with a foam dressing every three days, the left elbow was to be cleansed with saline, patted dry and skin barrier to wound edges and covered with foam dressing every three days, the right proximal pretibial (right shin) had orders to cleanse with saline, pat dry, apply barrier cream to peri-wound, cover with calcium alginate and cover with foam dressing every day shift every other day and as needed, and for the left medial knee blister to be cleansed with saline, patted dry, covered with Adaptic and abdominal pad and secured with roll gauze every other day shift and as needed. Review of the History and Physical completed on 03/07/24 at 2:10 P.M. for Resident #59 was incomplete, not signed, and did not reference any skin conditions or wounds. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact, required maximal assistance for activities of daily living and moderate to maximal assistance for mobility with functional impairments to both lower extremities. Resident #59 was noted to have no pressure ulcers and did not have the application of nonsurgical dressings and had Hospice services for chronic respiratory failure. Review of the Care Area Assessment (CAA) Summary revealed ADL functional potential, urinary incontinence, psychosocial well-being, mood, activities, falls, nutritional status, psychotropic drug use and pressure ulcers triggered. Review of both the admission and the comprehensive care plan revealed no mention of skin conditions or wounds. Review of the assessment completed for skin breakdown on 03/06/24 and 03/15/24 revealed Resident #59 was at risk for skin breakdown. Review of the progress notes from 03/05/24 to 03/22/24 revealed no skin concerns, and no mention of wounds. Review of the medical record for the weekly skin assessments revealed they were absent. Review of the medication and treatment administration records for March 2024 revealed treatments were documented as administered as ordered. Review of Nurse Practitioner #216's medical visit dated 03/18/24 at 2:06 P.M., noted a hematoma to the left knee with dressing clean dry and intact and a recommendation to continue pressure bandage over wound. Review of the Hospice notes (sent to the facility on [DATE]) revealed Hospice Nurse #215 was called for an unplanned visit to reassess a stage 4 pressure wound to the left knee. Hospice Nurse #215 visited on 03/18/24 at 6:30 P.M. and wrote orders to cleanse the wound area with normal saline, pat dry, apply [NAME] honey to open wound (until honey alginate arrives), cover necrotic area with Adaptic dressing and cover with abdominal pad and secure with border gauze every two days or as needed if dressing is soiled, saturated, or loosened. Hospice Nurse #215 returned on 03/19/24 to reassess the left knee wound dressing and found a moderate amount of bright red dried blood saturated on the gauze dressing. A dressing change was completed, and redness noted to the outer edge of the wound. The wound measured 2 cm with tunneling at 12 to 3 o'clock and outer edges of open wound were beefy red. Review of the Hospice notes by Hospice Nurse #215 dated 03/20/24 revealed the left knee wound measured 12 cm by 4 cm by 2 cm (length by width by depth), was irregular in shape, and had distinct edges with 51 to 75 percent of the tissue necrotic. There was a moderate amount of bloody drainage and the skin surrounding the wound was red with nonpitting edema. The treatment order was changed to cleanse the wound with normal saline, pat dry, apply 4-inch ribbon of Medi honey to the open wound, cover open area with oil emulsion dressing and apply iodine solution with a gauze to the eschar area of the wound, cover with abdominal dressing and wrap with gauze dressing and secure with tape. The wound dressing was ordered to be changed daily and if soiled or saturated. Review of a follow up and reassessment of the wound by Hospice Nurse #215 on 03/21/24 revealed the left leg wound had been deteriorating and the dressing to the left leg was in place but appeared to be soiled with bloody drainage. The dressing was removed, and the wound was odorous with large dark eschar within the deep wound bed that had dark bloody drainage with clots that appeared to be jelly-like. Wound edges were red and macerated with slough present with edema around the wound. The dressing was replaced, and a new order was written to cleanse the left knee wound with quarter strength Dakin's solution, pat dry, apply betadine to the eschar areas, paint around pink wound edges with Medi honey and loosely pack the wound bed with calcium alginate, cover wound with abdominal pad, wrap with kerlix and secure with tape, change every 48 hours and as needed if soiled. Review of the nurse progress notes on 03/22/24 revealed at 3:26 A.M. Resident #59 experienced increased agitation, was climbing out of bed and confusion was noted. At 8:17 A.M., Resident #59 was found on the floor, and noted to have confusion. At 9:19 A.M., Resident #59 was again agitated and attempted to climb out of bed, Ativan 0.5 mg was administered. At 1:20 P.M., Resident #59 was sent to the hospital for evaluation. Review of the Emergency Department (ED) medical record dated 03/22/24 revealed Resident #59 was sent for a wound check and evaluation of deteriorating mental status. Resident #59 was alert only to person and place upon arrival to the ED. Review of the ED Physician assessment dated [DATE] and timed 2:45 P.M., revealed Resident #59 had a large wound to the left knee with surrounding erythema, with a foul smell. In assessing the wound an attempt to remove the dressing noted the gauze that had clotted and appeared entangled in the wound, at which time the wound was recovered without gauze removed due to concerns of heavy bleeding. Resident #59 was started on antibiotics (intravenous Rocephin and Vancomycin) and given fluids due to concerns for sepsis and encephalopathy. Review of the radiography (X-ray) of the left knee completed on 03/22/24 revealed a large region of soft tissue prominence and subcutaneous air medial thigh indicating substantial cellulitis and potential subcutaneous abscess. Review of the hospital medical record dated 03/22/24, revealed Resident #59 was admitted to the hospital with diagnoses that included toxic metabolic encephalopathy, necrotic soft tissue of the left medial thigh and calf with infectious disease, and vascular and wound care consults made for surgical debridement of the wound. Review of the computed tomography (CT) scan of the left knee of Resident #59 completed on 03/23/24 revealed the presence of a complex gas containing fluid collection in the medial soft tissues of the distal thigh extending past the knee joint into the proximal lower leg measurements at least 19.8 cm in length. In addition, there was a soft tissue laceration extending to the fluid collection with no involvement of the muscular compartments seen, with a mass effect upon the vastus medialis muscle of the distal thigh. Review of the operative note for Resident #59 dated 03/25/24 revealed a diagnosis of infected necrotic wound, left lower extremity with an excisional debridement completed. The wound extended from the mid distal thigh to the proximal calf and involved the medial aspect of the thigh and knee. Large eschar over the wound with purulent drainage. The procedure involved a large skin flap on the lateral aspect of the wound was removed, tunneling seen proximally at the 12 o'clock position about 5 cm, and after debridement the wound measured 15 cm x 9 cm x 1 cm (length by width by depth). Cultures revealed polymicrobial, proteus, methicillin-resistant staphylococcus aureus (MRSA) and enterococcus organisms. Review of the Infectious Disease progress note dated 03/27/24 and times 3:33 P.M., recommended treatment of Levaquin 500 milligrams (mg) once a day by mouth and intravenous vancomycin 2,000 mg once daily through 04/07/24. Review of the hospital discharge summary and the continuation of care paperwork dated 03/29/24 and timed 5:16 P.M., revealed Resident #59 was to return to the facility with treatment that included a wound vacuum to the left medial knee. Orders included for the left medial knee wound that included to cleanse the wound and the area around the wound with soap and water after removing old dressing. Dry intact skin completely, apply skin prep to peri-wound then drape, using black foam to cover wound bed, including to make sure the foam is tucked into the tunneling noted at 12 o'clock. The wound vacuum is to be set at 125 millimeters of mercury (mmHg) continuously, at medium intensity, with the track pad to be placed off the wound to a non-pressure area. The dressing was ordered to be changed twice a week and as needed with the wound vacuum machine kept in upright position, and the cannister changed weekly and as needed. Additional orders included Levaquin 500 mg once a day by mouth and intravenous vancomycin 2,000 mg once daily through 04/07/24 and to follow up with wound care. Observation on 04/03/24 at 9:15 A.M. of Resident #59 revealed staff at bedside due to an increase in the confusion. Resident #59 was sitting on the side of the bed talking to self, dressing noted to the left knee was dated 04/03/24 and was clean dry and intact with black foam visible in the center of the wound with tubing extended out the left side of the dressing connected to a portable wound vacuum under Resident #59's bed. The wound vacuum was set at 125 mmHg per orders. Interview on 04/03/24 at 12:23 P.M. with the facility Medical Director #600, who is Resident #59's primary physician, verified knowledge of Resident #59 having a blister to the left knee upon admission. Medical Director #600 stated no other communication had been received in regard to Resident #59's left knee blister/wound. Medical Director #600 further verified no knowledge of the left knee blister breaking open and had he been called he would have seen the resident. Interview on 04/03/24 at 2:35 P.M. with the DON revealed she could not find documentation in Resident #59's medical record reflecting the monitoring and ongoing assessments of Resident #59's wounds and further verified the medical record for Resident #59 lacked documentation of the wound measurements, wound changes, or notification of change in condition. The DON stated Resident #59 did not have a care plan for either skin alterations or wounds. Observations on 04/04/24 at 11:00 A.M. and 3:00 P.M. found Resident #59 in bed, with head of bed elevated, call light within reach and dressing to left knee clean dry and intact with wound vacuum under the left side of the bed draining brownish colored fluid. The wound vacuum was functioning at 125 mmHg. On 04/08/24 at 9:00 A.M., Resident #59 was observed in bed on the right side with a wound vacuum intact and functioning at 125 mmHg. Interview on 04/04/24 at 3:00 P.M. with Licensed Practical Nurse (LPN) #156 verified Resident #59 had a fluid filled blister on left knee with skin surrounding the blister red in color. LPN #156 stated she never had to call a provider about the wound, remembered the specifics related to the dressing changes and verified dressing changes were completed. LPN #156 verified she did not complete wound documentation when completing the dressing change and further verified the weekly skin assessments for Resident #59 were not completed and the care plan did not reflect the care needs related to the skin conditions Resident #59 had. 2) Review of the medical record for Resident #42 revealed an admission date of 11/19/23. The resident had diagnoses including acute kidney failure, acute respiratory failure, hypertension, heart failure, diarrhea, morbid obesity, and perforated intestine requiring surgical intervention. Review of the nursing admission assessment dated [DATE] revealed Resident #42 had an abdominal surgical incision that measured 15 cm by 0.3 cm by 0 cm (length, width, depth). Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had mild cognitive impairment, required maximal assistance for activities of daily living and had a surgical wound. Review of the care plan for Resident #42 revealed an actual impairment to skin integrity due to a surgical wound. Interventions included to follow facility protocols for treatment of injury, encourage good nutrition, and weekly treatment documentation to include measurement of each area of skin breakdown to include length, width and depth, type of tissue and exudate and any other notable changes or observation. Review of the current physician order for Resident #42's surgical incision was written on 02/24/24 for the abdominal incision to be cleansed with normal saline, pat dry, apply calcium alginate with silver wound dressing to the wound bed and cover with transparent adhesive dressing once daily and as needed. Review of the treatment record for Resident #42 revealed treatments were documented as being completed as ordered. Review of the weekly nursing skin assessments and wound assessments for Resident #42 revealed the following: on 01/16/24, the abdominal surgical wound measured 6.0 cm by 4.0 cm by 0.1 cm with no description; on 01/19/24, the assessment references three abrasions to the abdomen with no measurements or description; on 01/26/24, the abdominal surgical incision had granulation tissue present and measured 12.7 cm by 5.2 cm by 0.1 cm; on 02/02/24 and 02/09/24 an abdominal surgical incision was noted, no measurements or description; on 02/02/24, the surgical wound measurement was 11.8 cm by 4.8 cm by 0.1 cm without a description; on 02/09/24, measurements were 12.6 cm by 5 cm by 0.1 cm with the wound well approximated; on 02/16/24, the abdominal surgical incision measured 13.2 cm by 6.5 cm by 0.1 cm; on 02/16/24 the surgical incision measured 13.2 cm by 6.5 cm by 0.1cm; on 02/23/24 the weekly skin assessment was blank; on 02/23/24, stated the overall impression was unchanged and measurements were 14 cm by 5 cm by 0.1 cm; on 02/29/24, stated the wound was well approximated and the tissue surrounding the wound was intact, measurements were 14 cm by 4.2 cm by 0.1 cm; on 03/01/24, the assessment referenced abdomen with no description on measurements present; on 03/08/24, the assessment was blank; on 03/19/24, the assessment listed a surgical incision, no measurements; and on 03/28/24 the skin assessment was blank. Review of the Nurse Practitioner note dated 03/08/24 documented the midline abdominal wound dressing was saturated with serosanguineous fluid. Review of the Nurse Practitioner note dated 03/27/24 documented the skin around the surgical incision was excoriated. Observation on 04/04/24 at 10:30 A.M. of Resident #42 revealed a clean dry transparent dressing with a white material laying underneath the transparent dressing dated 04/03/24 on the left abdomen and a colostomy draining brown liquid to the right abdomen. The skin around both the ostomy and the dressing were noted to be red and excoriated. Interview with Resident #42, at the time of the observation, revealed skin is excoriated from the colostomy breaking open and leaking. Resident #42 stated different bags are being used and doing better and the staff are applying a cream to the abdomen. Interview on 04/04/24 at 4:00 P.M. with the Director of Nursing verified weekly skin assessments, wound monitoring including the measurements, and appearance of Resident #42's surgical wound did not occur and further verified the last assessment of Resident #42's wound was on 02/29/24. Review of the undated policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed neglect was defined as failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the undated policy titled Wound Treatment Management, noted wound treatments are completed to promote wound healing by providing evidenced based treatments in accordance with current standards of practice and physician orders. Wound dressings will be provided in accordance with physician orders, including cleansing method, type of dressing and frequency of dressing change. Wound treatments will be documented in the treatment administration record or in the electronic health record. The effectiveness of treatments will be monitored thorough ongoing assessment of the wound. Considerations for needed modifications include lack of progression toward healing, changes in characteristics of the wound and changes in the resident's goals and preferences. Review of the undated policy titled Skin Assessment, directed full body assessments are part of the systematic approach to pressure injury prevention and management. Full body assessments, head to toe skin assessment will be conducted by a licensed nurse upon admission, re-admission, daily for three days and then weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Documentation of the skin assessment includes the date and time of the assessment, documentation of observations, document of wounds, description of wound including measurement, color, type of tissue in the wound bed, drainage odor, pain, and any other information as indicated and appropriate. Review of the undated policy titled Notification of Changes, directed the resident's physician should be notified promptly of any circumstance which requires a need to alter treatment, including the initiation of a new treatment, or a negative or decline in a wound presentation. This deficiency represents non-compliance investigated under Complaint Number OH00152361.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of the facility investigation, review of a personnel file, review of an emergency medical services (EMS) run report, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPNs), and review of the cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR for one resident (Resident #05) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm, and/or death when Resident #05 did not receive timely CPR after she was discovered with no pulse or blood pressure. This affected one (#05) of three residents (#05, #06, #07) who expired unexpectedly at the facility. Additionally, the facility failed to ensure five [LPNs #101, #123, #134, #141, and Registered Nurse (RN) #138] of 31 nurses employed by the facility had a current CPR certification for Healthcare Providers. This placed all 39 current residents (#11, #12, #14, #15, #18, #22, #23, #24, #25, #28, #29, #31, #32, #35, #36, #38, #39, #40, #41, #44, #45, #48, #49, #52, #54, #56, #59, #60, #61, #64, #67, #70, #72, #74, #78, #80, #81, #83, and #86) designated with a Full Code resuscitation status at potential risk for more than minimal harm that is not Immediate Jeopardy. The facility census was 79. On [DATE] at 4:05 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:15 P.M. when Resident #05, who was a Full Code resuscitation status, was found unresponsive by State Tested Nurse Aide (STNA) #113. STNA #113 notified LPN #225 of Resident #05 being unresponsive, and EMS was notified at 10:22 P.M. LPN #225 assessed Resident #05 who was absent of vital signs and was pale. LPN #225 chose to exit the memory care unit and ran down the hall yelling for assistance from other staff members, passing a crash cart on the nearest unit. LPN #226 and Registered Nurse (RN) #147 went to Resident #05's room and she was found lying on the bed alone. No other staff were in the room and life-saving measures had not been initiated. RN #147 and LPN #226 placed Resident #05 on the floor and began chest compressions and staff followed with a crash cart. Resident #05 was left alone without CPR initiated for approximately two minutes per interview with RN #147. Through investigation, it was discovered LPN #225 refused to perform chest compression on Resident #05 due to a shoulder issue; however, no such shoulder issue was noted in LPN #225's personnel file. EMS arrived at 10:31 P.M. and took over life-saving interventions. The EMS physician called the time of death at 11:09 P.M. The physician and Resident #05's family were notified of the resident's death and notified the funeral home, who picked up Resident #05 on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], LPN #225, who did not perform CPR on Resident #05, was suspended pending investigation. LPN #225 was informed she could not return to work until further notice. • On [DATE], disciplinary action was taken with LPN #225 for not initiating CPR for a resident with a Full Code resuscitation status. LPN #225 was called on [DATE] by Human Resources (HR) #192, the DON, and the Administrator, with the intention of terminating employment. LPN #225 would not answer the phone or return the calls. LPN #225 then texted the facility on [DATE] after hours and resigned without notice. • On [DATE], the Administrator notified Medical Director #300 of the incident. • On [DATE], the DON and the Administrator reported LPN #225 to the Ohio Board of Nursing. • On [DATE], the DON/Designee completed an audit of all residents that expired in the past six months to ensure that their Code Status was followed with no concerns identified. • On [DATE], the DON/Designee completed an audit of all current residents and compared the advance directives to the physician order for accuracy with no concerns noted. • On [DATE], the DON/Designee completed an audit of all licensed nurses to ensure CPR certifications were current. The facility identified five (LPNs #101, #123, #134, #141, and RN #138) nurses did not have current CPR certifications for Healthcare Providers as a result of the audit. • On [DATE], the DON/Designee completed an audit of all current staff to ensure all are available and able to perform job duties. • On [DATE], the DON/Designee completed all staff education on abuse/neglect and misappropriation. All staff were educated in person or via telephone and all education was completed on [DATE]. • On [DATE], the DON/Designee completed all staff education on the importance of initiating CPR immediately on full code residents. All staff were educated in person or via telephone and all education was completed on [DATE]. • On [DATE], the DON/Designee completed all staff education on the necessity of informing management in the event you cannot fully perform job duties. All staff were educated in person or via telephone and all education was completed on [DATE]. • On [DATE], a Code Blue drill was conducted with no concerns identified. • On [DATE], a Quality Assurance Performance Improvement (QAPI) meeting was held, and a Performance Improvement Plan (PIP) was implemented following notification of Medical Director #300 via phone by the Administrator. The Administrator, Social Service Director (SSD) #194, the DON, Minimum Data Set (MDS) Coordinator #197, Unit Manager LPN #166, Unit Manager RN #148, Unit Manager RN #136, Business Office Manager (BOM) #193, Maintenance Director (MD) #196, admission Director (AD) #191, HR #192, Physical Therapy Director (PTD) #251, and Chief Operating Officer (COO) #500 were present for the meeting. • The DON will monitor for code status compliance by interviewing licensed nurses about the facility's CPR policy and procedure, as well as requesting return demonstration of the CPR process. Compliance checks will be conducted on three nurses two times weekly for three months. The findings will be reviewed at the monthly QAPI committee meeting. • The DON/Designee will audit all new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will be conducted four to five times a week for three months. The findings will be reviewed monthly at the QAPI committee meeting. • The DON/Designee will perform Code Blue drills three times a month for three months and will cover all shifts. The findings will be reviewed at the monthly QAPI committee meeting. • On [DATE], the medical records for Resident #06 and Resident #07, who expired unexpectedly at the facility, were reviewed and staff responded appropriately. • On [DATE], between 7:15 A.M. to 12:00 P.M., interviews with LPN #108, LPN #134, LPN #141, LPN #159, STNA #109, STNA #137, STNA #150, and STNA #156 verified all were educated on the facility's abuse and neglect policy, the CPR policy and importance of initiating CPR timely, and importance of notifying the facility if unable to fully perform job duties. Interview with all staff members confirmed each possessed adequate knowledge and retention of the policies, procedures, and expectations of the education provided. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and non-compliance due to five nurses working at the facility that had expired CPR certification. Findings included: Review of Resident #05's medical record revealed an original admission date of [DATE] and a readmission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia, bipolar disease, and fibromyalgia. Review of a physician order dated [DATE] revealed Resident #05 had a Full Code resuscitation status. Review of Resident #05's care plan dated [DATE], revised on [DATE], revealed the resident had a Full Code resuscitation status. An intervention included to initiate CPR in the absence of a pulse. Review of a progress note dated [DATE] revealed Resident #05's code status was reviewed during a care conference and Resident #05's family wished for the resident to remain a Full Code resuscitation status at that time. Review of nursing progress notes dated [DATE] at 2:10 P.M. revealed Resident #05 was very anxious and agitated during the shift. Staff members attempted to provide redirection activities with little success. A nurse practitioner was notified and provided new orders that were implemented. At 3:36 P.M., an antianxiety medication was administered due to continued anxiousness and agitation and was noted as ineffective at 4:28 P.M. A nurse practitioner with psychiatric services was contacted and provided new orders. At 5:19 P.M., Resident #05 was administered an antipsychotic medication due to continued behaviors. At 6:15 P.M., Resident #05 was noted to continue with the same behaviors of yelling out, restlessness, and anxiousness. Resident #05 complained of being short of breath, but continuously took her nasal cannula off which supplied supplemental oxygen, and the resident was reminded several times to keep the oxygen on. Resident #05's lung sounds were clear throughout, and oxygen saturation levels were at 94 percent (%). A nurse practitioner was contacted and gave orders for a chest x-radiation (x-ray) diagnostic image and a urinalysis to be obtained. Resident #05's responsible party was made aware of the resident's behavior and the new orders. Review of a progress note dated [DATE] revealed on [DATE] Resident #05 was checked on between 9:30 P.M. and 10:00 P.M. and was last seen with her nasal cannula on watching television in bed. A nurse aide (STNA #113) noticed Resident #05 looked pale and noticed her nasal cannula was not in her nose and she was holding it in her hand. The nurse aide notified the nurse (LPN #225) of Resident #05's condition and found Resident #05 was unresponsive and vital signs were absent. The nurse told the nurse aide to contact EMS and CPR was started immediately until EMS staff arrived and took over life saving measures. Resident #05 expired at 11:09 P.M., and notifications were made to the on-call physician, unit manager, family, and funeral home. Review of the facility investigation initiated on [DATE] revealed the DON obtained a statement via an interview from LPN #225 regarding Resident #05's death who resided on the locked memory care unit. Further review of the investigation revealed LPN #225 instructed STNA #113 to call EMS. LPN #225 then left the memory care unit, running and yelling down the hall, and passed a crash cart on the nearest unit. RN #147 and LPN #226, from another unit, ran a crash cart back to the memory care unit to Resident #05's room. Chest compressions were started on Resident #05 by LPN #226 and RN #147 while LPN #225 refused to complete chest compressions. LPN #225 informed the DON she could not do chest compressions due to shoulder issues. It was determined there was no documentation in LPN #225's personnel file indicating any restrictions to performing regular or essential job duties. The investigation determined chest compressions were not immediately started on Resident #05 when she was found absent vital signs, was unresponsive, pale, and had a Full Code resuscitation status in place. Review of an EMS run report dated [DATE] revealed Resident #05 experienced cardiac arrest at 10:20:00 P.M. on [DATE]. EMS received the telephone call from the facility at 10:24:37 P.M., the call was dispatched at 10:25:20 P.M., and EMS staff were enroute to the facility at 10:27:04 P.M. EMS staff arrived at the facility at 10:29:03 P.M. and reached Resident #05 at 10:31:00 P.M. Further review of the EMS run report revealed staff indicated the last known time Resident #05 was well was at 9:30 P.M. and facility staff found Resident #05 unresponsive at 10:20 P.M. When EMS staff arrived, Resident #05 was laying on the floor with staff performing chest compressions when EMS staff took over life-saving measures. Resident #05 was noted to be pulseless, and the resident was not breathing. EMS continued with life saving measures for approximately 30 minutes and Resident #05 continued to have no heartbeat. A physician was contacted to request life-saving efforts be discontinued, and time of death was given at 11:09 P.M. Interview on [DATE] at 9:51 A.M., with the Administrator and the DON revealed on [DATE] Resident #05 was found unresponsive, and LPN #225 refused to perform CPR. LPN #225 instructed STNA #113 to call EMS and then left the unit to get assistance from other nurses. Two nurses from other units responded and began CPR. The DON was not aware how long it took the staff to respond to Resident #05 and CPR to be initiated. The DON confirmed CPR was delayed by LPN #225's refusal to begin chest compressions. Telephone interview with RN #147 on [DATE] at 1:25 P.M. revealed, on [DATE], she was assigned to the [NAME] unit of the facility, and LPN #226 was assigned to the Evergreen unit. RN #147 stated she saw LPN #225 coming down the hall and heard LPN #225 yelling for assistance on the secured memory care unit. RN #147 stated a nurse aide from [NAME] unit got the crash cart, and when the staff arrived at Resident #05's room on the memory care unit, the resident was alone in the room lying in the bed. RN #147 stated she and the nurse aide placed Resident #05 on the floor and began CPR while STNA #113 was on the telephone with EMS. RN #147 stated LPN #225 stood in the doorway of the room and refused to assist with CPR. RN #147 estimated it took the staff two minutes to reach Resident #05's room after being alerted of the incident. Review of STNA #113's written statement, obtained through interview with the DON, dated [DATE] revealed STNA #113 entered Resident #05's room and noticed the resident looked very pale. STNA #113 and LPN #225 both could not get Resident #05 to respond to them, so LPN #225 told STNA #113 to call EMS. STNA #113 indicated LPN #225 then left the memory care unit and would be heard yelling for help. Two different nurses returned to the memory care unit and began life-saving measures on Resident #05 while LPN #225 left the unit to talk to EMS and let them in the door. Review of LPN #225's personnel file revealed a hire date of [DATE]. Further review revealed LPN #225 had a current basic life support (BLS) certification on file with an expiration date of [DATE]. There was no documentation in LPN #225's personnel file related to work restrictions or changes to job duties because of shoulder issues. Review of a disciplinary action document dated [DATE] revealed LPN #225 was terminated based on the facility policy to begin procedures for a resident that was in need of medical attention right away, as being charge nurse of a whole unit. Further review revealed a resident (#05) was unresponsive on the memory care unit where LPN #225 was the charge nurse. LPN #225 instructed STNA #113 to call EMS, but LPN #225 left the unit yelling and calling for help while passing a crash cart on the nearest unit. A crash cart was taken to the memory care unit and two different staff members began chest compressions while LPN #225 refused to perform chest compressions citing shoulder issues. There was nothing in LPN #225's personnel file indicting any job restrictions preventing LPN #225 from performing essential job duties. LPN #225 was noted to be BLS certified, and the facility determined LPN #225 did not immediately start chest compressions on Resident #05. Review of the facility policy titled, Cardiopulmonary Resuscitation, revised [DATE], revealed it is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding CPR. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to arrival of emergency medical services, and in accordance with the resident's advance directives. CPR certified staff will be available at all times. Staff will maintain current CPR certification for healthcare providers through CPR provided who evaluates proper technique through in-person demonstration of skills. CPR certification which included an online knowledge component yet still requires in-person demonstrations to obtain certification or recertification is also acceptable. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. 2. Review of the documentation provided by the facility revealed 31 nurses were currently employed by the facility. Of those 31 nurses, four LPNs (#101, #123, #134, #141) and one RN (#138) had expired CPR certification for Healthcare Providers. Interview on [DATE] at 12:54 P.M., with the DON verified five facility-employed nurses (LPNs #101, #123, #134, #141, and RN #138) had expired CPR certification. Review of the undated facility job description for Licensed Practical Nurses (LPNs) revealed LPNs must identify resident problems and emergency situation and initiate emergency care and lifesaving measures in the absence of a physician. This deficiency represents non-compliance investigated under Master Complaint Number OH00151169.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interviews, staff interviews, community member interviews, review of the facility's Self-Reported Incident (SRI), review of the facility's investigations, review of a police incident detail report, review of maintenance exit door operation tests, and review of facility polices regarding elopement, wandering residents, and resident alarms, the facility failed to provide adequate supervision for Resident #10, who was at risk for wandering and had a history of wandering/elopement. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #10 eloped from the facility, without staff knowledge, and the facility staff failed to respond appropriately. The lack of adequate supervision and timely response to interventions resulted in Resident #10 leaving the facility through an alarmed door, and by the time staff responded to the alarm, Resident #10 had crossed a two-lane road and was picked up in a vehicle by a neighbor of the facility approximately one-tenth of a mile, north of the facility. This affected one (Resident #10) of three residents reviewed for elopement. The facility's census was 86. On [DATE] at 4:05 P.M., the Administrator and Director of Nursing (DON) #407 were notified Immediate Jeopardy began on [DATE] at 10:57 A.M. when Resident #10 was not located on the secured unit of the facility and staff discovered Resident #10 had eloped from the facility. Resident #10 was found by a neighbor of the facility walking north on a two-lane road on the opposite side of where the facility was located. The weather was overcast with intermittent rain and the road pavement and grass on either side of the road was wet and covered with wet fallen tree leaves. Resident #10 previously eloped from the facility on [DATE] due to a visitor letting him out unbeknownst to staff members, and interventions were put into place to prevent future potential elopements at that time. Resident #10 was able to elope a second time on [DATE] through an alarmed exit door that was equipped with a 15-second delayed egress locking mechanism (the door alarms and remains locked for 15 seconds after pressure is applied to the door in the path of egress) without staff intervention. The Immediate Jeopardy was removed on [DATE] at 11:14 A.M., when the facility implemented the following corrective actions: · On [DATE], Resident #10 returned to the facility and was assessed with no injuries, pain, or change in condition, and vital signs were within normal limits. Resident #10 was placed on every 15-minute observations until one-to-one observations were initiated on [DATE] at 12:00 P.M. Resident #10's one-to-one observation would be performed by nurses and nurse aides and would continue until [DATE], at which time Resident #10 would be re-assessed to determine appropriateness for continued one-to-one observation. Resident #10's observation level status would continue to be reviewed daily until [DATE] and bi-weekly thereafter until Resident #10's discharge from the facility. Observation on [DATE] at 11:10 A.M., revealed Licensed Practical Nurse (LPN) #409 was on a direct one-to-one observation with Resident #10 in his bedroom. · On [DATE], Resident #10 was re-assessed for wandering and was assessed at high risk. · On [DATE], the facility initiated an SRI and investigation related to Resident #10's elopement on [DATE]. · On [DATE] at 2:00 P.M., all 11 exit doors of the facility were tested by Maintenance Director #342 for the operation of the doors, locks, and alarms with no concerns identified. Maintenance Director #342 tested all 11 exit doors again on [DATE] at 8:00 A.M. with no concerns identified. The facility would continue to test the operation of all 11 exit doors five times weekly for two weeks. · On [DATE], the facility conducted an elopement drill to assess staff response to resident elopement. The drill was conducted by DON #407 with 10 staff members participating in the drill. There were no concerns identified during the elopement drill. The facility would conduct elopement drills weekly for one month and findings would be discussed during the next Quality Assurance and Performance Improvement (QAPI) meeting scheduled for [DATE]. · On [DATE], all nine residents (#01, #04, #08, #10, #26, #35, #59, #63, and #81) the facility identified as at risk for elopement, had their elopement and wandering care plans reviewed and revised by Regional Minimum Data Set (MDS) Coordinator #416. The audit was to ensure all at risk residents had appropriate interventions in place to prevent elopement from the facility. · On [DATE], the facility held a QAPI meeting with all department heads, managers, the Administrator, and the Medical Director to discuss root cause analysis of Resident #10's elopement, review the admission process for respite stay residents, and discuss the facility's resident elopement, wandering, and resident alarms policies. · On [DATE], the Administrator compiled education materials regarding resident elopement, wandering, and resident alarms. On [DATE], the Administrator, DON #407, Director of Dietary Services #386, Admissions Assistant #356, Therapy Director #333, LPN Unit Manager #398, and LPN Unit Manager #411 educated a total of 115 staff members on the policies and procedures of the facility related to resident elopement, wandering residents, and response to resident alarms. All staff members were educated in person, by telephone, or by electronic media by [DATE]. The facility leadership would conduct audits two times weekly for four weeks to assess staff knowledge of the education provided. The results would be discussed in the next QAPI meeting scheduled on [DATE]. · On [DATE], review of the medical records for Resident #04 and Resident #63 revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. · On [DATE], between 10:53 A.M. and 11:14 A.M., four nurses (LPN #317, LPN #397, Registered Nurse (RN) #369, LPN #409) and three State Tested Nurse aides (STNAs) (STNA #379, STNA #349, STNA #353) verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed an admission date of [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, diabetes mellitus type II, mild cognitive impairment, hyperlipidemia, and essential hypertension. Review of an admission referral sent to the facility via facsimile (fax) on [DATE] revealed the referring agency talked to Resident #10's family member and indicated during the recent hurricane in the southern part of the United States, Resident #10 and his family lost their home and relocated to the state where the facility resided until their home could be fixed, which could take between three to six months. Resident #10's family member indicated Resident #10 had dementia and would get restless daily around 4:00 P.M., tried to leave the house, and needed to always have someone with him because he was an elopement risk. Resident #10's family member stated Resident #10 had respite services in the southern state and would like to have a respite stay in the state where the facility was located as well so Resident #10's wife could run errands as needed. Resident #10's family member indicated Resident #10 was independent with activities of daily living (ADLs). Review of an admission nursing assessment dated [DATE] revealed Resident #10 was admitted to the facility for a respite stay. Resident #10 was alert and oriented to person and situation but not time or place. Resident #10 was confused and exhibited short term memory problems. Resident #10 was assessed with a normal gait and no abnormalities were identified during the physician assessment. Resident #10 was assessed as independent with bed mobility, transfers, walking, and locomotion with no assistive devices required. Review of a wandering risk scale assessment completed [DATE], revealed Resident #10 was able to follow instructions, was ambulatory, could communicate, had a history of wandering, and a medical diagnosis of dementia or cognitive impairment. Resident #10 was assessed at high risk for wandering based on the results of the assessment. Review of the resident census data, from the electronic medical record, dated [DATE], revealed Resident #10 was admitted to the secure unit of the facility. Review of the comprehensive care plan initiated on [DATE], and revised on [DATE], revealed Resident #10 was an elopement risk and wanderer related to impaired safety awareness, disorientation to surroundings, history of attempts to leave the facility unattended and aimless wandering. The facility implemented interventions including to distract Resident #10 from wandering by offering pleasant diversions and structured activities, monitor Resident #10 for fatigue, and identify patterns of wandering and intervene as needed. Review of a nursing progress note dated [DATE] at 8:20 P.M. revealed a nurse administered medications to Resident #10 at approximately 8:00 P.M. and at approximately 8:20 P.M. a nurse aide approached the nurse who was concerned about the whereabouts of Resident #10. There were no exit doors alarming at that time. The secured unit was searched, as well as the entire interior and exterior grounds of the facility and Resident #10 was not located. The nurse contacted emergency services to report a missing person and contacted the facility administration. Resident #10 was located by local law enforcement and the police officers indicated they received a call of a man walking the ramp of the highway. The nurse met the police officers and transported Resident #10 back to the facility at approximately 9:00 P.M. Resident #10 was pleasantly confused, was assessed with no injuries, and was in no distress. Review of a police incident detail report dated [DATE] revealed a call was received on [DATE] at 8:35:04 P.M. of a missing person (Resident #10) and a physical description was provided. The police incident detail report lacked specific information and details about where and when Resident #10 was found or how Resident #10 returned to the facility. The incident was logged as closed on [DATE] at 8:58:00 P.M. Review of a skin assessment completed [DATE] revealed Resident #10 had no skin impairments. Review of a nursing progress note dated [DATE] revealed the on-call nurse practitioner and Resident #10's family were notified of the elopement. The maintenance department arrived at the facility to check the function of all door alarms. Resident #10 was placed on every 15-minute observations and a WanderGuard (an alarming devise worn by a person that triggers alarms and can lock monitored doors to prevent the person from leaving unattended) was placed on Resident #10's ankle. Review of an updated wandering risk scale assessment completed [DATE] revealed Resident #10 remained at high risk for wandering. Review of an SRI dated [DATE], revealed Resident #10 eloped from the facility on [DATE] at approximately 8:20 P.M. Resident #10 was found by local police and returned to the facility on [DATE] at approximately 9:00 P.M. with no injuries or change in condition. The maintenance department checked all exit doors on [DATE] and all locks and alarms were working appropriately. The facility began education with staff about resident elopement and procedures for incidents of elopement at that time. Resident #10 also had a WanderGuard placed to his right ankle and was placed on every 15-minute observations. Review of a written statement dated [DATE] from Resident #82 revealed on [DATE] she saw two men, one of the men was carrying a suitcase, and walked past her bedroom around the time of the incident on [DATE]. Review of a written statement from a visitor indicated he visited his girlfriend (Resident #23) on [DATE] on the secured unit. The visitor indicated he was approached by a man at the exit door, and they began a conversation with each other. The visitor indicated the man was clean cut, oriented to himself, and had a normal conversation with him. The visitor asked the man where he was going, and the man indicated he was leaving to go to another part of the state to see his daughter. The visitor indicated at the time the man had a suitcase in his hand. The visitor stated he entered the code to exit the door from the secured unit and he and the man exited together, continued talking while in the hallway, and again put in the door code in the main lobby, and he and the man exited together. The visitor indicated when he got to his car to leave, he looked back and did not see the man, so he thought he had gotten into his car and left. The visitor was not aware the man he talked to on [DATE] was a resident of the facility, admitted to the secured unit, and the man was Resident #10. Further review of the SRI dated [DATE] revealed the visitor who let Resident #10 out of the facility was educated on not allowing any person he did not know to exit any secured areas or outside the facility. The facility placed signs at the exit doors from the secured unit alerting visitors and staff to not allow anyone they do not know off the secured unit. The SRI was closed on [DATE] and was unsubstantiated. Review of a nursing progress note dated [DATE] revealed a maintenance staff member arrived at the facility on [DATE] at approximately 9:30 P.M. to check the function of the door alarms. Review of a maintenance door lock and alarm operations test revealed all exit doors and alarms were tested in the facility on [DATE] with no concerns identified. Review of a physician order dated [DATE] revealed a WanderGuard was placed on Resident #10's right ankle with instructions for staff to check placement, function, and skin integrity every shift. Review of Resident #10's elopement care plan revealed an intervention was added on [DATE] to include the use of a WanderGuard. Review of the [DATE] Medication Administration Record (MAR) revealed Resident #10's WanderGuard placement, function, and skin integrity were monitored every shift as ordered with no concerns identified. Review of a nursing progress note dated [DATE] revealed Resident #10 was alert to self, walked independently, and was exit seeking throughout the day. Resident #10 was pleasantly confused and easily redirected. Resident #10 continued every 15-minute observations and was accounted for the entire shift. Review of a nursing progress note dated [DATE] revealed Resident #10 was observed opening the east emergency exit door on the unit. The door alarm sounded, Resident #10 closed the door, and Resident #10 did not exit the facility. Resident #10 was encouraged not to tamper with the emergency exit doors and was redirected to his room without further incident. Resident #10's WanderGuard remained in place. Review of a nursing progress note dated [DATE] revealed Resident #10 was exit seeking throughout the shift but was easily redirected. Review of a nursing progress note dated [DATE] revealed Resident #10 opened the east emergency exit door and was fully dressed in a coat and had luggage. Resident #10 immediately closed the door once the alarm sounded. Resident #10's WanderGuard remained in place on his right ankle, and he was easily redirected. Review of a nursing progress note dated [DATE] revealed Resident #10 showed signs of agitation related to his WanderGuard and indicated he was going to cut it off. Resident #10 was encouraged not to tamper with the WanderGuard and educated that it was for his safety. Resident #10 was easily redirected and the WanderGuard remained in place to the right ankle. Interview on [DATE] at 8:33 A.M. with the Administrator revealed he was notified on [DATE] at approximately 8:30 A.M. of Resident #10's elopement from the facility. The Administrator stated the facility initiated a search and contacted the local police who found Resident #10 in the community. Resident #10 returned to the facility unharmed on [DATE] at approximately 9:00 P.M. The Administrator stated he was not sure of the exact location where Resident #10 was found, but that he was unaccounted for in the facility for approximately 40 minutes. The Administrator verified he initiated an investigation and opened an SRI. Through the investigation it was discovered a frequent visitor to the secured unit engaged in conversation with Resident #10 on [DATE]. The Administrator stated the visitor comes almost daily to visit Resident #23 and was given the code to the secured unit because of the frequency of his visitations and the time he usually visited was after work between 7:30 P.M. and 8:00 P.M. The visitor admitted to putting in the code to the secured doors and the main lobby exit door while walking and talking with Resident #10. The Administrator stated the visitor had no idea who Resident #10 was and mistook him for another visitor. The Administrator stated the visitor was educated about not letting people he did not know off the secured unit and signs were placed on the door indicating staff and visitors should not allow anyone they did not know out of the secured unit. The Administrator stated they closed the investigation and Resident #10 had no further elopements. A telephone interview was completed on [DATE] at 9:33 A.M. with STNA #353, who verified she was working on the secured unit on [DATE] when Resident #10 eloped. STNA #353 stated she last saw Resident #10 standing at the nurses' station around 8:00 P.M. and the nurse was administering his medications. STNA #353 stated she went into another resident's room to perform care and came out around 8:20 P.M. and did not see Resident #10. STNA #353 stated she checked Resident #10's bedroom and the entire unit but could not locate him. STNA #353 reported there were no alarms sounding at that time and there were no doors or windows open. STNA #353 stated she informed the nurse she could not find Resident #10 and they alerted the other facility staff and began a search. STNA #353 stated the nurse left the facility in her car and drove around looking for Resident #10 and she stayed on the unit with the residents. STNA #353 stated Resident #10 returned to the secured unit with the nurse and was not injured, in pain, or in distress. STNA #353 stated Resident #10 was dressed appropriately with shoes, a sweatshirt, and blue jeans. STNA #353 did not know where Resident #10 was found, and reported he was placed on every 15-minute observations and the nurse put a WanderGuard on him. STNA #353 verified there was a visitor on the unit prior to Resident #10's elopement who she identified as the visitor who visited Resident #23 frequently. STNA #353 stated she did not see Resident #10, or the visitor leave the unit so she could not say how they left the unit. A telephone interview was completed on [DATE] at 9:45 A.M. with LPN #332 who verified she was the nurse working on the secured unit on [DATE] when Resident #10 eloped. LPN #332 stated she started her shift on [DATE] at 7:00 P.M. and verified STNA #353 was the only other staff member working the secured unit at that time. LPN #332 stated [DATE] was the first time she had any interaction with Resident #10 and stated around 8:00 P.M. he was given his medications and he took them without issues. LPN #332 stated Resident #10 was one of the first residents she gave medications to that evening, so she continued with her medication administration to the rest of the residents on the secured unit. LPN #332 stated he was in and out of resident rooms giving them their medications when around 8:20 P.M., STNA #353 approached her and stated she could not locate Resident #10. LPN #332 stated she and STNA #353 did a search of the secured unit and could not find Resident #10, and no door alarms were sounding, and all doors and windows were closed. LPN #332 stated she informed the other staff in the building, called the director of nursing, and called emergency services to report a missing person. LPN #332 stated other staff members were looking inside the facility and outside the facility grounds, so she got into her car and drove the surrounding streets to look for Resident #10. LPN #332 stated she stopped at a nearby gas station and the attendant indicated they did not see anyone walking by, so she continued to the next gas station. LPN #332 stated at that time she received a call from emergency services who indicated they received a report of an elderly man walking on the road. The local police had Resident #10 and were not willing to take him to the facility but could meet LPN #332 in a parking lot to receive Resident #10. LPN #10 stated she was not familiar with the area and could not remember the exact location where she picked Resident #10 up from the police. LPN #332 could only remember it was the parking lot of a business but had no other information. LPN #332 stated Resident #10 was free from injuries, expressed no pain, was properly dressed, and was not in distress when she picked him up. Resident #10 returned to the facility without incident, and she received an order for a WanderGuard and every 15-minute checks for 24 hours. LPN #332 stated a maintenance staff member came to the facility on [DATE] to check all the doors and windows and found no concerns. LPN #332 stated she did not see how Resident #10 left the secured unit, but verified a visitor was on the unit visiting Resident #23 around the time Resident #10 was missing. Interview on [DATE] at 10:09 A.M. with Resident #82 confirmed she saw two older males walking past her room on [DATE] and one of them had a suitcase. Resident #82 stated the two men were talking and they were heading toward the exit doors in the main lobby. Resident #82 stated she did not recognize either male and did not hear any door alarms or commotion at that time. Resident #82 stated it was not until the facility started to look in resident rooms for Resident #10 that she realized one of the men she saw walking in the hallway was Resident #10. Resident #82 stated, later in the night on [DATE], she saw the man with the suitcase in the hallway again with staff and realized at that time it was the resident the facility was looking for. Interview on [DATE] at 10:46 A.M. with Maintenance Director (MD) #342 stated as part of the facility's routine testing and maintenance, all exit doors are tested for operation of locking mechanisms and alarms weekly. MD #342 stated there were no issues with any of the exit door alarms or locks during his previous monthly checks. MD #342 verified he was contacted on [DATE] around 8:50 P.M. by the Administrator to come to the facility to check and test the exit doors in the facility because a resident eloped. MD #342 stated he arrived at the facility on [DATE] at approximately 9:15 P.M. and began checking exit door locks and alarms and found no concerns. MD #342 stated all doors were locking, releasing, and alarming appropriately with no evidence any of the doors were tampered with. MD #342 reported he also checked every window on the secured unit to ensure there were no issues with them, and verified all windows and screens were in place with no evidence of anyone exiting through a window. Observation on [DATE] at 10:58 A.M. with MD #342 revealed upon entrance to the secured unit, the unit was configured in an L shape with the north hallway directly ahead and the east hall directly to the right and a nurses' station located in the elbow of the L. There were no alarms sounding upon entrance to the secured unit. MD #342 first tested the secured doors from inside the secured unit, and when tested, an audible alarm sounded, and did not open or stop alarming until a code was inputted into the keypad. MD #342 then tested the emergency exit door at the end of the north hall. The door alarmed once pressure was applied and remained locked while continuing to alarm for 15 seconds at which time the door opened but continued to alarm. MD #342 closed the door and inputted the code on the keypad to silence the alarm and re-engage the lock. MD #342 then stopped in the activity room on the north hall and duplicated how he checked the windows on [DATE]. MD #342 opened the window in the activity room which slid horizontally from right to left but only opened approximately five inches. MD #342 then proceeded past the nurses' station toward the dining room where the door was tested that lead to an enclosed courtyard with a tall vinyl fence with a gait on the north side of the exterior of the building, completing the perimeter on the west, east, and south side. MD #342 tested the door and it alarmed, remained locked, and released in 15 seconds while continuing to alarm with no issues. MD #342 again demonstrated the testing of a window in the dining room and, just as before, the window only opened approximately five inches. The last door tested was the emergency exit door on the east hall of the secured unit. The east emergency exit was equipped with a window and the facility parking lot and public street could be viewed from that location. MD #342 tested the east emergency exit door and when pressure was applied, the door began alarming and remained locked for 15 seconds. After 15 seconds, the door locks released, and the door opened while the alarm continued to sound. MD #342 inputted a code into the keycode to silence the door alarm and re-engage the locking mechanism. All doors and locks tested on the secured unit were working appropriately during all observations. At this time, three staff members were observed through the window of the east emergency exit door and they were standing by the public street, one of which was the Administrator on a cellular telephone. At approximately 11:00 A.M. on [DATE], this surveyor remained on the secured unit and approached Resident #10's bedroom in hopes to interview the resident. Observation inside Resident #10's bedroom at that time revealed Resident #10 was not in his room. Upon exit from Resident #10's bedroom, LPN Unit Manager #398 was observed with concerned eyes and a reddened face and was walking quickly to the nurses' station. Interview on [DATE] at 11:03 A.M. with LPN Unit Manager #398 revealed Resident #10 was unaccounted for and the facility was initiating a missing person alert. Observation on [DATE] at approximately 11:03 A.M. revealed facility staff began head counts of residents on the secured unit to ensure no other residents were missing. Observation of Resident #10's bedroom on [DATE] between 11:05 A.M. and 11:10 A.M. revealed the exterior window was closed and the screen was in place. Resident #10's WanderGuard was nowhere to be found. Interview on [DATE] at 11:12 A.M. with Activities Staff #362 revealed she was assisting with the head count on the secured unit and Resident #10 was not located. Activities Staff #362 stated the last time she saw Resident #10 was approximately 9:30 A.M. at the nurses' station. Interview on [DATE] at 11:14 A.M. with the Administrator revealed Resident #10 got out of the facility, flagged down a car on the street, and got in. The Administrator stated the local fire department had Resident #10 and was bringing him back to the facility. Interview on [DATE] at 11:17 A.M. with admission Assistant #356 stated she was not on the unit when Resident #10 eloped and was only assisting with monitoring the residents on the secured unit during the facility search. Admissions Assistant #356 verified she did not know of Resident #10's whereabouts. Observation on [DATE] at 11:20 A.M. revealed Resident #10 walking in the hallway toward the secured care unit with staff members. Resident #10 was appropriately dressed, was wearing shoes, and had a plastic grocery bag in his hand. Resident #10 was ambulating independently, was talking with staff in a pleasant manner, and was free from any apparent distress or pain. Once Resident #10 walked through the entrance of the secured unit, the door alarm began alarming, indicating the WanderGuard was in place. The facility staff escorted Resident #10 to his bedroom on the secured unit at that time. Interview on [DATE] at 11:21 A.M. with the Administrator revealed the person who picked Resident #10 up from the street was in the facility and could be interviewed at that time. This surveyor informed the Administrator it was necessary to remain with Resident #10 to ensure Resident #10's safety, but to inquire with the person about contact information and details surrounding the incident. Observation on [DATE] at 11:22 A.M. revealed Resident #10 sitting in his reclining chair in his bedroom. Resident #10 remained pleasant and was free from distress, pain, and apparent injuries. Further observation with Therapy Director #333 verified Resident #10 had a WanderGuard on his right ankle. Observation on [DATE] at 11:23 A.M. revealed Regional MDS Coordinator #416 assessed Resident #10's physical body and asked general questions about his health. Resident #10 was observed to have no injuries, no pain, no range of motion concerns, and was in no distress. At 11:24 A.M., Regional MDS Coordinator #416 confirmed Resident #10 had no abnormal findings. At 11:25 A.M., LPN #343 entered Resident #10's bedroom to obtain his vital signs with no abnormal findings noted. Interview on [DATE] at 11:25 A.M. with Resident #10 stated he was ready to go home, so he went out of his condominium (condo), went out to the street, and hitch-hiked. Resident #10 motioned by placing his thumb in the air and moving his arm and hand up and down when mentioning hitch-hiking. Resident #10 was asked twice how he was able to get out of the facility and Resident #10 kept replying he did not understand the question. Interview on [DATE] at 11:39 A.M. with the Administrator revealed he obtained the contact information for the person that picked Resident #10 up from the road. The Administrator stated the person was a neighbor of the facility and lived approximately four houses north of the facility. The Administrator stated the neighbor told him he saw an elderly man outside his house and could tell he was confused, so he picked him up in his vehicle. A telephone interview was completed on [DATE] at 11:42 A.M. with Neighbor #415 who verified he picked Resident #10 up from the public street on [DATE]. Neighbor #415 stated he could not remember exact times, but he was at his house, which was located on the same side of the road as the facility approximately three to four houses to the north. Neighbor #415 stated he could see a well-dressed elderly man that he did not recognize on the opposite side of the road putting his thumb in the air and trying to hitch-hike. Neighbor #415 stated it was raining out and cars kept going past Resident #10 and not stopping, so he got up, put his shoes on, got in his car, and drove to see if Resident #10 needed assistance. Neighbor #415 stated when he stopped and talked to Resident #10, he asked where he was heading, and Resident #10 gave the name of the city the facility was located. Neighbor #415 responded that if Resident #10 kept walking in the direction he was heading, he would end up in the state to the north, that boarded the state the facility was located in. Neighbor #415 stated he then let Resident #10 into his vehicle and asked him what part of the town Resident #10 was heading to, in which Resident #10 on[TRUNCATED]