**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, interview and record review, the facility failed to ensure that Resident (R)1 was provided appropriate supervision to prevent 2 separate elopements from the facility on 04/28/25. On 06/03/25 at 5:53 PM, the Administrator and the Director of Nursing were notified that the failure to ensure that Resident (R)1 was free from two separate elopement incidents from the facility on 04/28/25, constituted Immediate Jeopardy (IJ) at F689. On 06/03/25 at 5:53 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 04/28/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan. On 06/04/25 at 12:28 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility policy titled Elopement with a complete revision 11/01/2017 states, To safely and timely redirect patients/residents to a safe environment. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: restlessness and agitation, Schizophrenia, anxiety disorder, conversion disorder with seizures or convulsions, and moderate intellectual disabilities. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates she was severely cognitively impaired. Further review of the MDS revealed that R1 had no wandering behaviors during the assessment period. Review of R1's Progress Note dated 04/28/25, revealed, 3:29 PM-Resident was seen going out of door 5 she was immediately followed by staff we did not see her anywhere in the parking lot. I went back in to get more nurses once back outside I saw the resident laying in the middle of the road I called for her to be sure it was her as it was dark and I could not see after getting no response I went in the road and it was [R1] so me and 2 other nurses talked to her and got her to get up and follow us inside where she continued to try to escape so me and a certified nursing assistant (CNA) kept her at the nurses station and when we no longer could do so she got to her room where a CNA sat outside the door to watch her. The DON [Director of Nursing] and unit manager were alerted at the time of the incident. Review of R1's Progress Note dated 04/28/25 at 7:09 PM, revealed, Resident noted missing after alarm was sounding on unit 2 and staff checked her room. She was noted walking in the staff parking lot on the side of the building heading to the front of the building. After running to catch up with her, she put herself on the ground and started yelling and kicking staff as several assisted her onto a wheelchair (WC), and she slid herself back onto the ground. The Nurse Practitioner (NP) and unit manager notified and per NP order received to transport resident to the ER for evaluation. Resident remained alert, no injuries noted at that time. Review of the INTERACT Nursing Home to Hospital Transfer Form/Situation Background Assessment Recommendation (SBAR) dated 04/28/25 at 4:43 PM, from Magnolia Manor, unit 2, revealed the reason for the transfer states - Elopement, Combative. Usual functional status- Ambulates independently. Risk alerts- Agitation with risk to harm to self or others, may attempt to exit, and seizures. Review of Quarterly Nursing - Elopement Risk Observation dated 03/11/25 at 1:10 PM, revealed R1 has a history of wandering, has attempted to leave the health care center, has expressed a desire to leave the health care center, and has a diagnosis that requires supervision. During an interview with the Nurse Consultant in the presence of the current Administrator on 06/03/25 at 12:09 PM, revealed she is aware of the incident with R1 eloping from the building. The Nurse Consultant stated she heard this from either the Director of Nursing or the previous Administrator, however, she can't recall. The Nurse Consultant stated she was told R1 got out of the building while being in line of sight, R1 then placed herself on the ground, and was able to be re-directed back in the building. During an interview with the current Administrator on 06/03/25 at 12:11 PM, revealed that he has been in his role since last week, 05/28/25 and was unaware of this event. During a phone interview with Licensed Practical Nurse (LPN)1 on 06/03/25 at 12:38 PM, revealed she came in at 7:00 AM on 04/28/25, she was getting a report from LPN2 related to R1's elopement that occurred at 1:00 AM, and that R1 went out the back door on unit 2, was found in the street lying on the ground (main road). LPN1 revealed that while getting the report, R1 successfully eloped again around 7:00 AM. The alarms were going off, and another staff member went and checked R1's room; she was not there. Staff started looking for her, and R1 was found in the parking lot within line of sight and was redirected back to the building. LPN1 stated that CNA1 was able to redirect R1 into the building via a non-mechanical wheelchair. LPN1 confirmed that R1 successfully eloped the building twice on 04/28/25. During an interview with LPN2 on 06/03/25 at 1:04 PM, LPN2 stated on 04/28/25, around midnight, R1 was wandering throughout the building. That night, she exited door 5, which is located in unit 2, which is 4-5 rooms down from her room. The alarm goes off. She and the agency CNA (unable to recall name) split up and looked for her. R1 was not found on the premises, staff came back in the building, got more staff, 2 nurses from stations 3 & 4, and went back out the front door. LPN2 stated she saw a dark shadow on the main road. LPN2 stated she called R1's name out, and she would not respond. LPN2 walked up to the dark shadow and confirmed that it was R1; she was found alert/responsive, and ignoring LPN2. LPN2 stated staff tried talking to her, told her she can't lay in the middle of the road because it's dark and dangerous. During an interview with the Director of Nursing (DON) on 06/03/25 at 3:35 PM, revealed that she is aware of the incident related to R1. The DON stated she found out from the nurses, LPN2 specifically, and an agency nurse. The DON was told she got out, and staff looked for her and found her laying on the main road. The DON stated she was also told R1 eloped again, right before she arrived at her shift at around 7:00 AM. On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan, which included the following: Resident #1 was placed on room supervision after elopement attempt on 4/28/25 at approximately 1am. Room supervision consisted of visual observation of resident's room and supervision was interrupted during change of shift. Resident #1 was sent to emergency department for evaluation after elopement attempt at 7am. Upon return placed on 1:1 supervision remains on 1:1 supervision. Staff education provided regarding Resident Exit Seeking and Elopement Prevention on 4/30/25. Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 6/3/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed. The Director of Nursing was reeducated by the Clinical Consultant on 6/3/25 on Accidents and Incidents including: -elopement process and the elopement binder -elopement risk assessment process and putting interventions in place based on risks identified. All Facility Staff will be reeducated by 6/4/25 by the Director of Nursing/Designee on Accidents and Incidents including: -elopement process and the elopement binder Licensed Nurses will be reeducated by 6/3/25 by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified. Any staff not receiving this education by 6/4/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder. Interviews will continue for 30 days then 2 staff 3 times per week for an additional 60 days. Results of the audits will be review monthly during QAPI meeting. The Director of Nursing/Designee will review the facility activity report beginning 6/4/25 in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated. The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting beginning 6/4/25 for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff. The Medical Director was notified on 6/3/25 of the Immediate Jeopardy. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 6/4/25 to discuss contents of this plan. Administrator will oversee compliance of this plan. Allegation of Compliance: 6/4/25

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)4 was free of accidents for 1 of 4 residents review for accident hazards. Findings include: Review of the facility policy with a revision date of May 5, 2023, titled Fall Management revealed in the policy the definition of a fall, Fall refers to the unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses that included but was not limited to: pressure ulcer sacrum, hypertensive heart disease with heart failure, dementia, type 2 diabetes mellitus and major depressive disorder. Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 02/27/25, revealed a Brief Interview for Mental (BIMS) score of 13 out of 15, indicating R4 was cognitively intact. Additionally, the MDS revealed R4 required substantial/maximum assistance with bed mobility. Review of R4's Physician Orders revealed an order dated 01/27/20, for assistance of 2 with bed mobility. Review of R4's Progress Notes dated 03/04/25 at 7:10 AM, stated, Writer was doing wound care on resident at 6:55 am. When resident was laying over on her right side, she slides out of bed onto the floor. Writer was right there when it happened and tried to slow down her fall to the floor. Writer called Nurse Practitioner (NP). Resident states she is having a little right hip pain. NP was notified about that as well. Review of R4's Progress Note dated 03/05/25 at 8:11 AM, revealed, Writer called and spoke with resident's nurse at hospital. Resident was admitted with a right femoral fracture. Resident will be undergoing a right total hip replacement today or tomorrow. Review of R4's Progress Note dated 03/11/25 at 3:35 PM, revealed, Resident returned to facility at 1524 from hospital. Surgical sutures are on the left hip with a bordered gauze covering the area . Review of Department of Public Health (DPH) Five Day Self Report for R4 recorded under the details of reportable incident, On 03/04/2025 nurse was performing a dressing change. He pulled her toward him and turned her over. Her legs started sliding off the air mattress. Nurse quickly attempted to get to the other side of her bed to stop her from sliding. He attempted to hold her legs up but could not so he lowered her to the floor. He went and got 3 Certified Nurse Assistants (CNA's) to manually lift her to the bed because the batteries for the Hoyer were dead. There was no injury noted at the time. She was sent out to the hospital for x-rays and a fracture of the left femur was found. Intervention prior to reportable incident recorded, Resident was a 2 person assist for bed mobility, Immediate corrective action/assessment following reportable incident recorded, Nurse was disciplined for failure to complete duties as assigned. Review of a Corrective Action Form dated 03/04/25, revealed Licensed Practical Nurse (LPN)1 was given a verbal warning for a performance behavior. It recorded, Failure to complete duties as assigned. [R4] was a 2 person for bed mobility and employee did not have a 2nd person for treatment change, resulted in resident fall out of bed. Resident resulted with fracture to femur. During an interview on 04/21/25 at 1:30 PM, LPN1 stated, I was doing patient care, changing a dressing on [R4's] bottom. She was fidgeting with her legs. She was on her left side. She has an air mattress. Her leg was beginning to slide, I put it back. It happened again, both legs. I was holding her legs. I gently lowered her to the ground. I went and got help. At the time I did not know she was a 2 assist with bed mobility. During an interview on 04/21/25 at 1:59 PM, The administrator stated, He should have had a second person assist. He took accountability for his action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interviews, the facility failed to protect Resident (R)11 from neglect, by failing to administer (R)11's physician ordered antibiotics, resulting in loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to administer physician ordered antibiotics as treatment for a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F600. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Medication Management Program revised on 05/05/23, documented, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of R11 's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee. Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel: Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3 Surface Area 12.15 cm2 Exudate: Moderate Sero-Sanguinous Thick adherent black necrotic tissue (Eschar) 70% Slough 10% Other Viable tissues 20% (SubQ Muscle) Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness: Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm Surface Area 13.20 cm2 Exudate Moderate Sero-sanguinous Thick adherent black necrotic tissue (eschar) 70% Other viable tissue 20% Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed, Recommendation: Augmentin 875/125 mg BID x 14 days. Probiotics TID x 45 days. Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg. Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days. Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity. During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping ithe wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes. During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility. During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse. During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress. During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they vistited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well. During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024. During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected. On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included: Resident #11 no longer resides in the facility. An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/18/2024 to identify new physician orders. None identified. An audit of medication administration was completed by the Director of Nursing/Designee on 12/18/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None identified. Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024. Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate recommend orders have been transcribed, implemented, responsible party notified, and care plan updated. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified and care plan updated. These weekly audits will be monitored by the Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months. Ad Hoc QAPI will be held on 12/19/2024. The Medical Director was notified of the Immediate Jeopardy on 12/19/2024. Allegation of Compliance Date is 12/19/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review and interviews, the facility failed to provide treatment, consistent with professional standards of practice for Resident (R)11's Pressure Ulcer (PU)/Pressure Injury (PI). Specifically, the facility failed to administer an antibiotic to treat R11's wounds, resulting in a loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to provide treatment, consistent with professional standards of practice, to a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F686. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F686 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F686, constituting substandard quality of care. Findings include: Review of the facility's policy title, Wound Care Policies and Procedures Reference dated 09/2024, documented, All treatments should be in conjunction with a physician's order . Physician Orders will still be Required for Wound Care . Review of the facility's policy titled, Medication Management Program, revised 05/05/2023, revealed, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of R11's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee. Review of (R)11's Physician Orders revealed the following: Sodium hypochlorite solution (Dakins apply once daily for 30 days. Use ¼ Dakin's, lightly wet gauze for Wet to Dry (WTD). Do not wet to remove. Remove dry bandage quick like a band aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid. Secondary Tape (retention) apply once daily for 23 days; Gauze roll (stretch) 6 apply once daily for 23 days wrap from beneath toes to mid-calf to attempt to keep resident from being able to remove; Super absorbent gelling fiber pad apply once daily for 9 days. Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/14/24, order revealed dressing treatment plan (Diabetic Wound of Left, Lateral Ankle Full Thickness). Sodium (Na) hypochlorite solution (Dakins) apply once daily for 30 days; Use ¼ Dakins, lightly wet gauze and cover wound with wet gauze for WTD. Do not wet to remove. Remove dry bandage quick like a band-aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid. Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed the following: Recommendation: Augmentin 875/125 mg Twice a Day (BID) x 14 days. Probiotics Three times a day (TID) x 45 days. Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel: Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3 Surface Area 12.15 cm2 Exudate: Moderate Sero-Sanguinous Thick adherent black necrotic tissue (Eschar) 70% Slough 10% Other Viable tissues 20% (SubQ Muscle) Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness: Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm Surface Area 13.20 cm2 Exudate Moderate Sero-sanguinous Thick adherent black necrotic tissue (eschar) 70% Other viable tissue 20% Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg. Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days. Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity. During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping the wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes. During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility. During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse. During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress. During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they visited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well. During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024. During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected. On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included the following: Resident #11 no longer resides in the facility. An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/19/2024 to identify new physician orders. None identified. An audit of current wound treatment orders and wound physician notes will be completed on 12/19/2024 by the Director of Nursing/designee to validate wound treatments have been implemented as recommended by wound physician. An audit of medication administration was completed by the Director of Nursing/Designee on 12/1/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None Identified. Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024. Licensed nurses will receive reeducation on wound care by the Director of Nursing/Designee by 12/19/2024 including: -Transcribing physician wound treatment orders from wound physician notes -Providing treatment and care per physician's order Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate any recommended orders have been transcribed, implemented, responsible party notified, and care plan updated. Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified, and care plan updated. These weekly audits will be monitored by Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months. Ad Hoc QAPI will be held on 12/18/2024. The Medial Director was notified of the Immediate Jeopardy on 12/18/2024. Allegation of Compliance Date is 12/19/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and facility policy review, the facility failed to provide proper safety protocols for 5 out of 5 residents who smoke/vape, Residents (R)1, R2, R3, R4, and R5. Additionally, the facility failed to conduct smoking assessments for 2 out of 5 residents who smoke/vape, R4 and R5. Specifically, residents were smoking vapes in the facility and sharing vapes with other residents. On 04/30/2024 at 09:34 AM, the Administrator was notified that the failure to conduct assessments on residents who smoke/vape and failing to provide proper safety protocols for residents who smoke/vape constituted Immediate Jeopardy (IJ) at F689. On 04/30/2024 at 09:34 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/30/2024. The IJ was related to 42 CFR 483.25 - Quality of Care. On 04/30/2024 at 2:30 PM, the facility provided an acceptable IJ Removal Plan. On 05/01/2024 at 02:30 PM, the survey team validated the facility's corrective actions and removed the IJ, as of 05/01/2024. The facility remained out of compliance at F689 at a lower scope and severity of E. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Smoking Regulation, dated 11/1/2017, revealed, It is highly encouraged that the Facility retains a smoke free environment. If the Facility chooses not to retain a smoke-free environment (Smoking Facility), the Facility's Leadership will establish an appropriate and safe environment for smoking in the Facility to reduce risks to patients/residents who smoke, reduce risks of passive smoking for others, and reduce the risk of fire. The procedures included: 1. Staff is prohibited from smoking on facility's property except for those areas specifically designated for smoking. 2. If the Facility provides long-term care and is a Smoking Facility, a policy is established by the Leadership that permits patients/residents to smoke without written authorization from a licensed independent practitioner. This policy designates locations that are environmentally separate from all patient/resident care areas. 3. The Smoking Facility's Leadership will institute a smoking policy for patients/residents, that: A. Establishes where smoking can occur on facility property. B. Minimizes the smoke to the greatest extent possible. C. Discourages all such smoking. D. Provides education and options for smoking cessation activities. 4. The Smoking Facility's staff will complete the Safety Evaluation for Smoking Care Plan form (Assessment) for the patient's/resident's need for adaptive equipment upon admission, quarterly, and annually. When completed, the record is filed in the patient's/resident's medical record. 6. Patients/Residents will not smoke without direct supervision. This facility is a smoke-free environment. There are no designated smoking areas inside the building. Residents wishing to smoke during their stay will be permitted to do so only with staff supervision and only in designated areas. Smoking is strictly prohibited in any other areas of the facility and/or its property, without exception. Residents must utilize protective gear/apparatus (flame retardant smoking aprons, gloves, etc.) provided for in their safety evaluation and/or care plan, if applicable. Tobacco products are limited to tobacco and/or clove cigarettes, cigars and/or pipes. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with a diagnosis including but not limited to, calculus of kidney due to nephrostomy catheter. R1's MDS Quarterly Review dated 02/08/2024 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 15, indicating they are cognitively intact. Review of R1's smoking assessment revealed, Smoking materials: disposable vape observation dated 03/21/2024. Frequency of use: less than daily. Smokes in unauthorized areas: Minimal Problem. Mobility: Minimal Problem Review of R1's Electronic Medical Record (EMR) did not reveal documentation that R1 was assessed for acknowledgement of smoking policy. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with a diagnosis including but not limited to, hypoxemia. Review of R2's Quarterly MDS dated [DATE] revealed R2's BIMS score was 15. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, paraplegia and chronic obstructive pulmonary disease (copd). Review of R3's Quarterly MDS dated [DATE] revealed R3's BIMS score was 15. Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with a diagnosis including but not limited to, seasonal allergic rhinitis. Review of R4's Quarterly MDS dated [DATE] revealed R4's BIMS was 15. Review of R4's EMR did not reveal documentation that R4 was assessed for smoking/vaping. Review of R5's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, copd, and tobacco use. Review of R5's Quarterly MDS dated [DATE] revealed R5's BIMS score was 15. Review of R5's EMR, did not reveal documentation that R5 was assessed for smoking/vaping. During an interview on 04/29/24 at 1:48 PM, License Practical Nurse (LPN)1 stated to the surveyor, I just caught [R1] vaping in the room. He is keeping it in his gown. During an interview on 04/29/24 at 1:51 PM, R1 admitted to vaping in his room. During an interview on 04/29/24 at 3:05 PM, R1 stated, I gave the vape back to my roommate. We share the vape, it's not mine, it is his. During an interview on 04/29/24 at 3:11 PM, the Assistant Director of Nursing (ADON) stated, We have talked to the family members about supplying those (vapes) to the resident. We have educated the family members. During an observation and interview on 04/29/24 at 3:12 PM, R2 was vaping in the courtyard area of the facility and was unsupervised. When asked if he shares his vape with his roommate, R2 responded, I don't know what you are talking about. When asked does he vape in the room R2 responded, I don't know what you are talking about. During an interview on 04/29/24 at 4:53 PM, LPN2 stated, When I first came here to work it was a smoking facility. Then it was a non-smoking facility. Now, I am unsure. But yes, we have a problem with residents vaping. During an interview on 04/30/24 at 9:34 AM, the Administrator stated, We are a smoke free facility. We do not have a vaping policy. When we see or discover they are vaping, we confiscate the vape. They have noted they mail order them in the facility, they have them delivered with outside food via uber. We have educated the families not to bring in vapes for the residents. During an interview on 04/30/24 at 12:30 PM, R3 stated, A nurse told me I could smoke in the bathroom, but she was suspended for 2 to 3 days. Now we can only vape in the courtyard. I keep my vape in my drawer or locked in my bag, so it won't get stolen. The staff allow us to keep it on us. During an interview on 4/30/24 at 12:40 PM, the Administrator stated, On admission, they sign the no smoking document. During an interview on 04/30/24 at 12:56 PM, Registered Nurse (RN)1 stated, [R3] vapes, I am unsure how she gets her vapes, that is a mystery. The residents are good with the rules as far as I know. I am usure of a policy pertaining to vaping. During an interview on 04/30/24 at 2:06 PM, R4 stated, I vape. I just came from outside using my vape. I keep it locked in my book bag. I usually order it, and it comes in the mail. We are only allowed to vape in the courtyard. During an interview on 04/30/24 at 2:00 PM, R5 revealed that she smokes and has been for a long time. R5 stated that the facility does not allow people to smoke, so she started vaping instead. R5 further stated that she typically goes to the back yard to vape because it's easier to hide. Both she and her roommate vape in the facility. R5 continued, her roommate does vape in the room and conceals the vapors by blowing the smoke down her shirt. R5 revealed that someone who works in the facility buys her and her roommate vapes. R5 stated, I do not want to say her name because she might get fired. R5 revealed that the staff member was a nurse, but would not specify their name or give a description. R5 concluded that once she gets money in her account, she will typically give the nurse some money to buy vapes for her and her roommate and that they take turns buying vapes from the same nurse, this has been going on for a while now. During an interview on 04/30/24 at 4:00 PM, the Director of Nursing (DON) stated, We checked the smoking assessments, I was not aware of [R4] and [R5] vaping. We do not have smoking assessment for those residents. The facility's accepted removal plan revealed: Magnolia Manor [NAME] Plan of Removal F689_ 4/30/2024 Residents #1, #2, #3, #4, #5 smoking assessments were completed on 04/30/2024. Residents #1, #2, #3, #4, and #5 turned in their smoking material to the nurse for secure storage on 04/30/2024. The Administrator reviewed with the identified residents the smoking policy including: -All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage. -Residents may only smoke/vape in designated areas that have been approved and identified as a designated smoking area. -Residents will be supervised by facility staff while smoking/vaping during the entirety of the time. -Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule. -No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident. -Designated staff members, Social Services and Activity staff, may purchase, using the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation. Residents currently residing in the facility were asked by facility leadership if they currently use vapes or are smokers on 04/30/2024. An additional 11 residents identified as smokers/vapers. Those 11 self-identified as smokers, including the use of vapes will have a smoking acuity (assessments) completed by a licensed nurse on 04/30/2024 to determine any additional supervision the resident may require when smoking /vaping. The Administrator will review on 04/30/2024 with the residents, that have self-identified as smoker/vapers, and Facility Staff the smoking guidelines policy including: -All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage. -Residents may only smoke/vape in designated areas that have been approved and identified as designated smoking area. -Residents will be supervised by facility staff while smoking/vaping during the entirety of the time. -Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule. -No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident. -Designated staff members, social Services and Activity staff, may purchase from the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation. Residents who had smoking materials have turned in those smoking materials to the nurse for storage in a secured area on 04/30/2024. Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 04/30/2024. Any staff not receiving this smoking guidelines policy education on 05/01/2024 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will validate in clinical meeting Monday- Friday that Smoking Acuity (Assessment) has been completed for newly admitted residents identifying as a smoker/vaper. The Director of Nursing will randomly interview a minimum of 2 staff and 2 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with the smoking guidelines. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 04/30/2024 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 04/30/2024 to discuss contents of this plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, review of the Facility Reported Incident (FRI), the facility failed to ensure one of 15 sampled residents (Resident (R)1), who had a physician order for a pureed diet and nectar thickened liquids received adequate supervision to remain free from accident hazards. Specifically, R1 obtained a pimento cheese sandwich from the evening snack cart and consumed some of the sandwich, as a result, R1 was found unresponsive while seated in a wheelchair in his room. Staff immediately initiated cardiopulmonary resuscitation (CPR). The nurse staff found pieces of the pimento cheese sandwich in R1's mouth. This failure placed the resident at risk causing serious injury, serious harm, and death. On 05/01/23 at 7:18 PM, the survey team provided the Administrator and Director of Nursing (DON) a copy of the CMS Immediate Jeopardy (IJ) Template and notified them that an IJ existed on 04/29/23 and constituted Substandard Quality of Care (SQC). The IJ and SQC were related to 42 CFR 483.25 - Accidents (F689). On 05/02/23 at 9:00 AM, the facility presented a copy of their Corrective Action Plan dated 05/01/23. On 05/02/23 at 4:02 PM, the survey team validated that the facility removed the IJ as of 05/01/23, before the survey entrance. IJ at F689, severity J, cited as Past Non-compliance. Findings include: Review of R1's electronic face sheet located in the face sheet tab revealed R1 was admitted to the facility on [DATE] and had a readmission date of 03/02/23 with diagnoses including cerebral infarction, dysphagia following cerebral infarction (History of) and unspecified convulsions. Review of the resident's electronic physician's orders located on the orders tab revealed R1 had an order for honey thickened liquids, at risk for swallowing/choking, assist with feeding, pureed meals, and Speech Therapy (ST) to evaluate and treat for dysphagia. Review of the electronic annual Minimum Data Set (MDS) located under the MDS tab dated 03/24/23 revealed R1 has a BIMS score of 2 out of 15, which indicated the R1 was severely impaired, required supervision/one person assist while eating, and no speech therapy triggered at this time. The electronic Care Plan located under the care plan tab dated 04/04/23 identified R1 as having episodes of insomnia as manifested by not sleeping well at night, unable to stay asleep, and is at risk for alteration in nutrition related to dementia, weight loss, dysphagia with modified texture diet speech therapy related to dysphagia as needed. Review of the Incident Report, dated 04/29/23, revealed, R1 was identified by Licensed Practical Nurse (LPN)1 in his room in his wheelchair appearing to be asleep. LPN1 identified R1 was unresponsive and immediately called a code blue upon confirming R1's code status. LPN1 identified R1 to have pieces of a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids and was severely, cognitively impaired, and not capable of making safe decisions. During an interview on 05/01/23 at 12:14 PM, the Administrator stated that on 04/29/23 at 3:25 AM, a Certified Nurse Aide (CNA)1 on 200 hall saw R1 at the nurses' station sitting in his wheelchair and then observed R1 propel himself to his room. The Administrator stated that on 04/29/23 at 3:42 AM, LPN1 was walking down the hall and passed the resident's room and noticed the resident appeared to be asleep sitting up in his wheelchair. LPN1 entered the room and tried to wake R1, so that he could be transferred to the bed to rest. LPN1 noticed that R1 didn't respond. LPN1 determined that R1's skin was warm to touch, body movements were flaccid and no signs of a struggle. The Administrator stated that LPN1 realized that the resident didn't respond to physical stimulation and was unresponsive. LPN1 verified the resident's code status, by reviewing R1's face sheet, and initiated a code blue. CNA1 called 911. LPN2 came from the 300 hall to assist LPN1 with the code blue. The Administrator stated LPN1 identified R1's mouth was opened while initiating CPR, and observed a piece of a pimento cheese sandwich in R1's mouth. LPN1 removed the sandwich and CPR was initiated until EMS arrived. EMS arrived on 04/29/23 around 3:54 AM and EMS took over the code and called the time of death at 4 AM on 04/29/23. Continued interview with the Administrator revealed the nurse stated the resident somehow got the half pimento cheese sandwich from the snack cart for bedtime. Some of the sandwich was found behind R1 in his wheelchair. During an interview on 05/01/23 at 1:01 PM, LPN1 confirmed being the nurse on the 200 unit for the night and that she saw R1 around the nurses' station on 04/29/23 around 2:50 AM asking for more food. LPN1 confirmed R1 was on a pureed diet with nectar thick liquids. She stated she gave R1 the apple sauce off the snack cart. LPN1 stated she was getting ready to go to a different nurses' station when she went down the hall around 3:40 AM. LPN1 noticed R1 was in his wheelchair and appeared to be asleep. LPN1 stated his body was limp, skin was warm to touch, and body was flaccid. LPN1 checked his pulse on his wrist and neck and checked the resident for breathing. LPN1 stated she ran to the nurses' station to identify resident's code status and immediately called the LPN2 on unit 3 for assistance. LPN1 stated she got the crash cart and went to R1's room around 3:43 AM. LPN1 alerted the CNAs of the code blue being performed on the resident. LPN1 stated she and CNA1 were able to get the resident on the bed to perform CPR. There was another CNA who called 911 around 3:45 AM and told 911 it appeared that resident had probably aspirated. LPN1 stated she removed the sandwich from the resident's mouth. She confirmed she started doing compressions and suctioned food from the resident's mouth. LPN1 stated EMS arrived around 3:55 AM and took over CPR. The EMS connected R1 to an AED (Automated external defibrillator) and called R1's time of death around 3:58 AM. LPN1 stated she typically keeps snacks behind the nurse's station. She stated one of the CNAs blocked off the nurse's station to keep the resident from going to the snacks. She stated one of the CNAs later indicated the item used to block the nurse's station was pushed back and it appeared someone had moved it. LPN1 stated she doesn't particularly know where R1 got the sandwich. LPN 1 indicated R1 would ask for snacks, and this is why they would block the nurse's station at night. During an interview on 05/01/23 at 1:37 PM, CNA1 stated she was working with another CNA. CNA1 confirmed that she did not feed R1 any food or snacks. CNA1 stated that she was unaware of R1's diet. CNA1 stated she saw him by the nurses' station around 2:30 AM, completed rounds around 3:25 AM and later observed LPN1 running with the crash cart to R1's room. CNA1 stated she saw the resident in his wheelchair with head back and mouth open. She stated she called 911 immediately. EMS arrived and called R1's time of death. During an interview on 05/01/23 at 2:44 PM, the Director of Speech (DOS) stated that R1 was on speech therapy's caseload from 04/20/22 - 08/02/22. She stated the resident was last screened March 2023 and there were no changes to R1's diet as it was already pureed with nectar thick liquids and was still appropriate at the time of screening. During an interview on 05/01/23 at 5:36 PM, the Administrator stated the snack cart would be placed right near the nurse's station with bedtime snacks. The snacks are labeled and dated. The Administrator stated that CNA1 indicated the snacks were placed on the cart during the ice pass and she forgot to remove the snacks after completing the ice pass. The Administrator stated during that time of the night the snacks should be placed behind the nurse's station. During an interview on 05/01/23 at 5:44 PM, the DON confirmed there are other residents who are on a pureed diet, but they do not take food. During an interview on 05/01/23 at 5:48 PM, the Dietary Manager (DM) confirmed the bedtime snacks consisted of half sandwiches peanut butter and jelly, egg salad sandwiches and pimento cheese. Other snacks include pudding cups, applesauce, and fruit cups. She stated there are 18 residents who have a physician's order for pureed diet and snacks provided for the puree residents are pudding cups, puree fruit (available upon request), and apple sauce. During an interview on 05/01/23 at 5:51 PM, CNA2 stated she has been educated on resident's diet. She stated the snacks were kept behind the nurse's station after being passed out to residents. She stated the residents have meal cards to identify the resident's diet and if there are no meal cards available, she will refer to the nurse for the resident's diet. During an interview on 05/01/23 at 5:57 PM, Registered Nurse (RN1) stated the resident's diet is listed on the diet sheet and on the 24-hour report. She stated the snacks are kept behind the nurse's station or in the medication room. She stated the snacks are passed out by the direct care staff and leftovers are placed behind the nurse's desk or in the medication room. She stated that R1 would always let staff know when he wanted a snack. She stated the resident would always have a snack off of the snack cart which included pudding, applesauce, or jello. She stated the resident was supervised each time for feeding including meals. She was educated after the incident, on placing the snacks in the medication room and reviewing resident's diet before providing the resident a snack. During an additional interview on 05/01/23 at 6:06 PM, the Administrator stated during the investigation process for R1, residents who were identified as wanders, diet was compared, and behaviors were reviewed. The facility determined that there are no current residents at risk for wandering and consuming food not appropriate to their diet. The Administrator indicated that all staff have been trained to store the snack cart in the medication room. The facility's Corrective Action Plan dated 04/29/23 included the following: Summary of Incident: On 04/29/23, R1 was identified to have a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids. R1 was severely, cognitively impaired, and was not capable of making safe decisions. Immediate Action: On 04/29/23, the DON immediately implemented education on not leaving snack carts unattended, placing all snacks in the nourishment room, and monitoring all residents during mealtimes, snack times and activities including food/drink items. On 04/29/23, the DON investigated and conducted a root cause analysis of the incident. The investigation revealed R 1 was identified to be warm to touch flaccid with no bluish discoloration around mouth or gums on initial encounter. CNAs interviews with the DON established R1 was able to retrieve the pimento cheese sandwich from the snack cart and the nurses confirmed sandwich bag underneath resident when R1 was transferred from the wheelchair. Identification of others: Between 04/29/23 to 05/01/23, similar residents were assessed and were confirmed to not be at risk for wandering and retrieving food items. No other residents were affected by the deficient practice. Action taken: Interview on 05/03/23 at 10:57 AM, LPN2 confirmed being educated on Monday, 05/01/23 about monitoring all resident with meals, and when snacks are brought out to lock up all snacks, no drinks are allowed at the nurse's station, personal items and staff was also educated on reviewing resident's diet or meal ticket prior assisting residents with snacks or meals. Interview on 05/03/23 at 11:22 AM, RN2 confirmed being educated on supervising meals, any snack drinks etc. must be placed away so that it's not in the resident's reach. Educated on Monday morning, 05/01/23. Interview on 05/03/23 at 11:24 AM, the CNA/payroll and staffing confirmed when snacks come to the hall, all snacks need to be placed in a locked room. All residents are to be supervised during snack and mealtimes. Educated on identifying the resident diet order by looking at the meal ticket before assisting with meals. Interview on 05/03/23 at 11:45 AM, Dietary1 stated anyone with minced/pureed diets, snacks must be put away, so no residents have access to the snacks. The dietary hands the snacks to the nurses and the nurses are to place the snacks in the medication room and lock the door. Interview on 05/03/23 at 11:49 AM, CNA3 stated that all residents are to be supervised; snacks are to be kept in a locked room. Educated on learning the resident's diet and verifying diet prior to meal, snacks, or activities. When meals or any food is out staff is to remain in visible sight of residents especially residents with altered diets to ensure safety. Nursing and dietary staff will continue to check placement of snacks to be safely secured and all meals and activities involving meals to be monitored by staff. Documentation was reviewed and verified during the survey. There was Quality Assurance and Performance Improvement a (QAPI) meeting held on 05/01/23 at 10:00 AM. The facility will continue to review residents at risk for choking accident hazards and revise the Corrective Action Plan as needed.