**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of facility policy, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the development of, worsening of and promote the healing of a facility acquired pressure ulcer for Resident #44, a resident who was at risk for pressure ulcer development and dependent on staff for all activities of daily living (ADLs) including bed mobility, turning and repositioning, incontinence care for both bowel and bladder, showering, and dressing. This resulted in Immediate Jeopardy and actual harm when the facility failed to implement effective interventions to prevent the development of and timely and adequately treat a facility acquired pressure ulcer. On 06/13/24 Resident #44 was seen by a wound care team for moisture associated dermatitis (MASD) (MASD is a general term for skin inflammation or erosion caused by exposure to moisture and its contents) on the sacrum that had progressed from MASD measuring 0.3 cm in length by 0.4 cm width with 0.2 cm depth to a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer measuring 2.4 cm long by one cm wide with 0.3 cm depth. On 06/27/24 the ulcer deteriorated with an increase in size and measured 3.8 cm long by 1.8 cm wide with 0.7 cm depth. On 06/29/24 at 2:25 P.M. the resident was documented to have a change in condition with increased lethargy, no food intake at lunch, minimal fluid intake, abnormal vital signs including an elevated temperature of 101 degrees Fahrenheit, elevated heart rate of 90 and decreased blood pressure of 104/60. The resident had an elevated white blood cell count of 12.51 (indicative of infection) at this time. However, wound cultures ordered on this date were not obtained until 07/02/24. On 07/03/24 the resident was transferred to the hospital and admitted for treatment of sepsis secondary to decubitus/pressure ulcer. In addition, a concern that did not rise to Immediate Jeopardy but did result in Actual Harm occurred to Resident #10, who was at risk for pressure ulcer development and/or alteration in skin integrity when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. On 06/13/24 Resident #10 was assessed to have a new in-house acquired Stage III pressure ulcer measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth to the left lower buttock. The pressure ulcer deteriorated when assessed on 06/20/24 with an increase in size measuring 2.5 cm long by three cm wide with 0.1 cm depth and an increase in exudate drainage. Actual harm also occurred to Resident #72 on 06/20/24 when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. Resident #72 was assessed to have an in-house acquired Stage III pressure ulcer to the sacrum measuring 3.5 cm long by 4.5 cm wide with 0.1 cm depth. The pressure ulcer deteriorated when assessed on 07/01/24 with an increase in size measuring four cm long by 4.5 cm wide with 0.3 cm depth with documentation the wound progress was exacerbated due to new damaged skin around the wound. This affected three residents (#10, #44, and #72) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers (#7, #10, #44, #45, #46, #49, #58, #61, #65 and #72) The facility census was 78. On 07/09/24 at 12:35 P.M. the Interim Administrator and the Director of Nursing were notified Immediate Jeopardy began on 06/13/24 when Resident #44 was seen by wound care team including Wound Care Physician (WCP) #700 who identified a wound to the resident ' s sacrum had progressed from MASD to an in-house acquired Stage III pressure ulcer. In addition to failing to prevent the ulcer from developing, following the identification of the pressure ulcer, the facility failed to implement adequate and necessary care and treatment resulting in a deterioration in the pressure ulcer and acute change in resident condition resulting in hospitalization (on 07/03/24) for treatment of sepsis related to the pressure/decubitus ulcer. The Immediate Jeopardy was removed on 07/10/24 when the facility implemented the following corrective actions: • On 07/03/24 Director of Nursing (DON) #804 began staff education for licensed nurses and State Tested Nursing Assistants (STNAs) on the need to ensure that all pressure relieving interventions were in place in accordance with the plans of care and that incontinence care, turning and repositioning, and showers/bed baths were implemented timely and in accordance with the plan of care for all residents, including those with wounds. All nursing staff were also in-serviced on the need to inform the nurse if wound dressings become soiled with urine or stool so they can be changed. Staff training/education was provided between 07/03/24 and 07/10/24. Any staff not In-serviced by 07/10/24 would be in-serviced prior to their next working shift. • On 07/06/24 Resident #44 was re-admitted to the facility from the hospital. Licensed Practical Nurse/Wound Nurse (LPN/WN) #800 re-assessed the resident ' s sacral wound and a new order to cleanse with normal saline, apply Santyl nickel thick and cover with bordered gauze was obtained. The resident ' s care plan was reviewed and included interventions of turn and reposition side to side, lay down after meals, and Chamosyn to buttocks after incontinence episodes was initiated. All necessary physician orders including medication orders and wound care orders were reviewed to ensure accurately reflected in the care plan. • Between 07/08/24 and 07/11/24 LPN/WN #800 initiated review of care plans for all residents who had existing wound, Resident #7, #10, #44, #45, #46, #49, #58, #61, #65 and #72. • On 07/09/24 LPN/WN #800 again reviewed all necessary physician orders for Resident #44 and the facility implemented a plan to review these orders daily to ensure they were accurately reflected in the resident ' s care plan. The resident was also scheduled to see the wound care physician on 07/11/24. • On 07/09/24 and 07/10/24 Director of Nursing (DON) #804 began in-service with all licensed nurses on the need to ensure the physician was timely notified of all wound changes, treatments were implemented in accordance with orders, and all orders for cultures and labs were obtained timely and orders for antibiotics were implemented timely. Any staff not educated by 07/10/24 would be educated would be educated prior to their next working shift. • On 07/10/24 Licensed Practical Nurse/Wound Nurse (LPN/WN) #800, LPN #801, LPN #802, and LPN #803 completed skin sweeps and new Braden Scales on all facility residents. No new pressure ulcers or infections were identified. All resident care plans would be reviewed by 07/12/24 to ensure appropriate preventative interventions were in place and appropriate treatments were in place if appropriate. • On 07/10/24 DON #804 posted the STAT phone number for the lab at all nurse ' s stations to ensure staff had access and were calling the correct number when STAT labs need to be drawn, and in-serviced all nurses on the number as well as the need to contact the DON or Administrator if the lab cannot be reached. • On 7/10/24 LPN/WN #800 checked all culture containers (urine and swabs) and discarded all expired items and contacted the lab to request non-expired culture containers be provided. LPN/WN #800 would then check culture containers monthly and discard expired containers. • On 07/10/24 DON #804 in-serviced all licensed nurses on the process for monthly checking of culture containers for expired containers and on the need to check all containers, including swabs for expiration prior to use. • On 7/10/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON #804, LPN/WN #800, and Medical Director (MD) #900 to review the plan. MD #900 was notified of the Immediate Jeopardy on 07/10/2024 at the QAPI meeting. The meeting included a discussion of skin issues identified with the skin/wound CQI report. • The facility implemented a plan for LPN/WN or designee to complete observations of at least five random residents per day for four weeks to ensure pressure relieving interventions were being implemented in accordance with the plan of care, including offloading, incontinence care provided timely, and showers completed in accordance with the plan of care and shower schedule. The observation/audits would include residents with and without wounds. All audits would be reviewed by the QAPI committee. • The facility implemented a plan for LPN/WN or designee to complete observations/audits of at least three residents with wounds per day to ensure wound treatments were being implemented as ordered, dressings were changed if soiled, and new orders for labs or cultures are implemented timely. The audits/observations would be completed for four weeks, and all audits would be reviewed by the QAPI committee. Although the Immediate Jeopardy was removed on 07/10/24, the facility remained out of compliance at a Severity Level 3 (Actual Harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1.Review of Resident #44 ' s medical record revealed the resident had diagnoses including cerebral palsy, type two diabetes mellitus, overactive bladder, urinary incontinence, unspecified intellectual disabilities, hypertension and pressure ulcer of sacral region. Review of Resident #44 ' s care plan revised 11/06/23 revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included to be laid down after breakfast to promote skin integrity, bariatric bed for positioning, body check nightly, bath days and as needed, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, provide skin care every morning and night and as needed, reposition on rounds and as needed, resident preferences on baths/showers and side to side turns while in bed. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Review of Resident #44 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and required substantial to maximal assistance by staff for eating and dressing. The assessment revealed Resident #44 was dependent on staff for all other activities of daily living (ADLs) including oral hygiene, toileting, showers, personal hygiene, and bed mobility. Resident #44 was always incontinent of bowel and bladder. Review of the physician orders for Resident #44 ' s revealed the following orders: initiated 05/07/24 Chymosin Ointment 0.45%-20% apply to coccyx and right buttock topically every shift for incontinence and apply heavily with episodes of incontinence. Initiated on 10/19/2022 side to side turns while in bed, reposition on rounds and as needed, Low Air Loss (LAL) mattress to bed at all times initiated on 11/01/23, resident in bed after all meals. Weekly Skin Assessments every night shifts every Wednesday for health maintenance initiated 05/01/24, cleanse sacral wound with normal saline (NS), apply collagen sheet and bordered gauze three times a week and as needed on Tuesday, Thursday, and Saturday, initiated on 06/22/24. Review of the shower schedule for Resident #44 revealed the resident was to receive showers twice a week. Review of shower sheets for Resident #44 from the date range of 05/01/24 to 07/01/24 revealed Resident #44 had only received a shower on 05/06/24, 05/13/24, 05/16/24 and 06/05/24 during this time period. Review of a Wound Evaluation and Management Summary dated 06/06/24 by WCP #700 revealed Resident #44 had Moisture Associated Dermatitis (Site #3) noted as healing, measuring 0.3 cm length by 0.4 cm width with 0.2 cm depth. The treatment plan consisted of Chymosin twice daily for nine days. Review of a Wound Evaluation and Management Summary dated 06/13/24 by WCP #700 revealed Resident #44 ' s MASD to the sacrum exacerbated due to multifactorial events which was noted to have deteriorated to a Stage III pressure ulcer and was measuring larger in size at 2.4 cm long by one cm wide with 0.3 cm depth, with drainage of light serous (a clear to pale yellow watery fluid). On 06/13/24 WCP #700 changed the treatment plan to Collagen gel/paste three times per week for 30 days and cover with gauze island with border apply this as well three times per week for 30 days. Record review revealed the resident was assessed by WCP #700 on 06/20/24 at which time the Stage III pressure ulcer to Resident #44 ' s coccyx/sacrum measured 2.1 cm long by one cm wide with 0.7 cm depth, with light serosanguinous (a thin watery fluid, pink in color due to small amounts of red blood cells) drainage. The wound bed consisted of 20% thick adherent devitalized necrotic (dead) tissue, 20% slough (dead tissue separating from living tissue), and 60% granulation (new) tissue. There were no changes made to the wound treatment orders at this time. Review of Resident #44 ' s care plan updated 06/24/24 revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included Resident #44 was to be laid down after breakfast to promote skin integrity on buttocks, bariatric bed for positioning, bilateral heel protectors, body check nightly, bath days, and as needed, Chymosin ointment to buttocks every shift, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, and notify the physician with any changes. The plan indicated staff were to provide skin care every A.M. and P.M. and as needed. Resident #44 was unaware of bowel and bladder urges, unable to transfer to toilet due to total dependence on staff for transfers. The goals listed in the care plan were that the resident would remain as dry as possible without skin breakdown. Interventions included staff to administer overactive bladder medication per physician orders, change the resident as needed, assist the resident to ensure peri care after each incontinent episode to prevent skin breakdown, and check the resident every round for incontinence. The care plan indicated the resident was to receive showers twice a week. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Further review of the Wound Evaluation and Management Summary dated 06/27/24 by WCP #700 revealed the Stage III pressure wound to Resident #44 ' s coccyx/sacrum had deteriorated again with exacerbation due to multifactorial issues including poor incontinence care, poor turning and reposition, and not off-loading pressure by turning the resident every two hours and as needed to ensure direct pressure was not on the resident ' s coccyx/sacrum. On 06/27/24 WCP #700 measured the wound to be 3.8 cm long by 1.8 cm wide with 0.7 cm depth, with light serous drainage, 20% thick adherent devitalized necrotic tissue, 20% slough, and 60% granulation tissue. There were no changes to treatment orders at this time by WP #700. Review of Resident #44 ' s progress notes revealed a change in condition was noted on 06/29/24 with the resident having increased lethargy, no food intake at lunch, minimal fluid intake record throughout the day and (abnormal) vital signs with a temperature of 101.0 Fahrenheit (F)(elevated), pulse 90 (elevated), blood pressure (BP) 104/60 (hypotensive). Notification was made to Resident #44 ' s Nurse Practitioner (NP) who gave orders for a STAT Complete Blood Count (CBC), Complete Metabolic Panel (CMP), urinalysis with culture and sensitivity (UA C&S), wound cultures, and a chest x-ray. There was a delay in obtaining the laboratory work, and wound cultures due to expired wound culture collection swabs and no one contacting the appropriate number for STAT lab draws. The NP was updated on the delay and gave further orders to start Resident #44 on the antibiotic, Rocephin 1 gram (gm) intramuscularly (IM) for five days on 07/03/24 at 10:52 A.M. The antibiotics were not scheduled to be given until 07/04/24 but should have been started immediately per facility policy for antibiotic administration. Review of Resident #44 ' s wound culture results, ordered on 06/29/24, which was not collected until 07/02/24 due to all the wound culture swabs at the facility being expired, resulted on 07/06/24 revealed the cultures were positive for Escherichia coli. (E. Coli). On 07/03/24 at 11:45 A.M. Resident #44 ' s Primary Care Physician (PCP), Medical Director (MD) #900 was informed of the change in condition and the recommendations of the NP. MD #900 gave orders to send the resident to the emergency room for evaluation and treatment. Consequently, review of hospital records revealed Resident #44 was admitted to the hospital for treatment of the Stage III pressure injury of the sacral region. Resident #44 was hospitalized from [DATE] to 07/06/24 with treatment provided for sepsis including fluid resuscitation per hospital protocol for severe sepsis, along with two intravenous (IV) antibiotics of Cefepime and Flagyl. Resident #44 returned to the facility on [DATE] with continuation of antibiotics including Cephalexin and Flagyl by mouth. During an interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808, the STNA indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #44), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on 07/02/24 at 9:45 A.M. and 11:00 A.M. with STNA #809 and on 07/02/24 at 4:45 P.M. with LPN/WCN #800 of Resident #44 ' s positioning while in bed revealed Resident #44 was in the same position on her right side with positioning wedges used that were flat. The resident did not appear to be positioned properly on the positioning wedge pillows and pressure was not reduced from sacral wound at the time of these observations. Interview on 07/02/24 at 10:00 A.M. with LPN/WN #800 revealed Resident #44 ' s sacral wound had worsened from MASD to a Stage III pressure ulcer due to staff not providing her with timely incontinence care, staff not turning the resident per her plan of care, staff not repositioning the resident timely when she was in her wheelchair, and staff not providing showers or giving the resident a bed bath per her plan of care. LPN WN #800 also revealed staff were unable to collect the wound cultures ordered on 06/29/24 due to all the wound culture swabs being expired, and they would not receive new ones until Monday 07/01/24 when the lab brought them to the facility. Observation made on 07/02/24 at 2:03 P.M. of wound care for Resident #44 by LPN/WN #800 with assistance for turning and repositioning from STNA #809 revealed when removing the top sheet from the resident to perform wound care there was a strong odor of urine present, the resident ' s brief was dry, however when they rolled the resident over the dressing to sacral wound dated 07/01/24 had feces on the outside of the dressing and underneath the dressing in the wound. They provided incontinence care to the resident, removed the old dressing, washed hands and changed gloves and cleansed the wound with normal saline. Upon assessment of the wound, LPN/WN #800 found new necrotic tissue. While providing wound care LPN/WN #800 stated when she did the treatment last on 06/28/24 the center of the wound had white granulation tissue in the center of the wound and now there was necrotic tissue the approximate size of a quarter, with redness around the peri wound edges, indicating possible infection. The wound had a foul odor present. The wound was dressed per physician ' s orders with no concerns identified with wound care technique. The resident was turned onto her right side and positioning wedges used. Resident #44 was on a low air loss mattress. She had orders for a tilt and space wheelchair with a pressure reducing cushion in the chair which was present in the hallway. Interview via phone on 07/08/24 at 10:53 A.M. with WCP #700 revealed he stated MASD should never progress to a pressure ulcer. He stated the facility staff do not turn and reposition or provide timely incontinence care. WCP #700 stated Resident #44 ' s wound deterioration was a direct result of staff not caring for the resident appropriately and per her care plan. Interview on 07/09/24 at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they were able to provide only four shower sheets for Resident #44 for the time frame requested of 05/01/24 to 07/01/24. Interview on 07/09/24 at 12:30 P.M. with DON #804 confirmed Resident #44 developed an in-house Stage III pressure ulcer due to a lack of proper care, including staff not turning and repositioning the resident every two hours or as needed, staff not providing timely incontinence care, showers/bed baths, or providing proper care for the resident. Interview on 07/09/24 at 1:45 P.M. with DON #804 revealed when asked what the expectation was for antibiotic administration, DON #804 stated antibiotics should be scheduled to be given as soon as possible as they have a starter box in the medication room with antibiotics in them. She stated the nurse should have started Resident #44 ' s ordered Rocephin immediately on 07/03/24 and not scheduled it for 07/04/24. 2. Review of Resident #10 ' s medical record revealed an admission date of 12/05/23 with diagnoses including unspecified dementia with mild agitation, hypertension, chronic kidney disease stage II, and Stage III pressure ulcer of left buttock (06/13/24). Review of Resident #10 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required set up help or clean up help only for eating, he was independent for bed mobility, supervision, or touching assistance for oral hygiene, partial to moderate assistance for toileting, and substantial to maximal assistance for showers, dressing, and personal hygiene. Review of Resident #10 ' s care plan dated 06/11/24 revealed the resident had the potential for pressure ulcer development and or alteration in skin integrity related to decreased mobility and side effects related to medications. The goal was Resident #10 would have intact skin free of redness, blisters, or discoloration by or through the review date. Interventions included administering medications as ordered, monitor and document for side effects, administering treatments as ordered and monitor for effectiveness and staff will encourage the resident to turn and reposition on care rounds and as needed. Review of the shower schedule for Resident #10 revealed he was to receive showers twice a week. Review of progress notes for Resident #10 from 05/01/24 to 07/01/24 revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. Review of Resident #10 ' s physician orders revealed pressure reduction mattress to bed at all times initiated on 12/05/23, cushion to chair with non-skid above and below cushion initiated on 12/05/23, reposition on rounds and as needed initiated on 12/05/23, weekly skin assessments every day shift every Monday initiated on 05/06/24, pad and protect left buttock with foam dressing every day shift every Monday, Wednesday, and Friday initiated on 06/12/24. Review of Resident #10 ' s Initial Wound Evaluation and Management Summary dated 06/13/24 revealed the resident had an inhouse acquired Stage III pressure ulcer to the left lower buttock measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth with light serous drainage, 80 % granulation tissue. Treatment recommendations at this time were for Leptospermum honey, apply three times per week for 30 days and cover with dry dressing three times per week for 30 days, other recommendations were to off-load the wound, and reposition per facility protocol. Review of Resident #10 Wound Evaluation and Management Summary dated 06/20/24 revealed the wound deteriorated as the wound was larger in size measuring 2.5 cm long by three cm wide with 0.1 cm depth with moderate serous drainage, 20% thick adherent devitalized necrotic tissue, 10% slough, 50% granulation tissue and 20% other viable tissue including the dermis and subcutaneous tissue. Wound progress was noted to be not at goal. There were no changes made to the treatment plan at this time, and recommendations were to off-load the wound, and reposition per facility policy which was every two hours and as needed. Interview on 07/02/24 at 10:00 A.M. with LPN/WN #800 revealed Resident #10 developed a Stage III in-house acquired pressure ulcer that subsequently deteriorated due to the resident not being repositioned timely and per facility policy by facility staff. Additional review of Resident #10 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference. For the date range of 05/01/24 to 07/01/24 there were no shower sheets to evidence the resident had been given any showers in that time period. Interview on 07/01/24 at 3:22 P.M. with STNA #808 indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #10), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on 07/02/24 at 10:00 A.M. and 2:03 P.M. with STNA #808, and on 07/09/24 at 12:45 P.M., and 2:00 P.M., with STNA #809 of positioning for Resident #10 revealed Resident #10 was laying on his back with no pillows supporting his weight to offload the pressure to his left buttocks. Interview via phone on 07/08/24 at 10:53 A.M. with WCP #700 confirmed Resident #10 ' s wound deteriorated due to the resident not being repositioned timely and per facility policy to off load the pressure from the wound. Wound care observations were attempted on 07/08/24 at 10:00 A.M. and 1:00 P.M., however the resident refused to allow the State surveyor to watch his wound care. Interview on 07/09/24 at 11:30 A.M. with Resident #10 revealed he was alert and could answer questions. When asked about his showers, repositioning, and incontinence care he stated staff help but stated he had not had a shower in long time. The resident also stated he did not receive timely incontinence care or timely repositioning. Interview on 07/09/24 at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they could not produce shower sheets for Residents #10. 3. Review of Resident #72 ' s medical record revealed an admission dated of 02/17/16 with diagnoses including Parkinson ' s disease, disease of spinal cord, Stiff-Man syndrome, hypertension, and an in-house acquired Stage III pressure ulcer to the sacrum as of 06/20/24. Review of Resident #72 ' s care plan dated 05/24/24 revealed the resident was at risk for alteration in skin integrity related to Parkinson ' s disease. The goal was Resident #72 would have skin remain dry and intact through target date, interventions included air mattress to bed for skin preventions, body check nightly on bath days and as needed, chair cushion when in wheelchair or bedside chair, Chymosin ointment to buttocks as ordered by the physician, Resident #72 was to be laid down after breakfast to promote skin integrity on buttocks, keep linen dry and wrinkle free every shift, moisturizer daily to dry skin, barrier cream to buttocks, apply after each episode of incontinence. Review of Resident #72 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required supervision or touching assistance for eating, and was dependent on staff for all other ADLs including oral hygiene, showers, toileting, dressing, personal hygiene, and bed mobility. Review of the shower schedule for Resident #72 revealed he was to receive showers twice a week. Review of progress notes for Resident #72 from 05/01/24 to 07/01/24 revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. Review of Resident #72 ' s physician ' s orders revealed orders for Chymosin Ointment to buttocks/peri-area topically every shift for incontinence episodes initiated 07/01/24, Pommel Cushion to wheel chair with Dycem above and below, for positioning initiated 10/15/18, Bariatric bed for positioning initiated 11/27/18, check and change on rounds and as needed for incontinence care initiated 01/19/22, body pillow while in bed for positioning every shift initiated 04/29/24, Resident to be laid down in bed after all meals every shift for prevention initiated 04/29/24, weekly skin assessments evening shift on Wednesdays initiated 05/08/24, Cleanse stage III pressure ulcer to sacrum with normal saline apply Medi honey topically and cover with border gauze change three times a week and as needed every day shift on Tuesday, Thursday, and Saturday initiated on 06/21/24. Review of Resident #72 ' s Initial Wound Evaluation and Management Summary dated 06/20/24 revealed Resident #72 was being seen due to a new in-house acquired Stage III pressure ulcer to his sacrum measuring 3.5 cm length by 4.5 cm width with 0.1 cm depth, with light serous exudate, 50% granulation tissue, 20 % other viable tissue including dermis and subcutaneous (Sub Q) tissue, and 30% skin. Treatment orders at this time were for leptospermum honey applied three times per week for 30 days and cover with dry dressing three times per week for 30 days. Further recommendations were to offload the wound, and to reposition per facility protocol. Review of Resident #72 ' s Wound Evaluation and Management Summary dated 06/27/24 revealed Resident #72's Stage III pressure ulcer measured two cm length by 2.5 cm width by 0.1 cm depth with light serous drainage, 70 % granulation tissue, 10 % slough, and 20% other viable tissues including the dermis and Sub Q. There was no change to the treatment orders, or recommendations. Review of Resident #72 ' s Wound Evaluation and Management Summary dated 07/05/24 revealed Resident #72 ' s Stage III pressure ulcer to his sacrum deteriorated as evidenced by an increase in size with the ulcer measuring four cm length by 4.5 cm width by 0.3 cm depth, moderate serous drainage, 70 % granulation tissue, 10 % slough, 20 % other viable tissues such as dermis and sub-q. Wound progress

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of a Police Report, review of the facility Elopement Policy and Procedure and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when a door alarm sounded to prevent Resident #43, who was cognitively impaired, required a front wheeled walker for mobility with stand by assist (SBA) for ambulation, and demonstrated previous exit seeking behaviors, from eloping. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 11:00 A.M. when Resident #43 left the facility via an alarmed emergency exit door without staff knowledge. Although, the door Resident #43 exited did alarm as designated, Licensed Practical Nurse (LPN) #600 opened the door and because she did not see any resident(s) in the immediate vicinity, she reset the alarm without investigating further and/or completing a facility head count. LPN #600 also failed to check on Resident #43 despite having previous knowledge Resident #43 was on her assigned unit and had demonstrated exit seeking behaviors. On [DATE] at 11:08 A.M. a community member found Resident #43 approximately 0.3 miles from the facility at a park which he would have had to cross a heavily trafficked road to get to. The community member contacted the police to report Resident #43 was at a park by the tennis court stumbling around with an ankle bracelet to his ankle. Police Officer #618 responded and documented in his report that Resident #43 had multiple injuries and he contacted emergency rescue service (EMS) to transport Resident #43 to the hospital. Police Officer #618 contacted the facility, and they were unaware Resident #43 had eloped from the building. On [DATE] at 4:53 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 11:00 A.M. when Resident #43 who displayed exit seeking behaviors, exited the facility via an alarmed emergency exit door without staff knowledge. The door to the 100-Mahoning Hall had a key code and a 15-second delayed push release with keypad to override the alarm. LPN #600 heard the alarm and responded by opening the door but while holding the door open viewed only the immediate surroundings. LPN #600 did not see any resident(s); therefore, shut the door and reset the alarm. She then proceeded with her work; failed to complete a resident head count, investigate further and/or follow the facility policy and procedure regarding a missing person. Resident #43 was subsequently found located at a park down the street, sent to the hospital for evaluation and was found to have an abrasion to his left lower leg. The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 12:12 P.M. the Administrator was notified by phone on of Resident #43's elopement by Interim Director of Nursing (DON) #601 who stated that the police notified the facility that Resident #43 was at the park and then brought to the hospital. • On [DATE] the Administrator and Interim DON #601 initiated an immediate investigation with timeline of incident. • On [DATE] at 12:33 P.M. the Administrator instructed Maintenance Director #609 to report to the facility for immediate audit/testing of all doors. Environmental Director #610 was currently onsite and assisted the Maintenance Director #609 to complete. • On [DATE] from 12:58 P.M. to 1:05 P.M. Maintenance Director #609 and the Environmental Director #610 tested the exit doors by exercising for both locking mechanism intact and to initiated audible alert while in the open position without negative findings. • On [DATE] from 1:20 P.M. to 1:45 P.M. Environmental Director #610 tested all wanderguards for placement and response without negative findings. Wanderguard(ankle bracelet that triggers alarms and can lock monitored doors to prevent residents leaving unattended) checks were completed weekly prior to the elopement with the last one conducted by Medical Records #611 on [DATE] without negative findings. • On [DATE] from 1:20 P.M. to 1:45 P.M. in-servicing with all onsite staff on Door Alarms was completed by Maintenance Director #609. • On [DATE] from 1:50 P.M. to 1:51 P.M. Maintenance Director #609 and the Environmental Director #610 completed a door alarm testing drill with random residents at risk for staff response without negative findings. The alarm was answered by LPN #602 on [DATE] at 1:51 P.M. • On [DATE] from 12:20 P.M. to 6:46 P.M. the Administrator in-serviced Department Heads on Elopement and Addendum to Elopement (Door Alarms) via phone. • On [DATE] at 12:43 P.M. the Administrator googled the walking distance and time to park from the facility with a finding of 0.3 miles, six minutes with mostly flat terrain, and a road to cross. The Administrator also googled the weather for the area with findings of a temperature range from 76 degrees to 83 degrees Fahrenheit at 11:00 A.M and it was partly cloudy. • On [DATE] at 1:44 P.M. facility staffing was reviewed by Human Resources (HR)/Payroll Coordinator #612 and the Administrator. They reconciled actual staffing hours of Licensed Nursing and State Tested Nurse Aides (STNAs) for [DATE] which noted there were 3.13 hours per resident and the facility census was 84. • On [DATE] from 4:35 P.M. to 10:38 P.M. Environmental Director #610, HR/ Payroll Coordinator #612, Chief Financial Officer (CFO) #613, Activity Director #614 and Rehabilitation Director #615 in-serviced licensed nursing staff, STNA's, maintenance staff, housekeeping staff, activity staff, dietary staff, office staff, therapy staff, and laundry staff on the facility Elopement and Addendum to Elopement (Door Alarms). • On [DATE] at 5:10 P.M. Maintenance Director #609 checked camera locations for video. There was no designated camera to the 100-Mahoning Hall. • On [DATE] at 5:47 P.M. Resident #43's hospital record was reviewed by the Administrator which noted the resident was at his baseline and would be returning to the facility. On [DATE] at 6:41 P.M. the resident's wife was contacted and informed upon return, the resident would be moved to the facility secured unit. The resident continued to also have a Wanderguard device in place. • A Quality Assurance/ Performance Improvement (QAPI) update of timeline/abatement plan was held with department heads including the Administrator, Social Service Designee (SSD) #622, Dietary Manager #623, Environmental Director #610, Maintenance Director #609, Medical Records #611, Rehabilitation Director #615, Wound/ LPN #624, CFO #613, [NAME] #625, RN/ Interim Minimum Data Set (MDS) Coordinator #617, RN/ MDS Coordinator #619, Admissions #626, HR/ Payroll Coordinator #612, Business Office Manager #627, and Medical Director #605 on [DATE] at 9:15 A.M. and on [DATE] at 9:15 A.M. • On [DATE] at 10:30 A.M. RN/ Interim Minimum Data Set (MDS) Coordinator #617 revised Resident #43's Wander Elopement Risk care plan to reflect diagnoses and that the resident was unaware of own safety needs (decreased safety awareness). The care plan goals were updated to reflect the need to keep the resident safe by not leaving facility unattended. • On [DATE] Medical Records #611 updated the facility Elopement Book to include Resident #43 and ensured that like residents assessed for risk of elopement were updated. All residents with assessed elopement risk were audited to ensure residence on Secured Care Unit. On [DATE] at 3:10 P.M. Medical Records #611 reached out to Police Department to inquire their first immediate needs in the case of an elopement to aid in updating the facility elopement book. Based on this conversation Medical Records #611 ensured photos were current, highlighted contact phone numbers, notated that resident's name were in the collar and/or waist band of their clothing on the face sheet, and labeled the Wanderguard strap with the facility name on one side of the transmitter and labeled the Wanderguard strap with the telephone number to the facility on the other side of the transmitter. A pair of Resident #43's worn socks were added via Ziplock packaging on [DATE] at 3:50 P.M. as they were told this would be helpful for their search dogs to locate if needed. • On [DATE] at 5:09 P.M. an order was obtained to verify placement of alert ankle bracelet every shift for Resident #43 and like residents by Interim Director of Nursing #601 from Medical Director #609. This was verified on [DATE] at 9:20 A.M. as completed. • Interviews on [DATE] from 11:00 A.M. to 1:09 A.M. and [DATE] from 1:01 P.M. to 1:40 P.M. with Registered Nurse (RN) #644, LPN #600, #637, #639, #641, #646, STNA #630, #633, #636, #638, #640, Activity Assistant #608, Housekeeping #634, #635, #642, Occupation Therapy Assistant (OTA) #632 and Physical Therapy Asssiatnt (PTA) #631 verified they received the training and were knowledgeable regarding the facility elopement and Addendum to Elopement (Door Alarms) policy. Findings include: Review of the medical record for Resident #43 revealed an admission date of [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, hallucinations, cerebrovascular disease, and hypertension. Review of the Elopement Evaluation dated [DATE] and completed by LPN #600 revealed Resident #43 was not at risk for elopement. There was no other elopement evaluation completed until after an incident of elopement that occurred on [DATE] at which time revealed Resident #43 was at risk for elopement. Review of the admission/ Medicare five- day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was an eight (out of 15). The assessment revealed the resident had wandering, verbal, and physical behaviors one to three days during the seven-day assessment reference period. He required extensive assistance of two-staff for bed mobility, and transfers and extensive assistance of one-staff with ambulation and locomotion per the MDS assessment. Review of the nursing note dated [DATE] at 6:30 P.M. and completed by LPN #649 revealed Resident #43 was alert with confusion as he tried to hit staff with a walker and a tray table. The note revealed Resident #43 escaped from the facility front door and when approached by staff, he picked up a brick and attempted to hit staff with it. The note revealed the resident was brought back in the facility and was then sent to the emergency room for evaluation due to behaviors. Review of the care plan dated [DATE] revealed Resident #43 was a wander/ elopement risk as he had diagnoses that included dementia, previous attempts to leave the facility, and decreased safety awareness. Interventions included assist in orientation to facility with verbal cues, be observant around doorways, frequent observations to make sure the resident was accounted for, intervene if seen trying to leave, wanderguard to ankle, check every shift and as needed, and put familiar items to assist in identifying his room. Review of a nursing note dated [DATE] at 5:55 P.M. and completed by Agency RN #650 revealed the nurse contacted the family regarding Resident #43 getting out of the facility. The note revealed the staff brought Resident #43 back into the facility and Interim DON #601 had the staff place a wanderguard to his ankle. Review of the activity documentation dated [DATE] at 9:54 A.M. revealed Activity Assistant #608 documented she had completed a one-on-one activity with Resident #43. Review of Police Report #23-16937 dated [DATE] at 11:08 A.M. and completed by Officer #618 revealed emergency dispatch received a call from a community member on [DATE] at 11:06 A.M. that there was an older adult male stumbling around at the park wearing a hospital bracelet to his ankle. The report revealed Resident #43 had multiple injuries from falling and EMS transported him to the hospital. Review of a nursing note dated [DATE] at 11:35 A.M. and completed by LPN #600 revealed at approximately 11:30 A.M. she received a call from emergency dispatch stating Resident #43 was found down the street at a park. The dispatch informed the facility Resident #43 was going to be sent to the hospital as he sustained injuries. The note revealed Resident #43's door had been closed all morning because he was on COVID-19 isolation and that the last time she had seen him was when she provided his breakfast tray. The note revealed on [DATE] at 11:00 A.M. she had heard the side door alarming and when she checked she did not see anyone around the door as she even stepped outside and looked. The note revealed Primary Care Physician (PCP)/Medical Director #605 and Interim DON #601 were notified. Review of the facility SRI, tracking number 237796, dated [DATE] revealed the facility filed a report for emotional/verbal abuse. The SRI revealed on [DATE] at 11:57 A.M. the hospital emergency department reported Resident #43 was found at a park sleeping by the police department and was transported to the hospital. The resident was wearing a Wanderguard to his right lower leg and had a small abrasion to his left lower leg. Review of a witness statement dated [DATE] (untimed) and completed by LPN #600 revealed STNA #636 stated she was going on break and a minute later she was at the nursing station and heard an alarm sounding and went down to open the 100-Mahoning Hall side door. She revealed she opened the door and did not see anything. The statement revealed she presumed it was STNA #636 going out that door so put the code in to stop the alarm and proceeded to go to a resident's room. The statement revealed at approximately 11:30 A.M. to 11:35 A.M. she received a call from emergency dispatch that they had found Resident #43 at the park. Review of a witness statement dated [DATE] (untimed) and completed by STNA #636 revealed she had seen Resident #43 on [DATE] at approximately 7:50 A.M. when she dropped off his breakfast tray and did not see him any further until she had heard he was found at the park. Review of Google map documentation, dated [DATE] at 12:43 P.M. revealed the park was approximately 0.3 miles and a six-minute walking distance from the facility. Review of Hospital Discharge paperwork dated [DATE] and completed by emergency room (ER) Physician #651 revealed Resident #43 was found at the park sleeping by the police department, and EMS were called to transport him to the hospital for evaluation. ER Physician #651 revealed the resident was alert but confused and upon arrival was wearing shorts, t-shirt, and slippers. Resident #43 was found to have a small abrasion to his left lower leg/ shin area. ER Physician #651 discharged the resident back to the facility in stable condition. Review of a Physical Therapy Discharge summary dated [DATE] and completed by Physical Therapist #607 revealed Resident #43 was discharged from therapy as he ambulated with a front wheeled walker with stand by assist (SBA) up to 300 feet and stairs were listed as not applicable. On [DATE] at 8:26 A.M. Resident #43 was observed on the facility secured memory care unit sitting in the lounge area with a front wheeled walker next to him. He was wearing a Wanderguard to his right ankle. The resident was noted to be cognitively impaired, and during the interview he stated he and his wife never made it to the park. He stated, Guess I got turned around, so I started but then turned around and now back here. He was unable to provide any other information regarding the incident on [DATE]. Interview on [DATE] at 8:36 A.M. with the Administrator revealed on [DATE] at approximately 11:00 A.M. LPN #600 responded to the 100-Mahoning Unit side emergency exit door alarm and when she looked out the door, she did not see any resident(s) or a visible reason why the door alarm sounded. She revealed LPN #600 shut off the alarm by entering a code into the keypad and then proceeded assisting another resident (Resident #82) to discharge from the facility. She revealed LPN #600 should have conducted a head count to ensure all residents were accounted for, but she did not. She revealed at approximately 11:30 A.M. LPN #600 received a call from emergency dispatch that the police department had found Resident #43 down the street at the park, and the police department had EMS transport him to the hospital for evaluation. Interview on [DATE] at 9:25 A.M. with Maintenance Director #609 revealed the 100-Mahoning Hall side door was an emergency exit only with a 15-second door release and was alarm activated. He revealed once the bar on the door was pushed it activated an alarm to notify staff of a person exiting the facility. He stated to shut off the alarm, a code had to be placed into a keypad on the side of the door. He revealed on [DATE] the door alarm sounded appropriately, and LPN #600 shut off the alarm by entering the code into the keypad. Interview on [DATE] at 11:00 A.M. with LPN #637 revealed she was assigned to Station One (the unit Resident #43 resided on) with LPN #600 and STNA #636. She revealed she had administered the resident medication on [DATE] at approximately 8:00 A.M. She revealed she had not seen Resident #43 any further nor heard any door alarms sound after that. Interview on [DATE] at 11:09 A.M. with LPN #600 revealed she was assigned Station One and she was working on Resident #82's discharge from the facility. She revealed on [DATE] at approximately 10:55 A.M. she heard a faint alarm and finished grabbing the discharge paperwork off the printer and then checked to see where the alarm was coming from. She revealed the alarm was coming from the 100-Mahoning Hall Emergency exit door and that the keypad had lights flashing on it. She revealed she opened the door and while holding the door opened looked outside but did not see anyone in the vicinity. She revealed she thought it was possibly a family member for the resident that she was discharging that had accidentally pushed on the door or STNA #636 that was assigned on the unit as she had stated just prior, she was going on break. She revealed she placed the code into the keypad that silenced the alarm and proceeded to go back to working on the discharge that she was previously working on. She verified she had not asked the family or STNA #636 if they had set the alarm off, investigated further into the reason why the door alarmed and/ or conducted a head count to ensure all residents were accounted for. She revealed on [DATE] at approximately 11:30 A.M. she received a call from emergency dispatch stating Resident #43 was down the road at a park and that they were having him transported to the hospital for possible injuries. She revealed she was aware Resident #43 had demonstrated exit seeking behaviors prior to the incident as she stated he had made previous comments when she had worked: I am waiting for the bus, I need a car and that he had packed his bags in his room previously but verified she did not check on Resident #43 [DATE] after the door alarm sounded despite having knowledge he had exit seeking behaviors. Interview on [DATE] at 11:46 A.M. with LPN #641 revealed she was aware Resident #43 was displaying exit seeking behaviors a few weeks ago as he was outside but that she was not aware of the details. Interview on [DATE] at 12:14 P.M. with STNA #636 revealed she was assigned on [DATE] Station One with LPN #600 and LPN #637. She revealed she only saw Resident #43 on [DATE] at 8:00 A.M. as he peeked his head out the door but that she reminded him he was on isolation and to stay in his room and keep the door closed. She revealed she had not checked on him after that and went to lunch at approximately 11:00 A.M. and was not aware he exited the facility until LPN #600 stated she received a call from the police department, and he was at the park. Interview on [DATE] at 1:09 P.M. with RN #644 revealed Resident #43 demonstrated exit seeking behaviors prior to the event on [DATE] as one night she revealed he was at the front entrance door and stated, he was late to his plane trip as he was attempting to leave. Interview on [DATE] at 1:18 P.M. with Activities Assistant #608 revealed on [DATE] at approximately 8:45 A.M. she was passing water and newspapers. She stated she spoke briefly with Resident #43 and that she shut his door as he was on respiratory isolation. On [DATE] at 12:50 P.M. the surveyor walked from the facility to the park. Resident #43 would have had to ambulate down four concrete stairs from the 100-Mahoning Hall emergency exit to the sidewalk. The sidewalk to the park was cracked and uneven. The park was located on the other side of the street from the facility; therefore, at some point Resident #43 would have had to cross a heavily trafficked road with a posted 35 mile per hour speed limit. The distance was verified as 0.3 miles and was approximately a six-minute walk. Interview on [DATE] at 1:32 P.M. with Interim DON #601 verified the only elopement evaluation for Resident #43 prior to the incident on [DATE] was completed on admission on [DATE] when he was assessed as not at risk for elopement. She verified in the nursing notes on [DATE] and [DATE] the resident had demonstrated exit seeking behaviors. She revealed on [DATE] she was present and the resident was adamant on exiting the facility on [DATE] as he was trying all the doors in the facility trying to leave and instead of escalating his agitation, she had walked with him around the facility to attempt to decrease his agitation. She revealed he had a Wanderguard placed because of his exit seeking behaviors and he should have been reassessed, including completing an elopement assessment. Interview on [DATE] at 1:25 P.M. with Physical Therapy Assistant (PTA) #631 revealed she worked with Resident #43 frequently until he was discharged on [DATE] and his functional ability fluctuated day to day. She revealed on [DATE] he could only ambulate 15 to 30 feet with SBA, tolerated two to four minutes of standing and had balance issues. She revealed other days such as [DATE] he was able to ambulate 300 feet with his wheeled walker and 15-minutes balance tolerance without losing his balance. She revealed they had not attempted stairs due to his balance issues. The PTA revealed she did not feel the resident was safe to independently ambulate out in the community especially due to his severe impaired cognition, balance issues, impaired safety awareness, and high risk for falls. Review of the facility policy titled Missing Resident Policy dated [DATE], revealed the policy was to ensure the safety and protection of all residents that resided at the facility. The policy revealed the first person who was aware of a possible missing person must make the nurse of the station aware. The policy revealed the nurse would request all staff members involved immediately begin looking for the resident within the unit and if not located then the entire grounds should be searched. The policy revealed if the resident was not located then the Administrator, physician, family, and police department would be notified. The policy did not include if a door alarm sounded the procedure that would be followed such as conduct a head count immediately if there was no visible explanation for the alarm. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00145286 and Complaint Number OH00145185.