**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. 1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Review of Resident #323's admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . Review of Resident #323's hospital records dated 12/01/24 reflected the following: Patient is a [AGE] year-old male who presents to [Emergency Room] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following: Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family]. Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. Review of the facility's PIR dated 01/10/25 reflected on 01/06/25: This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. Review of the facility's policy titled Elopements dated 2018 reflected the following: Staff shall investigate and report all cases of missing residents. .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing/designee .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were. Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4 was provided with adequate supervision to prevent him from eloping from the facility's secured unit that was not in proper working condition on 07/24/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/24/24 and ended on 07/26/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of harm, severe injury, and possible death to residents who require supervision. Findings included: Review of Resident #4's admission Record, dated 09/11/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included parkinsonism (not a single disease, but a term for a group of conditions that affect movement and mimic Parkinson's disease), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), and anxiety disorder (persistent and excessive distress that affects daily life). Review of Resident #4's Optional State Assessment MDS Assessment, dated 06/27/24, reflected he had a BIMS score of 11 indicating moderate cognitive impairment. Review of the section regarding behavior reflected there was no wandering behavior exhibited. There were no active diagnoses listed on Resident #4's MDS Assessment. Review of Resident #4's physician's orders reflected an order to admit the resident 0to the secured unit of the facility on 06/18/24. Review of Resident #4's care plan, revised 07/26/24 reflected the following: Focus: The resident is at risk for elopement/wandering r/t History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly .Goal: The resident will not leave facility unattended through the next review date .Interventions: Exit and stairwell alarms, Frequent Monitoring, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Staff aware of resident's wander risk. Review of Resident #4's July 2024 progress notes reflected staff documented the frequent monitoring of him from 07/26/24 to 07/29/24. Review of Resident #4's Elopement Risk Evaluation, dated 06/18/24, reflected a score of 3 putting him at risk. Review of Resident #4's Elopement Risk Evaluation, dated 07/26/24, reflected a score of putting him at risk. Interview on 09/11/24 at 10:00 AM with Resident #4 revealed he remembered leaving the facility because the back door was open so he walked through it. Resident #4 said he did not hear an alarm going off when the door was open. Resident #4 said he wanted to go to the store and was by himself walking down the road and no one was with him. Resident #4 said he did not make it to the store because staff eventually caught up with him and put him in a car to take him back to the facility. Review of a provider investigation report reflected the following under the Investigation Summary section: On 07-24-2024 around 8 pm, [Resident #4] exited the back unit door and door alarm went off, staff promptly responded and ran after the resident and never losses sight off of the resident and returned him back to the facility safely, upon asking resident state that he wanted to walk to the convenience store. Head to toe assessment done no injury noted .elopement assessments completed .Facility checked the functioning of the back door and adjusted the door to ensure it closed completely and locked, additionally facility maintenance director changed the self closing hinge of the unit back door and started q 30 checking exit door by charge nurse and maintenance director daily. Staff were in serviced on elopement and an elopement drill was completed on all 3 shifts including weekends shift. Staff were in serviced on exit doors checking,proper functioning and reporting to maintenance director promptly in case of any technical error. Facility updated care plan of the resident,facility contacted residents rp but no one answered the call [sic]. Review of the facility's maintenance log reflected the following: 7/26 and 7/27: Exit door by unit not properly latched/door frame sets loose/must be reset twice to ensure door is locked behind all exit doors must be checked daily for proper latching and closure reset [sic]. Review of an invoice dated 08/09/24, from an Electronic Engineering company reflected the following: Description Service Call: Maglock on secure unit is going into delayed egress and needs to be adjusted .The second set of doors were located in the rear of the secured unit. Found that these doors were not locking and found no power present at the Maglock. Troubleshot the XDT board and found no issues & then traced the power wire to determine where it was receiving power from. While tracing the wire found an area that had been compacted near an AC duct. Cut and spliced the wire & then reconnected all wires. After reconnecting the wires, tested the Maglock and the keypad and everything is now working as designed. Job complete. Attempted telephone interview on 09/10/24 at 3:31 PM with CNA F was unsuccessful as there was no answer or return call. A witness statement, dated 07/24/24, written and signed by CNA F reflected the following: I was in the room taking care of residence the I saw one resident through the window running then I first called the memory nurse that one of you resident is out side I then came back and call other staffs [sic]. Attempted telephone interview on 09/10/24 at 3:33 PM to MA H was unsuccessful as there was no answer or return call. An undated witness statement signed by MA H reflected the following: On Wenesday July 24th when I was about to pass the bedtime meds on bluebonnet the charge nurse came to me and ask me to check all rooms on bluebonnet if everyone was there. Before my charge nurse instruct me one of the nurse came on [the hall] call the CNA and say to him help him because she is looking for somebody [sic]. Telephone interview on 09/10/24 at 3:38 PM with CNA K revealed she was in a room helping a resident and heard the nurse calling out for help. CNA K said she stayed behind to care for the residents while the other CNA left with the nurse to run after the resident. CNA K said the door alarm did not go off and the back door to the secured unit was wide open. CNA K explained that she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/11/24 at 9:16 AM with CNA I revealed it was around 8:30 PM when she was in a room assisting a resident to bed and changing them. CNA I said she heard the nurse said a resident was out of the facility so she left to help the nurse. CNA I said the resident left through the back door of the secured unit and the door alarm did not go off. CNA I explained that she had been trained on what do when a resident eloped from the facility. Attempted telephone interview on 09/11/24 at 3:37 PM to LVN J was unsuccessful as there was no answer or return call. An undated witness statement reflected the following: I [LVN J], charge nurse on 7/24/24, [the facility's] Memory Care [unit], while admitting a new resident the alarm was sounded off. I checked around and noted [Resident #4] had gotten out of the building. I immediately went after the resident. [CNA F] also noted resident coming around the building headed toward [a street near the facility]. CNA made this nurse aware that she would notify other staff to assist getting [Resident #4] back in the building. We were able to safely get resident back on unit. I never lost sight of resident and made sure he was safe resident verbalized I'm ok, 'I just wanted to take a walk' [sic]. Telephone interview on 09/11/24 at 9:45 AM with RN L revealed he was not working on the unit the day a resident eloped. RN L said he was helping to send a resident to the hospital and heard someone shout that a resident had eloped. RN L said he stayed in the facility to be with the other residents while the aide and nurse went to find the resident. RN L explained that she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/11/24 at 9:37 AM with CNA M revealed he was doing rounds when the nurse (LVN G) called and said a resident ran outside and she needed help bringing him back to the facility. CNA M said he and LVN G found the resident before the stop light before the railroad down the street from the facility. CNA M said the laundry lady had put the resident in her car to drive him back to the facility. CNA M said it was very late at night and were worried about walking him back to the facility. CNA M explained that she had been trained on what do when a resident eloped from the facility. Interview on 09/11/24 at 10:37 AM with LVN N revealed she was not there the day Resident #4 eloped. LVN N said afterwards she continued to monitor him and completed every 15-minute checks on him for a week to make sure he was safe in the facility. LVN N said she was also told to check the exit door to the secured unit every shift to make sure it was working properly. LVN N said if the exit door was not working she was supposed to notify the Administrator and Maintenance Director immediately. LVN N explained that she had been trained on what do when a resident eloped from the facility. Observation on 09/11/24 at 11:30 AM of the secured unit's exit door revealed it was locked and the keypad next to it had the light on indicating it was working. An attempt to push on the door to open it was unsuccessful, the door stayed closed and never opened. A piece of paper posted next to the door reflected: In case if alarm goes off, ensure that door is properly closed after resetting the password,if not than immedietly inform Administrator/Maintenance Director and log it in Maintenance log book. Please ensure that residents are safely back in the unit and follow P/P of elopement. Thank you, management. [sic] Interview on 09/11/24 at 11:33 AM with the Maintenance Director revealed he had only been at the facility for two months. The Maintenance Director said he has had to fix the back door to the secured unit a few times. The Maintenance Director said the facility called an engineering company to come out and permanently fix the door. The Maintenance Director said since the repair no other residents have eloped from the secured unit. The Maintenance Director said the door used to be able to be opened after pushing on it for so long but now it would not open unless the fire alarm went off or the staff entered the code to unlock it. The Maintenance Director said this change was made because residents were setting the door alarm off too many times at night, and it would not lock back so he would have to go to the facility to fix it to secure the door. The Maintenance Director said he checked the secured unit exit door regularly and completed a log for it. Interview on 09/11/24 at 11:57 AM with the DON revealed she was told Resident #4 pushed through the secured unit's exit door and started running away from the facility. The DON said staff told her they ran after him, but he was running very fast. The DON said staff brought him back to the facility and he was not harmed but he did make it off the facility property. The DON said afterwards they in-serviced all their staff regarding elopements. The DON said they also completed elopement drills and completed an elopement assessment on Resident #4. The DON said the Administrator had a company come out to fix the door as well. The DON said the facility knew Resident #4 was at risk of elopement because he came from another facility that did not have a secured unit where he was trying to elope from there. The DON said a lot can happen when a resident elopes from the facility such as they can be out of food and be hungry, become dehydrated, could be hit by a car, or could die. The DON said all staff were responsible for making sure residents do not elope. Interview on 09/11/24 at 12:20 PM with the Administrator revealed the DON told her that Resident #4 had eloped from the facility. The Administrator said Resident #4 had opened the door and the door alarm went off the nurse saw him and left after him, but he was very fast. The Administrator said multiple staff left to find Resident #4 and they found him on a road near the facility. The Administrator said staff got Resident #4 in one of their cars to bring him back to the facility. The Administrator said Resident #4 was not harmed and told staff he was going to the convenient store to get something. The Administrator said staff were in-serviced on elopements after the incident occurred. The Administrator said the nurse completed multiple assessments on Resident #4 such as skin, pain, and a head to toe which resulted in no findings. The Administrator said an elopement risk evaluation was also completed on Resident #4. The Administrator said the Maintenance Director checked the door and thought there was a glitch in the door alarm or something. The Administrator said they monitored the door for functionality for the next 72 hours and called an engineering company to fix it. The Administrator said two elopement drills were completed, one on 07/25/24 and one on 07/27/24. The Administrator said they knew Resident #4 was an elopement risk when he admitted because he was from another nursing facility where he wandered a lot and was at risk of eloping. The Administrator said anything can happen to a resident when they elope, and all staff were responsible for ensuring they did not. Interview on 09/11/24 at 2:22 PM with CNA D revealed she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/12/24 at 8:52 AM with LVN G revealed an aide called that a resident had left the building. LVN G said she went out of the facility and tried to follow that aide and saw another aide also trying to find the resident. LVN G said she saw one of the laundry ladies take her car and drive off to find the resident. LVN G said she went out to road and off to the side she saw a nurse and an aide with the resident. LVN G said they found the resident around [street name] before the train tracks. LVN G explained that she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 9:16 AM with LVN B revealed she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 10:34 AM with LVN O revealed she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 10:55 AM with CNA P revealed she had been trained on what do when a resident eloped from the facility. The Administrator was notified on 09/11/24 at 4:05 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #4 in an IJ situation on 07/24/24. The facility implemented the following interventions: Review of an Elopement Tool worksheet reflected the facility held an elopement drill on 07/27/24. Review of an Elopement Drill/Actual Event Participation Log reflected a date of 07/25/24. Review of an Elopement Drill/Actual Event Participation Log reflected a date of 07/26/24. Review of an Elopement Prevention and Management Program Evaluation worksheet reflected it had been completed. Review of an Exit Doors Check worksheet reflected the secured unit door was checked daily from 07/01/24 to 07/25/24. Review of Enhanced Supervision Monitoring Tools reflect staff were signing off that they had monitored the secured unit exit door on the following dates: 07/26/24, 07/27/24, 07/28/24, 07/29/24, 07/30/24, 08/01/24, 08/02/24, 08/03/24, 08/04/24, 08/05/24, 08/06/24, 08/07/24, 08/08/24, 08/10/24, and 08/11/24. Review of a sheet of paper titled Facility Personal Safety Device and Exit Door Alarm Testing Log for July 2024 reflected there were checks on all the doors, including the secured unit exit door. Review of an in-service titled Elopement and wandering policy and procedure aims to prevent and manage situations where individuals, particularly those with cognitive impairment, leave a designated safe area without authorization or supervision dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of an in-service titled Abuse and neglect, reporting abuse and neglect, forms of abuse, rounding Q 30 minutes in unit, rounding Q hour on the floor dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of an in-service titled Door exits/alarms ringing, all staff must ensure after resetting the password the exit doors are latched/closed and properly functioning dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of the facility's undated policy, titled Elopement reflected: .2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary .4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 11 residents (Residents #1, #2, and #3) reviewed for accidents. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent an unwitnessed fall with injury (non-displaced sacrum ring fracture) on 03/18/24. 2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility's secured unit on 01/31/24. 3. The facility failed to ensure the staff break room was locked at all times and residents did not have access to the microwave. Resident #3 sustained burns on his left foot first toe and second toe. An Immediate Jeopardy (IJ) situation was identified on 03/28/24 at 1:41 PM. While the IJ was removed on 03/29/2024, the facility remained out of compliance at a scope of pattern for a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision. Findings included: 1. Review of Resident #1's face sheet, dated 03/28/24 revealed the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included epilepsy (a brain condition that causes recurring seizures), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (a stroke) affecting right dominant side. Review of Resident #1's quarterly MDS assessment, dated 01/31/24, reflected he had a BIMS score of 06, which indicated severe cognitive impairment. His functional abilities for toileting hygiene and personal hygiene indicated he required substantial/maximal assistance meaning the helper did more than half of the effort. He was also substantial/maximal assistance for rolling left and right, sit to lying, lying to sitting on side of the bed, sit to stand, and chair/bed-to-chair transfer. Review of Resident #1's care plan, dated 11/01/23 , reflected the following: Focus: [Resident #1] [was] at risk for fall due to: unsteady gait, decreased balance and poor safety awareness .01/17/24 fall with no injury .Goal: Resident will have no reports of injuries that requires hospitalization or fractures related fall through next review date .Interventions: 01/17/24 Resident re-educated on the importance of calling for help for safety .Focus: [Resident #1] [had] an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance, Limited Mobility .Goal: the resident will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, mobility through the review date .Interventions: Personal Hygiene: The resident requires total assistance with personal hygiene care. Bed Mobility: The resident requires (X1) staff participation to reposition and turn in bed. Toilet Use: The resident is totally dependent on staff for toilet use. Review of Resident #1's progress notes for March 2024 reflected the following: - On 03/18/24 at 05:04 AM, LVN Z wrote: This nurse was alerted by resident yelling. The CNA explained that she went to gather more wipes as they run out during cleaning session, resident was found at the foot of the bed. Resident was assessed for external injuries, helped back in bed and assessed some more, he denied any pain for the moment being, V/S = 132/71 mmHg, P=74 bpm. R= 17, T=97.9, O2 SAT= 98% room air. Teachings were provided to resident on importance of safety, and how he needed help to move out of bed. DON was made aware, a message has been left for the on-call number, resident family was informed. Neuro ongoing. [sic]. - On 03/18/24 at 11:08 AM, LVN Y wrote: On continue follow up post fall Res complained of pain to right ankle. On Assessment, red area noted to right ankle with Rest of VS WNL. Tylenol 325mg 2 tabs given as ordered and was effective. NP [NP X] notified and X-ray proposed which she accepted. X-ray to right ankle called in STAT. RP [RP V] notified. [sic]. - On 03/18/24 at 5:52 PM, LVN Y wrote: X-ray to right ankle done and results pending with RP at bed side. - On 03/18/24 at 6:00 PM, LVN Y wrote: Res Transfer to ER for further evaluation post fall as decided by RP [RP V] who called 911 herself. [sic]. - On 03/20/24 at 2:53 PM, LVN Y wrote: Res arrived the building via a stretcher AAOX3 and denies any pain. VS WNL with no discomfort reported. DX of sacral fracture .[sic]. Review of an incident report for Resident #1, dated 03/18/24, prepared by LVN Z reflected the following: - Incident Description: Nurse Description: Nurse was alerted by resident yelling, the nurse headed to resident's room where she found him next to bed, yelling 'wipes, wipes'. The cna explained to the nurse that they run out of wipes during the cleaning session, she explained to resident that she will go get some more wipes from the supply room. [sic] .Resident Description: Resident kept screaming 'wipes, wipes' [sic]. - Immediate Action Taken: Resident was assessed for any external injuries, helped back in bed and assessed some more, he denied any pain for the moment being, V/S = 132/71 mmHG, P=74 bpm. R= 17, T= 97.9, o2 SAT= 98% room air. Teachings were provided to resident on importance of safety, and how he needed help to move out of bed. Review of Resident #1's hospital records, dated 03/18/24, reflected the following: History of present illness: .presents to the ED after falling out of bed while undergoing changing at his extended care facility yesterday. All HPI and past medical history have been obtained from patient's [RP] who is POA and states that while the patient was being changed/turned at the extended care facility yesterday afternoon, the patient accidentally rolled off the bed, hitting his entire right side .Assessment and Plan: 1: Sacral fracture, 2: Pelvic ring fracture .History: Additional Comments: CT scan of the pelvis was reviewed which shows very subtle sacral S2 fracture without significant displacement Review of Resident #1's x-ray results for his right ankle, dated 03/18/24, reflected there was no acute fracture or dislocation. Review of a form titled Extended Care Employee Termination Form, dated 03/27/24, reflected CNA T was terminated for negligence and was not eligible for rehire. Observation and interview on 03/26/24 at 10:45 AM with Resident #1 revealed he was sitting in his wheelchair in the activity room drinking coffee. Resident #1 was dressed, groomed, and appeared content; there were no obvious signs or symptoms of pain noted. Resident #1 replied with no to each question the State Surveyor asked so it was difficult to ascertain if he understood what he was being asked based on how he was answering. Observation on 03/28/24 at 9:59 AM of CNA JJ and CNA R providing incontinent care for a resident revealed they gathered all supplies and did not leave the resident alone. Interview on 03/26/24 at 2:30 PM with LVN Y revealed he came in on Monday (03/18/24) morning and the outgoing nurse said the resident fell at about 3:00 AM. LVN Y said he made his rounds and saw Resident #1 laying in bed and he was fine. LVN Y said he contacted RP #4 because the outgoing nurse was unable to contact her earlier. LVN Y said he completed an assessment on Resident #1 and noted he complained of pain to his right ankle and he administered Tylenol. LVN Y said he called Resident #1's doctor and got an order for an x-ray. LVN Y said the X-ray company took a few hours to get to the facility, but they came during his shift and so did RP V. LVN Y said RP V wanted Resident #1 to go to the hospital for further evaluation and called 911 herself. LVN Y said the ankle X-ray results came in the next day when Resident #1 was already at the hospital, but the results were negative, which indicated no injury. Attempted interview via phone on 03/27/24 at 10:02 AM with LVN Z was unsuccessful. Interview on 03/27/24 at 11:50 AM with CNA W revealed when she came in for her shift on 03/18/24, she was informed Resident #1 had a fall on the night shift. CNA W said Resident #1 was a two-person assist and he only complained of pain to his ankle where there was a bruise. Attempted interview via phone on 03/27/24 at 1:23 PM with NP X was unsuccessful. Interview on 03/27/24 at 1:54 PM with ADON U revealed Resident #1 had a fall on 03/18/24 and during the initial assessment there was no complaints of pain. ADON U said an X-ray was done after Resident #1 started to complain of pain and the results were negative. ADON U said Resident #1's RP wanted him to go to the hospital and they found a fracture of some sort on his sacrum. ADON U said CNA T was providing care and in midst of this service ran out of material so she told the resident she would be back. ADON U said she left to go and get more wipes and by the time she came back Resident #1 had fallen out of the bed. ADON U said Resident #1 was total care meaning staff providing all care for his incontinent needs. ADON U said at the time of the fall Resident #1 was a one-person assist but after the fall he was changed to be a two-person assist. ADON U said CNA T should have called for help to ask another co-worker or nurse to retrieve what she needed and stayed with Resident #1. ADON U said CNA T should not have left Resident #1 alone in the condition he was in being in the middle of providing him incontinent care. ADON U said CNA T was suspended pending the investigation and staff were in-serviced on fall risks and prevention and abuse/neglect. Interview via phone on 03/27/24 at 3:05 PM with CNA T revealed on 03/18/24 she went in to answer Resident #1's call light after her lunch break. CNA T said when she went into his room he wanted to be changed so she got her supplies and started changing him. CNA T said in the middle of care, the wipes finished, and she still needed to keep cleaning him. CNA T said she told him she was going to grab some more wipes and was going to come back and finish cleaning him. CNA T said she stepped out of the room to get wipes and came back to the room, and he was on the floor. CNA T said she could have called someone to come and bring wipes or stay with him before leaving to get more wipes. CNA T said she knew better than to leave a resident alone in the middle of providing care. CNA T said she was informed after the fall on 03/18/24 that Resident #1 was now a two-person assist. Interview on 03/27/24 at 3:25 PM with ADON S revealed on 03/18/24 Resident #1 had his call light on and he needed to be changed. ADON S said Resident #1 was a one-person assist at the time and CNA T was caring for him. ADON S said Resident #1 was very impulsive and didn't understand having to wait and hold on for something or for care. ADON S said if staff were running out of supplies during care, they should ensure the resident was safe and try calling someone else and not leaving the resident alone. ADON S said when Resident #1 was found the nurse assessed him and he had no injuries or pain noted at the time. ADON S said later on in the day he complained of pain to his ankle so an x-ray for his ankle was ordered and was negative. ADON S said Resident #1's RP came to the facility and requested him to be sent to the hospital because she felt as if something was broken. ADON S said the hospital found Resident #1 had a sacrum fracture. ADON S said the risk of leaving a resident in the middle of care was they were at increased risk of falls or injuries. ADON S said all staff were responsible for ensuring residents were always left in a safe and comfortable manner. Interview on 03/27/24 at 4:23 PM with the DON revealed Resident #1 had a fall on 03/18/24 and she went to go and see him and speak to LVN Y. The DON said LVN Y told her Resident #1 hurt the right side of his leg, that he was going to call the doctor to get an x-ray ordered. The DON said after the x-ray technician came and took the x-ray, Resident #1's RP said she did not want to wait for the results and wanted him to go to the hospital instead. The DON said on 03/20/24 the facility found out Resident #1 had a pelvic fracture. The DON said LVN Z was the one who found him the morning of 03/18/24 around between 4 and 6 AM when she heard a noise and saw him on the floor. The DON said CNA T went into Resident #1's room to answer his call light, began to gather supplies to care for him and realized she did not have enough to complete the job so she assured him she would be right back. The DON said she was not told by CNA T that she had actually started providing care and then ran out of supplies and left the room. The DON said if that was the case, CNA T should have asked someone for help by bringing her the additional items she needed. Interview on 03/27/24 at 5:23 PM with the Administrator revealed she was still investigating what happened on 03/18/24 with Resident #1. The Administrator said in the middle of the night when the CNA was rounding and checking on residents CNA T saw Resident #1's call light on. The Administrator said she went in to turn off the lights and saw Resident #1 wanted her to change his brief. The Administrator said CNA T agreed to change him so she put his bed to a high position to be able to start care, she had wipes and started caring for the resident. The Administrator said CNA T told her the bed was in a low position before she left the room because she ran out of wipes. The Administrator said Resident #1 was very impulsive and when CNA T left the room and returned, he was at the foot of the bed and screaming about wipes. The Administrator said CNA T should not have left Resident #1 in the middle of caring for him. The Administrator said during the initial assessment by LVN Z, Resident #1 did not have any complaints of pain or injuries. The Administrator said later in the day the next nurse checked on Resident #1 and he was noted to have complaints of pain to his ankle, so an x-ray was ordered. The Administrator said Resident #1's RP requested for him to be sent to the hospital where it was found he had a sacral non-displaced fracture. The Administrator said CNA T was suspended for almost 4 days during the investigation and before she was brought back to work a skills check off was completed for peri-care. The Administrator said Resident #1 has one word that someone says to him and he sticks to that word such as wipes so it was hard to understand from him what happened. The Administrator said all staff were in-serviced on abuse/neglect and fall prevention regarding the incident. The Administrator said CNA T should never have left Resident #1 after beginning care and should have ensured she had enough supplies before beginning peri-care. The Administrator said CNA T could have asked for help and stayed with Resident #1 to keep him safe because he has a history of impulsiveness and this incident caused harm to him. Follow-up interview on 03/28/24 at 8:42 AM with the Administrator revealed CNA T was terminated as of 03/27/24 because the facility confirmed her negligence regarding Resident #1's fall on 03/18/24 . The Administrator said CNA T told her last night (03/27/24) via phone she was providing care to Resident #1, ran out of wipes, and then left him to get additional wipes outside of the room and he ended up falling and sustained a fracture. The Administrator said she began an additional in-service regarding providing care to residents but had only been able to re-educate the day shift so far for today (03/28/24). Attempted an interview via phone on 03/28/24 at 9:49 AM with RP #4 was unsuccessful. Follow-up interview on 03/28/24 at 11:02 AM with the DON revealed as of this morning (03/28/24) she had just started an additional in-service with staff regarding following the facility's policy and procedures for peri-care. The DON said she was re-educating staff on making sure they had all supplies gathered and ready before beginning incontinent care for a resident. The DON said she was also completing skills check off competencies with staff regarding incontinent care as well. The DON said this was prompted because her and the Administrator contacted CNA T again last night to discuss what happened with Resident #1's fall on 03/18/24. Interview on 03/28/24 at 11:30 AM with CNA R revealed she knew to get all supplies before providing incontinent care and to not leave a resident alone during incontinent care. CNA R said she would use the call light to get the attention of someone else if she did run out of supplies during care. Interview on 03/28/24 at 11:35 AM with CNA Q revealed she knew to get all supplies before providing incontinent care and to not leave a resident alone during incontinent care. CNA R said she would use the call light to get the attention of someone else if she did run out of supplies during care. Review of the facility's undated policy titled Perineal Care reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: 1. Disposable wipes, 2. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Review of the facility's undated and blank Peri Care Audit Tool reflected the following actions: 2. Staff must gather supplies, have bags ready for linen and garbage and wash hands 2. Review of Resident #2's face sheet, dated 03/28/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder.) Review of Resident #2's care plan, updated 01/31/24, reflected the following: Focus: [Resident #2] is an elopement risk/wandered has History of attempts to leave facility unattended, Resident wanders aimlessly. [Resident #2] got out of the facility on 01/31/24 .Goal: The resident will not leave facility unattended through the review date. The resident's safety will be maintained through the review date .Interventions: 01/31/24 30 minute checks x 6 days .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate [sic]. Review of Resident #2's quarterly MDS Assessment, dated 02/29/24, reflected he had a BIMS score of 6, which indicated severe cognitive impairment. Review of an elopement risk evaluation, dated 01/31/24, reflected Resident #2 was at risk of eloping. Review of an incident report, dated 01/31/24, reflected for the Incident Description: Nursing Description: Res. had finished his breakfast and directed to his room. Apparently, able to leave the unit without any alarm sounds noted. Res. was found by another staff coming to work, and brought back resident to the facility. Res. noted holding his Bible and card that he received from his mother recently. Resident Description: Res. Stated that he went to the back door and was trying to get home to his mother. [sic]. Completed by LVN BB. Observation and interview on 03/26/24 at 10:40 AM with Resident #2 revealed he was laying in his bed with a blanket covering him. Resident #2 said he left the facility but could not remember how or why or where he went or when it was. Resident #2 said he felt safe in the facility and did not travel much anymore. Observation on 03/26/24 at 11:00 AM of the secured unit's back door revealed it was secured, locked, and appeared to be functioning properly. Interview on 03/26/24 at 2:30 PM with LVN Y revealed he was aware of the facility's policy and procedures regarding a resident eloping. LVN Y explained that he knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN Y said he knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/26/24 at 2:50 PM with CNA J revealed she was aware of the facility's policy and procedures regarding a resident eloping. CNA J explained that she knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. CNA J said she knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/26/24 at 4:08 PM with LVN BB revealed early in the morning on 01/31/24 she was serving breakfast in the dining room on the secured unit. LVN BB said Resident #2 was always the first resident to finish their breakfast and she had to redirect him to his room afterwards. LVN BB said she took Resident #2 to the hallway and then went back to the dining room because she was helping other residents finish their meals. LVN BB said the next thing she knew the front desk was calling saying Resident #2 was seen by Housekeeper KK on her way to work. LVN BB said apparently Resident #2 pushed on the back door of the secured unit and walked around the back and went to the front of the building. LVN BB said she called the DON and Administrator immediately to report what happened. LVN BB was instructed to count all residents and ensure no one else was missing or had eloped. LVN BB said all residents were accounted for and Resident #2 was back in the building . LVN BB said she spoke with Resident #2 and said he was carrying his Bible and a card sent to him by his [family member] so he was trying to get home to her. LVN BB said she checked his skin and he had no injuries. LVN BB said she thought something was wrong with the door to the secured unit at the time since there was not an alarm that went off. LVN BB said usually when someone tried to open that door the alarm would go off letting staff know that someone was trying to leave. LVN BB said the ADON came to check the door as well and she was able to just push the door open, it was not locked and did not require a 15-second release, and the alarm did not sound. LVN BB said the Maintenance Director came and fixed the door right away that day (01/31/24). LVN BB was able to explain the facility's policy and procedures regarding a resident eloping. Interview on 03/27/24 at 5:20 PM with LVN K revealed she was aware of the facility's policy and procedures regarding a resident eloping. LVN K explained that she knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN K said she knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/28/24 at 9:58 AM with LVN L revealed he was aware of the facility's policy and procedures regarding a resident eloping.LVN L explained that he knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN L said he knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview via phone on 03/28/24 at 11:35 AM with CNA LL revealed Resident #2 eloped from the secured unit back in January. CNA LL said it happened during breakfast time and she was helping other residents to eat their food. CNA LL said Resident #2 finished his meal and liked to go to his room after so when the nurse saw him finish his food she directed him to his room. CNA LL said all of a sudden she heard Resident #2 was found out of the facility and she was not sure how he got out. CNA LL said she asked Resident #2 how he got out of the facility, and he said he went out the back door, but the alarm did not go off. CNA LL said she never noticed the back door to the secured unit was not working. CNA LL said she no longer worked at the facility. Interview via phone on 03/27/24 at 12:49 PM with the Regional Maintenance Director revealed he did not know anything about the back door to the secured unit not functioning back in January because he was not specifically assigned to this facility. Attempted interview via phone on 03/27/24 at 12:56 PM with the Maintenance Director was unsuccessful. Interview on 03/27/24 at 1:54 PM with ADON U revealed Resident #2 eloped from the secured unit and was found down the street at the stop sign. ADON U said a Housekeeper was driving to work and saw Resident #2 and brought him back to the facility. ADON U said an incident report, pain assessment, and skin assessment were completed on Resident #2 and nothing was found. ADON U said Resident #2 was also placed on 30-minute checks by staff, the doctor, and the RP were also notified of the incident. ADON U said the facility checked the back door to the secured unit and there was something wrong with the door arm that they readjusted to make sure it shut and locked. ADON U said after they readjusted the door arm, they noticed it was closing faster and was now locking. ADON U said after the incident occurred, all staff were educated on the facility's policy and procedures for elopements. ADON U said when residents eloped they were at risk of a lot, including injury or death. Interview via phone on 03/28/24 at 4:02 PM with Housekeeper KK revealed she was driving to work on 01/31/24 and found Resident #2 walking outside. Housekeeper KK said she put Resident #2 in her car and brought him back to the facility. Housekeeper KK said she found Resident #2 down the street from the facility about 5 minutes away . Interview on 03/28/24 at 3:25 PM with ADON S revealed Resident #2's (family member) sent him something in the mail with an address on it and that was where he was going to when he eloped. ADON S said Resident #2 was on the secured unit of the facility because he had a history of eloping from previous facilities where he admitted from. ADON S said the facility completed elopement drills, completed in-services for staff, and also put Resident #2 on 30- minute checks. ADON S said the elopement drills were completed on 01/31/24 and 02/06/24. ADON S said the risk of residents eloping from the facility was they could get injured. ADON S said all staff were responsible for making sure residents did not elope. Interview on 03/28/24 at 4:23 PM with the DON revealed a Housekeeper staff member came to the facility and said she thought this person was their resident. The DON said the previous receptionist for the facility told the Housekeeper staff member that it was a resident and identified the person as Resident #2. The DON said she asked where he was going and he was going to the address on the envelope he received from his family member. The DON said Resident #2 was found down at the corner to the left of the facility. The DON said Resident #2 told her he got out of the secured unit through the back door and jumped over the fence. The DON said the nurse had just walked him to his room after eating breakfast when this occurred. The DON said she had the Maintenance Director check on the door to evaluate what happened and why the alarm did not go off. The DON said the Maintenance Director readjusted the door and it was fixed to where the alarm would go off and it was locking. The DON said Resident #2 was assessed and placed on 30-minute checks. The DON said Resident #2 had not eloped again since this incident on 01/31/24. The DON said all staff were educated to know about the facility's elopement policy and procedures. Review of an elopement drill log, dated 02/06/24, indicated the facility completed an elopement drill with staff on this day. Review of an elopement drill log, dated 03/17/24, indicated the facility completed an elopement drill with staff on this day. Review of maintenance logs titled Monthly door Check included a check of the rear exit from the locked unit was checked on the following dates: 01/22/24, 01/29/24, 02/05/24, 02/12/24, and 02/19/24. Review of maintenance logs titled Doors, Locks, and Alarms Inspection Log included a check of the rear memory care exit was checked on the following dates: 02/26/24, 03/01/24, 03/04/24, 03/08/24, 03/11/24, 03/15/24 and 03/25/24. Review of an in-service titled: Code white= missing person policy and procedure, dated 01/31/24, reflected staff were in-serviced on the facility's policy and procedures regarding elopements. Review of an in-service titled: Elopement Monitoring Safety of Residents, dated 03/28/24, reflected staff were in-serviced on the facility's policy and procedures regarding elopements. Review of the facility's policy, dated July 2017, and titled Wandering and Elopement reflected: Definition: a resident who does not have the capacity who leaves the facility unaccompanied. VIII. Response to Resident Elopement, A. The Facility Staff member who finds that a resident is missing will alert Facility Staff. B. The Charge Nurse will call Code ________ and organize a search. Facility Staff will search areas of the Facility, including common areas, bathrooms, showers, outside areas, etc .F. The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred IX. Return of a Resident .H. all facility will receive an inservice on hire and annually regarding the elopement policy [sic]. 3. Record review of Resident #3's face sheet revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: depression (mental health disorder), nasal bone fracture (a break in the bone over the ridge of the nose) and contusion of scalp (a bruise on the scalp). Record review of Resident #3's quarterly MDS assessment, dated 01/8/24, reflected Resident#3's cognitive skills for daily decision making were moderately impaired with a BIMS score of 07. Record review of Resident #3's care plan, revised 02/15/24, reflected: [Residents #3] was at risk for skin breakdown rule out decreased mobility . 1/24/24 burn wound to left dorsal 2nd toe, 1/24/24 burn wound to left dorsal 1st toe resolved on 2/14/24. Goals: Resident will have no reports of skin breakdown through next review date. Interventions: 1/24/24 burn to left dorsal first toe size 1.3 x 1.5 x no measurements. Treatment of hydrogel and bordered gauze dressing daily. 2/14/24 Burn wound to left dorsal 2nd toe size 2.1 x 1.1 x 0.1cm. Treatment to continue with xeroform and bordered island gauze dressing. 2/21/24 burn to left dorsal 2nd toe size 1.3 x 0.7 x 0.1cm. Treatment to continue with xeroform and bordered gauze dressing and skin prep (A waterproof skin barrier which protects the skin from irritation and trauma resulting from tape or dressing applications.). 3/13/24 Burn to left 2nd toe size 0.7 x 0.2 x 0.1 cm. Treatment skin prep. Record review of Resident #3's skin assessment, dated 01/22/24, reflected skin was intact. Record review of Resident #3's incident report, dated 01/24/[TRUNCATED]