**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found 26 hours after he eloped. The facility did not have a plan in place for monitoring the windows to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of experiencing accidents, injuries, and/or death. The findings included:Record review of Resident #1's face sheet dated 09/12/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis included cerebral infraction (long term effects of a stroke), left middle cerebral artery mixed receptive-expressive language disorder (a language disorder in which both the receptive and expressive areas of communication may be affected in any degree from mild to severe), heart failure, cardiomyopathies (progressive heart disease), aphasia following cerebral infraction (unable to comprehend after a stroke), cannabis intoxication with delirium (a disturbance in attention and awareness along with other cognitive impairments), and methamphetamine abuse (a synthetic stimulant to increase alertness and energy). Record review of Resident #1's entry MDS dated [DATE] revealed Resident #1's BIMS was not completed. During interviews with staff on 09/12/2025 from 11:00a.m. to 3:00p.m., (LVN A, LVN B, CNA C and RN D) and record review of progress notes revealed Resident #1 was cognitively impaired. Resident #1's care plan dated 09/10/2025 revealed, Resident #1 was confused. The baseline care plan also stated that the resident had behavior concerns- confusion. The care plan revealed Resident #1 was ambulatory. Record review of Resident #1's elopement assessment revealed the resident was not marked as having cognitive impairment. The elopement risk also did not indicate Resident #1 was an elopement risk. During an interview with Resident #1's FM #1 on 09/12/2025 at 9:34a.m., revealed the resident was admitted to the facility on [DATE] at around 6pm. She said the facility called her on 09/11/2025 at around 8:30am and said he had left the facility. She said that Resident #1 did not even know who his FM was when asked. She said the facility was trying to get the family to sign a document that stated they were not liable, but she said she would not sign the documents. She said Resident #1 had never been in a facility before. She said the facility would give her different stories as to what happened. During an interview with Resident #1's FM #2 on 09/12/2025 at 9:59a.m., revealed the facility called and told her that Resident #1 was gone. She said the facility said they checked on Resident #1 at 6:30am and when they checked again at 8:30am he was not there. She said he had been homeless. She said when they went to see Resident #1 right before he was discharged from the hospital, he did not know who they were. She said that the police had not come to talk to the FM. She said the facility had called the police when Resident #1 eloped from the facility. During an interview with LVN A on 09/12/2025 at 11:15a.m., revealed she had gone to do her rounds around 6:00am and Resident #1 was in the bed. She said she went back to see if Resident #1 got his breakfast around 8:00am and he was not in the room. She said she checked to see if Resident #1 was in the bathroom, and he was not. She said she then called the ADM. She said she did a head count and staff searched for Resident #1. She said that when she was searching for Resident #1, she noticed the window up and the screen was off. She said with Resident #1 being confused he was considered an elopement risk. She said she did not know why the other nurse did not mark Resident #1 on the elopement assessment as cognitively impaired. She also said she was trained on completing the elopement assessment in the computer in July of 2025. During an interview with LVN B on 09/12/2025 at 11:26a.m., revealed she admitted Resident #1. She said when he came in, he was friendly. She said as soon as EMS dropped him off, he was walking around the facility. She also said that he was not trying to exit the building and did not say he wanted to leave. She said he looked normal but when you had a conversation with him, he could not remember stuff. She said he was confused. She said he could not tell her what day it was, who the president was, and what month it was. She said he did not appear anxious when he was walking around the facility. She said she did not consider him an elopement risk. She also said he did not appear to be one that would elope. She said with Resident #1 on the elopement assessment she would have checked the box that he was cognitively impaired, but he was not going around to the doors or showing he wanted to leave. She said that she had been trained on completing the elopement assessment in the computer in October 2024. During an interview with CNA C on 09/12/2025 at 11:38a.m., revealed that she worked with Resident #1. She said he was admitted to the facility on [DATE]. She said at 6:15a.m., she went into Resident #1's room and introduced herself and he introduced himself. She said he had the cover over his head when she first went into the room and Resident #1 seemed anxious and really confused. She said she showed him how to use the call light and asked Resident #1 if he needed anything before, she left the room. She said he wanted her to close the door when she left. She said that she did consider Resident #1 an elopement risk with how confused he was. During an interview with the RN C on 09/12/2025 at 12:05p.m., revealed staff had been trained on completing the elopement assessments in the new computer system. She said that the facility rolled out the new system mid-July of 2025. She said she did not have any interaction with Resident #1 but saw in his medical records that he was confused. She said she did not know Resident #1 was walking up and down the hall when he got to the facility. She said she did not consider Resident #1 an elopement risk because he did not say he wanted to leave. She said he was aimlessly wandering. She said the box on the elopement assessment for cognitively impaired should have been checked. She said just because he was confused did not make him an elopement risk. She said he would have to have behaviors showing he was an elopement risk. She said he was not going towards the doors or saying he wanted to leave. During an interview with RN D on 09/12/2025 at 3:00p.m., revealed that she had done Resident #1's admission and assessment. She said that Resident #1 got to the facility around 6:00pm and she signed papers for EMS and then introduced herself to Resident #1. She said she did her assessment and asked Resident #1 who the president was, what was the date, and other questions. She said he appeared to know what was going on but when she started talking to him, he did not know what was going on. She said the only question he could answer was his name. She said he did not appear to be anxious or wandering the halls. She said she did the elopement risk and Resident #1 did not appear to be an elopement risk at that time . She said when she finished with him it was 7:00p.m., she said he did not show her that he was somebody who would be exit seeking. She said he stayed in his room the whole night. She said when she finished with Resident #1, she got him some food for the kitchen. She said on the assessment she should have marked cognitively impaired. She said she overlooked the question. She said the hospital did not give her enough information, and the hospital did not call her and give her a report. During an interview with the MD on 09/12/2025 at 4:04p.m., revealed that she would not expect the staff to increase supervision on the resident due to his medical history of homelessness and drug abuse. She said she would not consider him an elopement risk. She said there were a lot of residents who had strokes and different neurologic disorders, which do not try to elope. She also said it was hard to distinguish who had the capacity of knowing where the risk come from. She also said staff could not predict the resident's behavior or if he was going to elope. She said they encourage residents to walk, and they are safe to move around the facility. She said she would not have staff increase supervision for a new admission for 72 hours. She said staff already round frequently and do regular vitals and medications and then the aids give out medication She said there were a lot of people who their baseline was neurologic conditions and then become confused after they come to the facility. She said they could have been more vigilant in figuring out what happened. During an interview with FM #2 on 09/12/2025 at 12:32pm revealed that Resident #1 had just showed up to FM #1's house. She said Resident #1 was acting aggressive and FM #1 feared him. Record review of Investigation Report for intake dated 9/11/2025 revealed that the facility had a QAPI meeting regarding the incident, CNA C wrote a statement, and the ADM and DON were re-educated by the CN. There was no training done for staff related to elopement. There was no retraining on the elopement assessments. Record review of progress notes dated 09/12/2025 at 1:05pm revealed that the ADM phoned FM #1 of Resident #1 who verified Resident #1 was at her house. FM #1 told the ADM that Resident #1 was agitated and appeared to be under the influence. FM #1 told the ADM that police were at her house and Resident #1 was refusing to go to the hospital. The ADM documented that the police escorted Resident #1 away from FM #1's house a block away the FM's house. Record review of Wandering and Elopements Policy revised March 2019 revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure: Determine if the resident is out on an authorized leave or pass; If the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). This was determined to be an Immediate Jeopardy (IJ) on 09/12/2025 at 5:05p.m. The ADM was notified. The ADM was provided with the IJ template on 09/12/2025 at 5:05p.m. The following Plan of Removal submitted by the facility and was accepted on 09/13/2025 at 12:15 PM. PLAN OF REMOVALF689On 09/12/2025 an abbreviated survey was initiated at facility. On 09/12/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate jeopardy states as follows: The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of elopement risk: Regional [NAME] President of Operations and Regional Nurse Consultant educated the facility administrator and DON on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. The Administrator/Director of Nursing/Designee educated all facility staff on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. DON/Designee completed an elopement drill for all facility staff. Initiated:9/12/2025. Completion: Ongoing Administrator/Designee secured all resident windows to a maximum opening of 6 inches. Initiated: 09/11/2025 Completion: 09/11/2025 Administrator/Designee assessed all wander guard door alarms, and no issues were identified. Initiated: 09/11/2025 Completion: 09/11/2025 DON was educated by Regional [NAME] President of Operations and Regional Nurse Consultant on accurate completion of elopement evaluation. DON/Designee to re-educate all licensed nurse on accurate completion of the elopement evaluation. Signatures obtained to demonstrate understanding. Initiated: 09/12/2025 Completion: 09/12/2025 DON/Designee completed elopement risk assessments on all residents in facility with no further residents deemed at immediate risk of wandering/elopement risk. Resident in question was found at his sister's house on 09/12/2025. Initiated 9/11/25. Completed 09/11/2025. Staff that are on leave from the facility will be re-educated by Administrator/DON/Designee on elopement risks prior to next shift. This facility does not employ the use of agency personnel. Initiated: 09/12/2025 Completion: Ongoing The policy and procedure already in place for elopement and reporting was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no revisions required. Initiated: 9/12/2025 Completed: 9/12/2025 To prevent future occurrences, Resident #1 was located and decided to discharge from the facility AMA. APS report filed 9/12/25. All residents residing in facility were screened for elopement risk. No additional residents identified. Initiated 9/11/25. Completed 09/11/2025. Facility Administrator discussed findings from survey allegations with medical director to ensure continuation and participation of all practitioners with resident elopement risks. Initiated: 9/12/2025 Completed: 9/12/2025 The Medical Director was notified of Immediate Jeopardy. Initiated: 9/12/2025 Completed: 9/12/2025 Monitoring included: Observations on window in room [ROOM NUMBER] on 09/13/2025 at 11:59am revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:01pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:04pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:05pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:07pm revealed that the window stopped at 6 in. During an interview with LVN E on 09/13/2025 at 12:38p.m., revealed she had been trained on elopement and completing the elopement assessments. She said the training covered what to do if there was an elopement, what to do to assess the resident and how to answer the questions. She also said she would ask about behaviors. She said elopement was when a resident left the facility without staff and did not sign out. She said signs of an elopement were wandering around the facility pushing on doors and looking for a way out. She said for a new resident staff would look at the resident's chart and elopement assessment to see if the resident was an elopement risk. She said if a resident eloped staff were to call a code yellow, look for the resident in the room, bathroom, closet, under the bed, as well as do a head count and put a trash can in the doorway of a room after it had been searched. She also said staff would look outside the facility around the building, drive around the neighborhoods looking for the resident. She also said staff would call the DON, ADM, MD, and RP. She said if a resident was an elopement risk staff were to call the DON and the MD to get orders for a wander guard. She said she did do the elopement drill and staff were searching and called a code yellow. During an interview with CNA F on 09/13/2025 at 1:14p.m., revealed that he had been trained on elopement. He said the training covered what to do if someone was missing. He said staff were to call a code yellow, do a head count of all residents, check rooms, closets and outside and make sure everything was clear. He said elopement was when resident left the facility and did not sign out and staff could not find the Resident. He said staff were to also call the nurse and the ADM and inform them of the missing resident. He said that signs of an elopement risk were pushing doors and asking how to get out. He said if he had a new resident and did not know if the resident were an elopement risk he would look at the resident's chart and ask the nurse about the resident. He said that he did participate in the elopement drill and staff searched for a missing resident and put the trash can in the door once done searching the room.During an interview with CNA G on 09/13/2025 at 1:38p.m., revealed she had been trained on elopement. she said the training covered what to do if someone was missing. She said staff were to search for the resident that was missing. She also said that staff were to call a code yellow and notify the charge nurse. She said signs of elopement were the resident wanting to leave. She said she was in the elopement drill and the ADM had staff searching like a resident was missing. During an interview with LVN H on 09/13/2025 at 1:53p.m., revealed that he had been trained on elopement and completing the elopement assessments. He said that the training covered how to report a resident who is confused and watch new residents what to do and who to notify. He said elopement was when a resident left the facility without notifying staff. He said signs of elopement were when a resident wanders from door to door, confused and going into other residents' rooms. He said to find out if a new resident were an elopement risk he would look at the report from the previous nurse, go check on the resident and observe the resident. He said if a new resident were an elopement risk he would let the DON know and call the doctor to get orders for a wander guard. He said that signs of elopement were a resident and pushing the doors and wanting to leave. He said he did attend the elopement drill and staff looked for residents, did a head count of residents, and called a code yellow. During an interview with LVN I on 09/13/2025 at 2:01p.m., revealed that she was trained on elopement and completing the elopement assessments. She said the training covered what to do when a resident was missing. She also said the training covered when doing the assessment staff were to ask the resident questions and get to know the resident's history. She said that elopement was when a resident left the facility without staff knowledge. She said signs of elopement risk were wandering to the doors, asking to leave, and cognitive impairment. She said if a resident was missing staff were to check the last place the resident was, check the whole facility, rooms, shared areas, bathrooms and outside. She said staff were to notify the DON, ADM, RP, and MD. She said depending on what is found out about the resident would depend on if the staff were to call the doctor and get an order for wander guard. During an interview with CNA J on 09/13/2025 at 2:23p.m., revealed she had been trained on elopement. she said the training covered what to do if a resident was missing. She said that elopement was when the resident left the facility without notice and did not sign out. She said a sign of elopement risk was when a resident would wander to the doors and push on them to get out. She said to find out if a new resident were an elopement risk she would ask the charge nurse about the resident. She said when a resident was missing staff were to call a code yellow, search all halls, all rooms, everywhere. She said staff were to report to the nurse, DON, and ADM if a resident was missing. She said she did participate in the evacuation drill. She said the staff went to all the halls, checked the rooms, the bathrooms, under the beds. She said when staff came out of a room after searching staff would put a trash can in the doorway to show the room had already been searched. During an Interview with the RDO on 09/13/2025 at 2:12pm revealed that he did review the policy and did not make any revisions to the policy.During an interview with the MD on 09/13/2025 at 2:19pm revealed that the administrator did discuss the finding and ensured continuation and participation of all practitioners with resident elopement risk. Record Review revealed that the RDO re-educated the ADM with CN present on 09/12/2025. The CN educated the DON on 09/12/2025. Record review of Wandering and Elopements, policy Interpretation and Implementation In-service and Elopement Drill revealed that the DON educated staff and conducted an elopement drill with 39 of 90 staff. Record review revealed that wander guard monitoring checklist has been completed for all shifts starting Sept. 1, 2025. Record review of Elopement Evaluation Observation In-service Training dated 09/12/2025 revealed 16 of 34 Licensed Nurses were in-serviced on completing the elopement assessments. Record review of elopement risk assessments revealed 93 0f 93 residents had elopement risks assessments completed. Six residents identified as elopement risk. 6 of 6 residents' elopement risk assessment, care plan and MDS match. Record review revealed some PRN staff have been educated. Record review of AMA dated 09/12/2025 revealed the resident refused to sign.Record review revealed that the medical director was called by the ADM on 09/12/2025 at 1:14pmRecord review revealed that a QAPI meeting was held on 9/11/2025. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain, in that: The facility failed to: Provide pain medication ordered for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering, decreased mobility, decreased quality of life, and decreased quality of care. Findings included: Review of Resident #1s undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and most current re-admission [DATE] diagnoses including malignant neoplasm of peripheral nerves and autonomic nervous system (rare cancers that start in the lining of the nerves), abrasion of lower back and pelvis, adrenocortical insufficiency (occurs when the adrenal glands don't make enough of the hormone cortisol) and pain. Review of Resident #1 's MDS dated [DATE] reflected a BIMS of 15 indicating no cognitive impairment. Further review revealed over the last 5 days she had pain or hurting, experienced pain frequently, and pain had made it difficult for her to sleep occasionally. Verbal descriptor scale of pain over the last 5 days revealed the intensity of her pain has been severe. Over the last 5 days the resident had received a scheduled pain medication. Review of Resident #1's care plan dated 08/22/2023 revealed category of special care monitor for the presence of pain/intolerance during self-care activities. Category dated 08/22/2023 ADLs Functional Status/Rehabilitation Potential Monitor/record/report for presence of pain/intolerance during transfers. Review of hospital records dated 04/09/2023 until discharge of Resident #1 to the facility on [DATE] reflected patient endorsed worsening lower left extremity pain and swelling for the last couple of weeks. She lived at a skilled nursing facility, and they ran out of her pain medication 2-3 weeks ago and she presented to the ED for uncontrolled lower left extremity pain and leg wound. She had a history of malignant neoplasm of peripheral nerves of thorax and malignant peripheral nerve sheath tumor of chest (a type of cancer that can occur in various locations of your body). Patient's cancer was locally advanced and not curable. As a result of the cancer, she experienced chronic pain for which she was on chronic opiates (including methadone). Hospital records indicate they initially thought her uncontrolled pain on presentation was due to her cancer, but X-rays revealed her femur was broken in several places. Review of Resident #1's paper chart medication orders reflected the following: *methadone schedule II 5 mg. amount to administer: 1 tab; oral twice a day pain unspecified 02/02/2024 open ended. * methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. * hydromorphone schedule II tablet 4 mg. amount to administer; 4 tabs, oral every 6 hours hold for sedation pain, unspecified, 02/08/2024 - open ended. In an interview on 04/22/2024 at 12:26 pm the DON revealed that medication administration documentation was completed in the paper chart for residents. If a medication was not given, the person who was responsible for administering the medication drew a circle around their initials indicating that the medication was not administered to the resident. The DON further stated a note was written on the back of the paper medication administration record, or sometimes both a circle and a note was written on the back of the paper medication administration indicating on the paper medication record that a resident's medication was not given. Additionally, if there was a blank in the space that should indicate the time and date a medication was scheduled to be given, the medication was not given. The DON said that if Resident#1 was not given her pain medication, it was because the medication was not available to give to her. Record review of Resident #1's February 2024 paper MAR revealed the following: Handwritten notes on reverse side of Resident #1's of the MAR for methadone schedule II 10 mg. reflected the pain medications were not available to administer on the following dates. 02/20/2024 3:00 pm Methadone 10 mg. - not available 02/21/2024 3:00 pm Methadone 10 mg. - not available 02/22/2024 3:00 pm Methadone 10 mg. - not available 02/25/2024 3:00 pm Methadone 10 mg. - not available 02/26/2023 3:00 pm Methadone 10 mg. - not available Handwritten circles were around the initials of the staff member and a blank space in a date and time box reflected methadone schedule II 10 mg. was not given to the resident, 25 times because it was not available and therefore not administered. 02/09/2024 7:00 am 02/12/2024 3:00 pm 02/14/2024 11:00 pm 02/16/2024 3:00 pm 02/20/2024 7:00 am and 11:00 pm 02/21/2024 3:00 pm and 11:00 pm 02/22/2023 11:00 pm 02/23/2024 7:00 am, 3:00 pm, and 11:00 pm 02/24/024 11:00 pm 02/25/2024 11:00 pm 02/26/2024 7:00 am and 11:00 pm 02/27/2024 7:00 am, 3:00 pm, and 11:00 pm 02/28/2024 7:00 am, 3:00 pm, and 11:00 pm 02/29/2024 7:00 am, 3:00 pm, and 11:00 pm Handwritten circles were around the initials of the staff member which reflected hydromorphone schedule II table 4 mg. was not given to the resident, 16 times because it was not available and therefore not administered. 02/17/2024 - 02/20/2024 Handwritten notes on reverse side of Resident #1's of the MAR revealed hydromorphone reflected, 02/17/2024 hydromorphone on order (nurse notified). Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 5 mg. tab. was not given to the resident, 20 times because it was not available and therefore not administered. 03/01/2024 11:00 am and 7:00 pm 03/02/2024 11:00 am and 7:00 pm 03/03/2024 - 03/10/2024 11:00 and 7:00 pm Record review of Resident #1's March 2024 paper MAR beginning 02/08/2024 revealed the following: Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 10 mg. reflected that the ordered medication was not given to the resident, 17 times because it was not available and therefore not administered. 03/01/2024 - 03/02/2024 03/03/2024 7:00 am 03/03/2024 3:00 pm 03/04/2024 - 03/06/2024 Handwritten note on the reverse side of the methadone schedule II 10 mg. MAR reflected, date illegible, MD Notified. Handwritten circles around the initials of the staff member who was responsible to administer hydromorphone schedule II tablet 4 mg. reflected that the ordered medication was not given to the resident, 38 times because it was not available and therefore not administered. 03/02/2024 1:00 pm 03/03/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/04/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/05/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/06/2024 1:00 pm, 7:00 am and 1:00 pm 03/16/2024 7:00 pm 03/17/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/18/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/19/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/20/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/21/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/22/2024 1:00 am Handwritten notes of reverse side of Resident #1's hydromorphone schedule II tablet 4 mg schedule II MAR reflected the following handwritten notes : 03/02/2024 awaiting pharmacy for methadone 5 mg., methadone 10 mg., and hydromorphone II, 03/16/2024 residents medication not given awaiting pharmacy see nurses notes, 03/17/2024 resident medication not given hydromorphone 4 tabs see nurses notes, and 03/19/2024 am hydromorphone 4 mg (4 tabs) not available will notify NP in AM. Record review of Resident #1's April 2024 paper MAR beginning 02/08/2024 revealed the following: Review of Resident #1's paper medication administration record for April 2024 order reflect tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 5 mg. was not given to the resident, 4 times because it was not available and therefore not administered. 04/08/2024 11:00 am and 7:00 pm 04/09/2024 11:00 am and 7:00 pm Handwritten circles around the initials of the staff member who was responsible to administer methadone schedule II 10 mg. was not given to the resident, 10 times because it was not available and therefore not administered. 04/06/2024 11:00 pm 04/07/2024 7:00 am, 3:00 pm, and 11:00 pm 04/08/2024 7:00 am, 3:00 pm, and 11:00 pm 04/09/2024 7:00 am, 3:00 pm, and 11:00 pm Handwritten circles around the initials of the staff member who was responsible to administer hydromorphone schedule II tablet 4 mg. was not given to the resident, 18 times because it was not available and therefore not administered. 04/05/2024 1:00 am, 7:00 am, and 1:00 pm 04/06/2024 1:00 am, 7:00 am, and 1:00 pm 04/07/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/08/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/09/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm Interview with Resident #1 on 04/22/2024 at 11:27 am revealed she was feeling better since her return from the hospital, and she was getting her pain medications. She said there have been several times she had not received her pain medications while living at the facility and it was because they have run out of them. She said occasionally they will give her Tylenol #3 when her pain medications are not available, but it does not help very much. She said she was always in pain at a constant level, on a pain level of a 6 - 7 all the time and she told the facility she was in pain. Prior to her last hospital admission on [DATE] she said she had not been given pain medications for a long time but was unsure of how long she had not been receiving them. She said she told them the pain was in her legs and that this was a different and terrible pain. She said her legs hurt very badly. The day she was admitted to the hospital she had a shower, and the pain was terrible, and she was crying from the pain and LVN A saw her crying. She called EMS herself to be taken to the hospital. Interview with LVN A on 04/24/2024 at 2:55 pm revealed Resident #1 sometimes did not get her pain medications because they could not get the prescription for the order filled. At times they would give her Tylenol #3, but it was not effective, and the hydromorphone helped her more. LVN A revealed Resident #1 was in pain every day, because of her condition, cancer. LVN A revealed Resident #1 was crying and Resident #1 told LVN A she said she was having pain and Resident #1 told LVN A the pain was too much. LVN A called the NP for Tylenol #3 on 04/09/2024 and it was administered to Resident #1, but it did not help, and you could see from Resident #1's facial expressions and Resident #1's crying that the Tylenol #3 did not help. LVN A said she had never seen her crying that way. LVN A revealed she was in pain every day and it was important for her to give Resident #1 her pain medications because she was in pain, and she was a cancer patient. Interview with the DON on 04/24/2024 at 1:14 pm and 04/26/2024 at 3:09 pm revealed Resident #1 had a diagnosis for pain because she had cancer and Resident #1 had orders for prescription pain medications and the NP and MD took care of Resident #1's pain medication and that the facility had nothing to do with Resident #1's insurance, it was with the doctors. The DON said Resident #1 was in pain all the time, but they could not get her prescription filled, so there was nothing to do. The DON revealed it was not okay for Resident #1 to even have gone a day without her pain medication and the DON understood how high Resident #1's pain level was. The DON revealed she was not aware that Resident #1 was crying because of her pain. The staff did not bring it to her attention that she was crying except the day she went to the hospital. The orders from the doctor should have been filled. Resident #1 suffered from chronic pain and the facility was aware that she suffered from chronic pain. The DON was responsible for making sure medications are ordered and that there is a process in place to make sure residents receive the medication. Interview with the Administrator on 04/26/2024 ADM at 2:50 pm revealed he was aware that there was a struggle and an issue with her Resident #1 her pain medication and it was his understanding that the pain was addressed. He thought it was addressed because they contacted the MD, and another mediation was ordered that resolved the pain and that did not happen. If a resident goes without pain medication the resident could have severe pain and suffering. He revealed Resident #1's needs were not being meet and he knew she was in pain but did not know she was crying. He revealed he was aware Resident #1 called the EMS because of her pain and was surprised to hear that Resident #1 called the EMS as opposed to a staff member. He revealed the nursing staff and facility did not meet her needs. Facility Policy Administering Medications dated 04/2019 revealed the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication . If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. This was determined to be an Immediate Jeopardy (IJ) on 04/23/2024 at 5:57 pm. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/23/2024 at 5:57 pm. The following POR was accepted on 04/25/2024 11:01 am. and included: On 4/19/2024 an abbreviated survey was initiated at [facility]. On 4/23/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: IJ Component: F697 Pain Management Facility failed to issue prescription pain medications Hydromorphone and Methadone as ordered for [AGE] year-old female resident. Immediate Actions: 1. Resident returned to facility on 4-21-24. Upon return, pain assessment was completed by a licensed nurse and resident denied pain and was documented on 4-21-2024. 2. Resident returned to facility on 4-21-2024 with a new order to discontinue hydromorphone and methadone and start morphine. Morphine medication was filled and dispensed 4-21-2024. A licensed nurse assured medication filled and assesses pain every shift. Completed 4-21-2024. Facility Plan to ensure compliance: 1. DON/designee will re-educate pain management with emphasis on the assessing recognizing, identifying, and addressing the underlying cause of the pain as well as assuring medication is in the facility. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and Administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain management education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/24/2024. 2. Licensed nurse to perform pain assessments on all current residents and address any pain that is identified. Completed 4/23/2024 3. The Regional Consultant Nurse provided in-service to DON, ADON, and Administrator. DON/designee to re-educate licensed nurses on pain assessment, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD). Licensed nurses will be in-serviced as needed thereafter. Licensed nurses will be in-serviced as needed thereafter. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Licensed nurses will be in-serviced as needed thereafter. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain competency check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 4. The Medical Director was notified by Administrator on 4/23/2024 at 9:00 pm on the immediate jeopardy citation. 5. An Ad-hoc QAPI meeting was held on 4/23/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: 1. DON/designee will perform medication reconciliation twice a week and ongoing to ensure pain medication is available for residents receiving pain medications. 2. DON/designee will review the 24-hour report Monday through Friday, and RN designate will review the 24 hour report every Saturday and Sunday, to ensure residents pain is being documented and controlled, MD is being notified, and changes of condition are documented and interventions are initiated for pain management. 3. The above will be reviewed in the monthly facility QA meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. On 04/26/2024 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 04/26/2024 at 11:26 am with RN A revealed she worked the 6:00 am - 2:00 pm shift and she was in-serviced on pain management and pain assessment. When she goes to a patient room, she is going to ask them if they are in pain and check their vitals and see if heart is elevated if they are in pain. She revealed that if you look at a patient, you can tell if they are pain. If the patient is in pain, ask where the pain is if they know what was causing it and when it started. Interview on 04/26/2024 at 11:38 am with RN B revealed he worked either 8:00 am - 5:00 pm or 6:00 am - 2:00 pm was in-serviced in pain assessment and management. He revealed all residents should be assessed for pain. Pain depends on the individual and was based on their diagnosis and if they have chronic pain. He revealed pain was individual for every person and should be prioritized as much as anything else if not more. If a resident cannot verbally tell you, they are in pain then he needs to see if the resident was grimacing or moaning. Staff need to look at resident's pain history. Interview on 04/26/2024 at 12:11 pm with LVN B revealed she attended an in-service about pain assessment in detail. She revealed there are two ways to assess a resident's pain one was to ask them and the second is to look at them. If they cannot tell them look at their diagnoses and assess residents completely if they can't respond. Pain is different for everyone. It can depend on their tolerance and their diagnoses. Interview on 04/26/2024 at 12:46 pm with LVN A revealed she works the 2:00 pm - 10:00 pm shift and the 10:00 pm - 6:00 am shifts and was PRN and she attended an in-service about pain. She said she received a copy of a document that discussed pain assessment and management and discussed the procedures of identify pain with a resident. Interview on 04/26/2024 at 12:49 pm with LVN C revealed she was PRN she has worked all there of the facility shifts. She attended an in-service regarding pain management. She learned about different types of pain and that residents may have different symptoms that may indicate that they need something different. She revealed nurses need to evaluate the individual needs and differences of each of the residents when evaluating for pain. Interview on 04/26/2024 at 1:17 pm with LVN D revealed he works 10:00 pm - 6:00 am and was in-serviced about pain management. If a resident can speak, you can ask them and they can tell you about their pain and a resident cannot speak you need to see if they are grimacing or frowning to assess their level of pain. Interview on 04/26/2024 at 2:08 pm with LVN revealed he works the 10:00 pm - 6:00 am shift and she was in-serviced about pain management. To assess a resident for pain she can look at the face of the resident for a grimace, ask if they are hurting, ask the severity of the pain and assess for all symptoms. She revealed nurses need to check their full body for their position and vitals. She revealed she does a head-to-toe assessment. Interview on 04/26/2024 at 2:26 pm with RN C revealed he works either 6:00 am - 2:00 pm or 2:00 pm - 10:00 pm and she was in-serviced on assessing pain. To assess pain, you look at the patient and ask how they are doing and if they say they are in pain ask questions about the pain including where did it start and how long has it lasted. If someone was nonverbal you must look at their facial expressions. The resident might be moaning or crying or be depressed. You can touch them and know if they are in pain or not. Interview on 04/26/2024 at 2:36 pm with LVN F revealed he works 2:00 am - 10:00 pm and he attended some in-services about medication. He received an in-service about pain assessment and pain management, and they discussed how to assess the resident's pain for both verbal and nonverbal residents and that pain is different and unique to all residents. Interview on 04/26/2024 at 2: 05 pm with the Administrator revealed he received in-services on 4/23/24 from the RVPO about on pain management and pain and ensuring resident pain control needs are met by facility staff. He learned about symptoms of pain and making sure he understands the nurse's role for assessing for pain and to make sure the medical staff address resident pain immediately. Interview with the DON at 3:09 pm revealed she was in serviced by RNC about the maintenance of resident pain control with the understanding of pain control management and communication with her nursing staff. Reviewed the 04/23/2024 in-service given by RNC to the DON regarding pain assessment and management. Reviewed the 04/23/2024 in-service given by the RVPO to the Administrator regarding pain assessment and management. Reviewed the 04/23/2024 in-service given to the nursing staff by the DON regarding pain assessment and management. Review of staff list and in service trainings reflected 80% of staff in serviced. The Administrator was informed the Immediate Jeopardy was removed on 04/26/2024 at 3:52 pm. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents reviewed (Resident #1) for pharmacy services. The facility failed to: Provide pain medication ordered, for three consecutive months for different time frames, for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. While the IJ was removed on 04/26/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A second IJ was identified on 05/15/2024 at 2:54 pm in the same area of non-compliance. The Administrator and the DON were notified. The Administrator was provided with an additional IJ template on 05/15/2024 at 2:54 pm. This failure could place residents at risk of not receiving the therapeutic benefits of medications which could lead to advanced injury, increased pain, and diminished quality of life. Findings included: Review of Resident #1s undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and most current re-admission [DATE] diagnoses including malignant neoplasm of peripheral nerves and autonomic nervous system (rare cancers that start in the lining of the nerves), abrasion of lower back and pelvis, adrenocortical insufficiency (occurs when the adrenal glands don't make enough of the hormone cortisol) and pain. Review of Resident #1 's MDS dated [DATE] reflected a BIMS of 15 indicating no cognitive impairment. Review of Resident #1's Quarterly MDS dated [DATE] reflected, over the last 5 days she has had pain or hurting, over the last 5 days she experienced pain frequently, over the last 5 days pain had made it her for her to sleep occasionally. Verbal descriptor scale of pain over the last 5 days revealed the intensity of her pain has been severe. Over the last 5 days the resident had received a scheduled pain medication. Review of Resident #1's care plan dated 08/22/2023 revealed category of special care monitor for the presence of pain/intolerance during self-care activities. Category dated 08/22/2023 ADLs Functional Status/Rehabilitation Potential Monitor/record/report for presence of pain/intolerance during transfers. Review of hospital records dated 04/09/2023 until discharge of Resident #1 to the facility on [DATE] reflected patient endorsed worsening lower left extremity pain and swelling for the last couple of weeks. She lived at a skilled nursing facility, and they ran out of her pain medication 2-3 weeks ago and she presented to the ED for uncontrolled lower left extremity pain and leg wound. She had a history of malignant neoplasm of peripheral nerves of thorax and malignant peripheral nerve sheath tumor of chest (a type of cancer that can occur in various locations of your body). Patient's cancer was locally advanced and not curable. As a result of the cancer, she experienced chronic pain for which she was on chronic opiates (including methadone). Hospital records indicate they initially thought her uncontrolled pain on presentation was due to her cancer, but X-rays revealed her femur was broken in several places. Review of Resident #1's paper chart medication orders reflected methadone schedule II 5 mg. amount to administer: 1 tab; oral twice a day pain unspecified 02/02/2024 open ended. Review of Resident #1's paper chart medication orders reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. Review of Resident #1's paper chart medication order reflected hydromorphone schedule II tablet 4 mg. amount to administer; 4 tabs, oral every 6 hours hold for sedation pain, unspecified, 02/08/2024 - open ended. In an interview on 04/22/2024 at 12:26 pm the DON revealed that medication administration documentation is completed in the paper chart for residents. If a medication is not given, the person who is responsible for administering the medication drew a circle around their initials indicating that the medication was not administered to the resident. DON further stated a note was written on the back of the paper medication administration record, or sometimes both a circle and a note was written on the back of the paper medication administration indicating on the paper medication record that a resident's medication was not given. Additionally, if there was a blank in the space that should indicate the time and date a medication was scheduled to be given, the medication was not given. The DON said that if R#1 was not given her pain medication, it was because the medication was not available to give to her. Review of handwritten notes on reverse side of Resident #1's paper medication admission record for February 2024 for Resident #1's order for methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended reflected the pain medications were not available to administer to Resident #1. 02/20/2024 3:00 pm Methadone 10 mg. - not available 02/21/2024 3:00 pm Methadone 10 mg. - not available 02/22/2024 3:00 pm Methadone 10 mg. - not available 02/25/2024 3:00 pm Methadone 10 mg. - not available 02/26/2023 3:00 pm Methadone 10 mg. - not available Review of Resident #1's paper medication administration record for February 2024 beginning 02/08/2024 reflect methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication and a blank space in a date and time box reflected that the ordered medication was not given to the resident 25 times because it was not available and therefore not administered. 02/09/2024 7:00 am 02/12/2024 3:00 pm 02/14/2024 11:00 pm 02/16/2024 3:00 pm 02/20/2024 7:00 am and 11:00 pm 02/21/2024 3:00 pm and 11:00 pm 02/22/2023 11:00 pm 02/23/2024 7:00 am, 3:00 pm, and 11:00 pm 02/24/024 11:00 pm 02/25/2024 11:00 pm 02/26/2024 7:00 am and 11:00 pm 02/27/2024 7:00 am, 3:00 pm, and 11:00 pm 02/28/2024 7:00 am, 3:00 pm, and 11:00 pm 02/29/2024 7:00 am, 3:00 pm, and 11:00 pm Review of Resident #1's paper medication administration record for February 2024 beginning 02/08/2024 reflected hydromorphone schedule II table 4 mg. amount to administer 4 tabs. oral every 6 hours hold for sedation pain unspecified 02/08/2024 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 16 times because it was not available and therefore not administered. 02/17/2024 - 02/20/2024 Review of the reverse side of Resident #1's paper medication administration record for February 2024 for hydromorphone reflected, 02/17/2024 hydromorphone on order (nurse notified). Review of Resident #1's paper medication administration record for March 2024 order beginning 02/08/2024 reflect methadone schedule II 5 mg. tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 20 times because it was not available and therefore not administered. 03/01/2024 11:00 am and 7:00 pm 03/02/2024 11:00 am and 7:00 pm 03/03/2024 - 03/10/2024 11:00 and 7:00 pm Review of Resident #1's paper administration medication for March 2024 order beginning 02/08/2024 reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 17 times because it was not available and therefore not administered. 03/01/2024 - 03/02/2024 03/03/2024 7:00 am 03/03/2024 3:00 pm 03/04/2024 - 03/06/2024 Review of reverse side of Resident #1's paper medication administration record for March 2024 for methadone schedule II 10 mg. reflected, date illegible, MD Notified. Review of Resident #1's paper medication administration record for March 2024 for order beginning 02/08/2024 reflected hydromorphone schedule II tablet 4 mg. amount to administer: 4 tabs; oral every 6 hours hold for sedation pain unspecified 02/08/24 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 38 times because it was not available and therefore not administered. 03/02/2024 1:00 pm 03/03/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/04/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/05/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/06/2024 1:00 pm, 7:00 am and 1:00 pm 03/16/2024 7:00 pm 03/17/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/18/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/19/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/20/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/21/2024 1:00 pm, 7:00 am, 1:00 pm, and 7:00 pm 03/22/2024 1:00 am Review of reverse side of Resident #1's paper medication administration record for March 2024 for hydromorphone schedule II tablet 4 mg schedule II reflected the following handwritten notes: 03/02/2024 awaiting pharmacy for methadone 5 mg., methadone 10 mg., and hydromorphone II, 03/16/2024 residents medication not given awaiting pharmacy see nurses notes, 03/17/2024 resident medication not given hydromorphone 4 tabs see nurses notes, and 03/19/2024 am hydromorphone 4 mg (4 tabs) not available will notify NP in AM. Review of Resident #1's paper medication administration record for April 2024 order beginning 02/08/2024 reflect methadone schedule II 5 mg. tab. oral twice a day 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 4 times because it was not available and therefore not administered. 04/08/2024 11:00 am and 7:00 pm 04/09/2024 11:00 am and 7:00 pm Review of Resident #1's paper administration medication for April 2024 order beginning 02/08/2024 reflected methadone schedule II 10 mg. amount to administer: 3 tablets; oral every 8 hours pain, unspecified, 02/08/2023 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 10 times because it was not available and therefore not administered. 04/06/2024 11:00 pm 04/07/2024 7:00 am, 3:00 pm, and 11:00 pm 04/08/2024 7:00 am, 3:00 pm, and 11:00 pm 04/09/2024 7:00 am, 3:00 pm, and 11:00 pm Review of Resident #1's paper medication administration record for April 2024 for order beginning 02/08/2024 reflected hydromorphone schedule II tablet 4 mg. amount to administer: 4 tabs; oral every 6 hours hold for sedation pain unspecified 02/08/24 - open ended. The handwritten circles around the initials of the staff member who was responsible to administer the medication reflected that the ordered medication was not given to the resident 18 times because it was not available and therefore not administered. 04/05/2024 1:00 am, 7:00 am, and 1:00 pm 04/06/2024 1:00 am, 7:00 am, and 1:00 pm 04/07/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/08/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm 04/09/2024 1:00 am, 7:00 am, and 1:00 pm, and 7:00 pm Interview with Resident #1 on 04/22/2024 at 11:27 am revealed she was feeling better since her return from the hospital, and she is getting her pain medications. She said that there have been several times she has not received her pain medications while living at the facility and it is because they have run out of them. She said occasionally they will give her Tylenol #3 when her pain medications are not available, but it does not help very much. She said she is always in pain at a constant level, on a pain level of a 6/10 - 7/10 all the time and she told the facility she was in pain. Prior to her last hospital admission on [DATE] she said she had not been given pain medications for a long time but was unsure of how long she had not been receiving them. She said she told them that the pain was in her legs and that this was a different and terrible pain. She said her legs hurt very badly. The day she was admitted to the hospital she had a shower, and the pain was terrible, and she was crying from the pain and LVN A saw her crying. She called EMS herself to be taken to the hospital. Interview with LVN A on 04/24/2024 at 2:55 pm revealed Resident #1 sometimes did not get her pain medications because they could not get the prescription for the order filled. At times they would give her Tylenol #3, but it was not effective, and the hydromorphone helped her more. LVN A revealed Resident #1 was in pain every day, because of her condition, cancer. LVN A revealed Resident #1 was crying and Resident #1 told LVN A she had pain and Resident #1 told LVN A the pain is too much. LVN A called the NP for Tylenol #3 on 04/09/2024 (the day Resident #1 went to the hospital) and it was administered to Resident #1, but it did not help, and you could see from Resident #1's facial expressions and Resident #1's crying that the Tylenol #3 did not help. LVN A said she had never seen her crying that way. LVN A revealed she was in pain every day and it was important for her to give Resident #1 her pain medications because she was in pain, and she is a cancer patient. Interview with the DON on 04/24/2024 at 1:14 pm and 04/26/2024 at 3:09 pm revealed Resident #1 had a diagnosis for pain because she had cancer and Resident #1 had orders for prescription pain medications and the NP and MD took care of Resident #1's pain medication and that the facility had nothing to do with Resident #1's insurance, it was with the doctors. The DON said Resident #1 was in pain all the time, but the pharmacy could not get Resident #1's prescription filled because of insurance and paperwork delays, so there was nothing to do. The DON said that because Resident #1's medication was Schedule II controlled narcotics, they did not have them in the e-kit. The DON revealed it was not okay for Resident #1 to have gone even one day without her pain medication and the DON understood how high Resident #1's pain level was. The DON revealed she was not aware that Resident #1 was crying because of her pain. The staff did not bring it to her attention that she was crying except the day she went to the hospital. The orders from the doctor should have been filled. Resident #1 suffered from chronic pain and the facility was aware that she suffered from chronic pain. The DON is responsible for making sure medications are ordered and that there is a process in place to make sure residents receive the medication. Interview with the Administrator on 04/26/2024 ADM at 2:50 pm revealed he was aware that there was a struggle and an issue with obtaining Resident #1's pain medication and it was his understanding that her pain was addressed. He thought it was addressed because they contacted the MD, and another mediation was ordered that resolved the pain and that did not happen. If a resident goes without pain medication the resident could have severe pain and suffering. He revealed Resident #1's needs were not being meet and he knew she was in pain but did not know she was crying. He revealed he was aware Resident #1 called the EMS because of her pain and was surprised to hear that Resident #1 called the EMS as opposed to a staff member. He revealed the nursing staff and facility did not meet her needs. Facility Policy Administering Medications dated 04/2019 revealed the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. This was determined to be an Immediate Jeopardy (IJ) on 04/23/2024 at 5:57 pm. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/23/2024 at 5:57 pm. The following POR was accepted on 04/25/2024 11:01 am. PLAN OF REMOVAL On 4/19/2024 an abbreviated survey was initiated at [NAME] Woods 1 Nursing Center. On 4/23/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: IJ Component: F 755 Pharmaceutical services Facility failed to issue prescription pain medications Hydromorphone and Methadone as ordered for [AGE] year-old female resident. Immediate Actions: 1. Resident returned to facility from the hospital on 4-21-24. Upon return, pain assessment was completed by licensed nurse, resident denied pain and was documented on 4-21-2024. 2. Resident returned to facility on 4-21-2024 with new order to discontinue hydromorphone and methadone and start morphine. Morphine medication was filled and dispensed 4-21-2024. A licensed nurse assured medication filled and assesses pain every shift. Completed 4-21-2024 Facility Plan to ensure compliance: 1. Licensed nurse to perform pain assessments on all current residents and address any pain that is identified. Completed 4/23/2024 2. DON/designee to re-educate licensed nurses in the process for unavailable medications and medications refusal to include steps to follow when medications are unavailable or refused by the resident. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain medication education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 3. DON/designee to re-educate licensed nurses on contacting physician for alternative pain medication to include obtaining a new order for an available pain medication from the E kit (facility's emergency medication kit). DON/designee to re-educate certified medication aides to notify licensed nurse when medication is not available. The Regional Nurse Consultant and [NAME] President of Operations provided in-service to DON and administrator. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain medication education by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated on 4/23/2024. Completed 4/23/2024 4. The Medical Director was notified by Administrator on 4/23/2024 at 9:00 pm on the immediate jeopardy citation. 5. An Ad-hoc QAPI meeting was held on 4/23/2024 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring 1. DON/designee will perform medication reconciliation twice a week and ongoing to ensure and obtain pain medication is available for residents receiving pain medications. 2. DON/designee will review the 24-hour report daily to ensure residents pain is being documented and controlled, MD is being notified, and changes of condition are documented, and interventions are initiated for pain management. This process will be ongoing. 3. The above will be reviewed in the monthly facility QA meeting for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. On 04/26/2024 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview on 04/26/2024 with the DON at 3:09 pm revealed she was in serviced by RN C about the maintenance of resident pain control with the understanding of pain control management and communication. Interview on 04/26/2024 11:0 am with CMA A who said she attended an in-service about medication management and how early to let the DON and nurses know they are running out of medications and what to do if a resident refuses a medication. She revealed she was to tell the nurse or DON 7 days prior to a resident running out of medication. At day 7, prior to no more medications, she is going to let the charge nurse, the nurse manager, and the DON know the resident only has 7 days of medication left. She will let the charge nurse and the DON know immediately if the resident does not have any medication available for the resident. If a resident refuses medication, she will notify the nurse who will make the notation in the resident's chart. Interview on 04/26/2024 at 11:58 am with CMA B revealed he attended an in-service about medication ordering. He must let the DON and nurse know if they run out of any medication and have none to administer to a resident. If the resident has 8 days left of a medication, he needs to notify the nurse or DON so the pharmacy can be notified, or he needs to call the pharmacy. If it is a narcotic, he needs to tell a nurse or the DON that they only have 8 days left of medication and the resident needs a refill. If a resident refuses medication, he needs to let the nurse knows so he or she can put a note in the chart. Interview on 04/26/2024 at 1:12 pm with CMA C revealed he works 6:00 pm - 2:00 pm shift and was in-serviced on medication availability. At day 7, prior to the resident running out of a medication, you must tell the charge nurse and if resident refuses medication you tell the charge nurse. If there is no medication in the facility for a resident, they will tell the nurse and he or she will try and get it from the e-kit. If there are any medication problems he will inform the DON, especially if there is no medication in the facility for the resident. Interview on 04/26/2024 at 1:29 pm with CMA D revealed he works 2:00 pm - 10:00 pm shift and was in-serviced on ordering medications specific to pain management medications. CMAs are supposed to let the charge nurse know when they are down to a 7-day supply of medications. At day 7 they will re-order or let the ADON or charge nurse reorder medications. If the facility is out of a medication he needs to get with the supervisor and the charge nurse to see if they can get it from the e-kit and he will inform the DON that the medication was not available. If the resident refuses a medication, let the nurse know. Interview on 04/26/2024 at 2:01 pm with CMA E revealed she works the 2:00 pm - 10:00 pm shift and she was in-serviced about ordering medications. If you are out of medications, you do not circle it. You notify the nurse, and she will get it from the e-kit. If you are out of a medication, you report it to the nurse and DON. At the point that a resident has only 7 days left of a medication, inform the nurse so she can request it. If the resident is complete out of a medication, the DON needs to be informed. If a resident tells you they do not want a medication, if they refuse it, let the nurse know. Interview on 04/26/2024 at 11:26 am with RN A revealed she worked the 6:00 am - 2:00 pm shift and she was in-serviced on the process for unavailable medications and how to order them and when to go to the e-kit. She will let the DON know if there are any problems with ordering medication or a resident does not have a medication. She has been educated what to do if a resident refuses a medication. Interview on 04/26/2024 at 11:38 am with RN B revealed he works either 8:00 am - 5:00 pm or 6:00 am - 2:00 pm was in-serviced in making sure that the residents have all their prescribed medication, when and how to order them and when to use the e-kit. She will inform the DON if there are any problems with resident medications. She will make a note in the resident's record if they refuse medication. Interview on 04/26/2024 at 12:11 pm with LVN B revealed she attended an in-service about the correct way to order medications and let the DON know if there are any medication issues and to put a note in the residents record if they refuse a medication. Use the e-kit to get medication if you can if and you can't make sure to notify the DON. Interview on 04/26/2024 at 12:46 pm with LVN A revealed she works the 2:00 pm - 10:00 pm shift and the 10:00 pm - 6:00 am shifts and is PRN and she attended an in-service making sure residents have their medications and how to make sure they have them. Use the e-kit and if the medication is not available, let the DON know immediately. Interview on 04/26/2024 at 12:49 pm with LVN C revealed she is PRN she has worked all three of the facility shifts. She attended an in-service regarding ordering medications and making sure the resident has the necessary medications. It is good to use the e-kit and let the DON know if there are any medications issues. Put a note in the resident record if they refuse to take one of their medications. Interview on 04/26/2024 at 1:17 pm with LVN D revealed he works 10:00 pm - 6:00 am and was in-serviced about getting resident medications to make sure beforehand there is not a problem. Use the e-kit and if any issues, let the DON know. Interview on 04/26/2024 at 2:08 pm with LVN revealed he works the 10:00 pm - 6:00 am shift and she was in-serviced about obtaining the correct medications for a resident. It is important to let the DON know about any medications that are not available to the Resident and to use the e-kit and order medications before they run out. Interview on 04/26/2024 at 2:26 pm with RN C revealed he works either 6:00 am - 2:00 pm or 2:00 pm - 10:00 pm and she was in-serviced on getting resident medications ordered and how and when to use the e-kit and to write it in the resident chart if they refuse medications. Interview on 04/26/2024 at 2:36 pm with LVN F revealed he works 2:00 am - 10:00 pm and he attended some in-services about medications. He was told to let the DON know if there are not medications for the resident in the facility and to try and use the e-kit if something is missing. Interview on 04/26/2024 at 2: 05 pm with the Administrator revealed he received in-services on 4/23/24 from the RVPO about on pain management and pain and ensuring resident pain control needs are met by facility staff. He learned about symptoms of pain and making sure he understands the nurse's role for assessing for pain and to make sure the medical staff address resident pain immediately. Interview with the DON at 3:09 pm revealed she was in serviced by RNC about the maintenance of resident pain control with the understanding of pain control management and communication with her nursing staff. Reviewed the 04/23/2024 in-service given by RNC to the DON regarding pain assessment and management. Reviewed the 04/23/2024 in-service given by the RVPO to the Administrator regarding pain assessment and management. Reviewed the 04/23/2024 in-service given to the nursing staff by the DON regarding pain assessment and management. Reviewed Resident #1's pain assessment dated [DATE] completed by a licensed nurse. Interview and observation on 04/26/2024 at 2:50 pm of Resident #1 revealed she was out of bed, in her wheelchair, out of her room, visiting another resident and she said her pain was better and she was now taking morphine. Reviewed new order dated 04/21/2024 to discontinue hydromorphone and methadone and start morphine. Reviewed 04/23/2034 pain assessments performed by a licensed nurse on all current residents. Reviewed email dated 04[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from neglect for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for neglect. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital on [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on 01/16/2024. An Immediate Jeopardy (IJ) was identified on 01/19/2024 at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:10 pm. While the IJ was removed on 01/21/2024 at 4:35 pm the facility remained out of compliance at a scope of pattern and potential for more than minimal harm that is not immediate jeopardy, due to all staff not being trained by 01/21/2024 at 4:35 pm. These failures placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings includes: Record review of Resident #71's undated face sheet reflected she was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency (vitamin deficiency), unspecified pain, and type 2 diabetes mellitus with unspecified complications. Record review of Resident #71's Braden scales for predicting pressure sore risk dated 05/18/2023, 05/25/2023, 06/01/2023, 06/08/2023, 09/08/2023, 11/22/2023, 12/28/23 and 01/12/2024 reflected a score of 9 (with 9 or less indicating very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 at risk for developing pressure ulcer or injuries). Record review of Resident #71's weight reflected the following: 06/02/2023 weight of 160 pounds 09/01/2023 weight of 148 pounds, -5 pounds in a month 10/01/2023 weight of 143 pounds, - 17 pounds in 4 months 11/01/2023 weight of 130 pounds, -13 pounds with 9.9% within a month 12/01/2023 weight of 125 pounds, -5 pounds in 1 month 01/01/2024 weight of 118 pounds, -7 pounds in 1 month Resident had a total of 42 pounds weight loss from 06/02/2023 to 01/01/2024. Review of Resident #71's comprehensive care plan dated 11/1/2023 reflected Nutritional Status for Resident #71 was at risk for trending weight loss, edited 12/28/2023 reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident # 71's Dietician note dated 11/03/2023 reflected: Resident with continued weight loss; Significant weight loss -8.33% x 90 days· Add 1 ensure shake QD to aid in further meet needs. Record review of Resident #71's wound notes written by TLVN S dated 12/13/2023 reflected Resident #71's foot wound developed on 12/13/23, right lateral ankle, right heel with necrotic, hard area. Paint with betadine daily at this time. Record review of Resident #71's acute Care Plan dated 12/13/2023 revealed Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident # 71's physician orders reflected Resident #71 was not ordered any supplements for wound healing since the wound developed on 12/13/2023. Record review of Resident #71's wound care notes dated 12/22/2023 reflected: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes dated 12/29/2023 reflected: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes dated 01/02/2024 reflected: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. MAR reflected the medication was given from 01/06/2024 through 01/10/2024. Record review of Resident #71's wound care notes dated 01/09/2024 reflected: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size is 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound noted also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Bactrim was discontinued and Keflex 500mg 1 PO X 10 days started on 01/11/2024. Review of Resident #71's physician orders reflected nutritional supplements to promote wound healing were not stated until 01/10/2024. Record review of Resident #71's Medication administration record reflected the following: Prostat 30ml to promote wound healing 1 x day dated 01/10/2024. Multivitamin with mineral 1 x day dated 01/10/2024. Vitamin C 1 x day dated 01/10/2024. Record review of Resident #71's wound care notes also reflected Bactrim DS PO BID X 7 days was discontinued on 01/11/2024 and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated 1/12/2024 reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's progress notes written by LVN Y dated 01/12/2024 reflected Resident #71 was discharged to the local hospital ER on [DATE] at about 4:05 pm. Record review of Resident #71's nurse's notes dated 1/12/24 at approximately 3:51pm reflected per Resident #71's family's request, Resident #71 was sent to the local hospital ER 1/12/24 for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous, with exudative drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated 1/13/24. Record review of Resident #71's [NAME] blood Cell count (WBC) dated 01/12/2024 reflected a value of 22.0 mm (high), normal range 4.5-11.0 (White blood cells- they defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range is 3.4 to 5.4 g/dL (If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) During an interview with Resident #71's family member on 1/18/24 at 10:28am, Resident #71's family revealed Resident #71 expired on 1/18/24 at approximately 4:00am. Review of Resident #71's death certificate reflected Resident #71 died on [DATE] with causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Resident #85 Review of Resident # 85's undated face sheet revealed a [AGE] year-old female with admission date of 12/12/2023. Her diagnoses include anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) subsequent encounter for closed fracture with routine healing. Review of Resident # 85's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no impairment. It was also reflected Resident #85 was at risk of developing pressure ulcer, dependent for lower body dressing and putting on or removing footwear. Review of Resident # 85's acute Care Plan dated 12/13/2023 reflected Resident #85 had skin issue at left tibia. Record review of Resident #85's wound doctor's notes dated 12/22/2023 reflected: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's physician orders reflected an order dated 12/28/2024 for: Pro-Stat AWC (amino acids- protein hydrolys) liquid; 17-100 gram-kcal/30 ml; amt: 30 ml; oral Record review of Resident #85's wound doctor's notes dated 12/29/2023 reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated 01/02/2024 reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated 01/03/2024 reflected: chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress noted dated 01/08/2024 at 10:00pm written by RN I reflected: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records dated 01/17/2024 reflected Resident # 85 was admitted due to sepsis of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA(Methicillin-resistant Staphylococcus aureus- infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used ), Klebsiella (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions) and pseudomonas on 01/09/2024. Blood culture also positive for MRSA on 01/09/2024. Status post hardware removal, washout, and external fixation on 1/10/2024, wound vac change on 1/12/2024. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done 1/16/2024. Resident #87 Review of Resident # 87's undated face sheet revealed a [AGE] year-old male with admission date of 12/26/2023. His diagnoses included Unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, pain unspecified. Review of Resident # 87's admission MDS assessment dated [DATE] revealed a BIMS score of 15. It also reflected Resident #58 was dependent for upper and lower body dressing, at risk for developing pressure ulcer. Review of Resident # 87's acute Care Plan dated revealed Resident #87 had skin condition on his buttock, middle back and left Achilles. Review of Resident #87's comprehensive care plan dated 01/18/2024 revealed Resident #87 required assistance with ADLs, resident at risk for pressure ulcer, resident is limited in mobility all or most of the time. Review of Resident #87's wound care notes reflected wound on Resident #87 buttocks was first seen on 12/31/2023. Review of Resident #87's wound care notes dated 1/16/2024 reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note dated 01/02/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note dated 01/09/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's clinical records revealed he was not ordered nutritional supplements until 01/12/2024. Record review of Resident #87's physician orders reflected an order dated 01/12/2024 for: Liquid Protein Fortifier (protein hydrolysate, milk) liquid; 1 gram-4 kcal/6 ml; amt: 30ml; oral Vitamin C (ascorbic acid (vitamin c)) tablet; 500 mg; amt: 1 tab; oral Twice A Day Zinc-220 (zinc sulfate) capsule; 50 mg zinc (220 mg); amt: 1 tab; oral Once A Day Record review of Resident # 87's wound doctor's note dated 01/16/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs. x 7 days pending culture results. During an interview on 01/19/2024 at 09:26 am, TLVN S started Resident # 71's wounds started about 2 months ago. She stated she rounded with the wound doctor 01/09/2024 and did wound care on Resident # 71 on 01/12/2024. TLVN S stated Resident #71's wound had gotten worse, the right foot was macerated (soft like soak in a liquid), and the dressing was saturated with greenish drainage (like pseudomonas) with foul odor. She Resident #71 was not on any supplements for wound healing since her foot wound started two months ago. She also stated the new DON brought to her attention that Resident #71 needed to be on protein supplement and vitamins to aid in her wound healing. TLVN S stated Residents #71, 85, and 87 were at risk for developing pressure ulcers due to her medical conditions such as immobility. TLVN S also stated Resident #s 71, 85 and 87 should have been on supplements for wound healing. During an interview on 01/19/2024 at 10:34 am, the DON stated Braden scale assessment should be done upon admission, monthly, when there was skin issues, nutritional changes to make sure the individual was not declining. The DON stated, if a Resident's Braden scale reflects high risk for pressure ulcer development, the facility should consult the dietician for recommendation for supplement due to increased need for protein. The Resident should be turned/repositioned frequently, staff should ensure the Resident was eating, labs such as albumin levels should be check for wound healing. The DON stated nutrition, turning and repositioning play a big role in wound prevention and healing. She stated when she started work at the facility sometimes after 01/08/2024, while reviewing wound care documents, she realized Residents with wounds were not on nutritional supplements for wound healing and recommended that those Residents were ordered supplements. She stated she was not sure why those residents were not on nutritional supplements. During an interview on 01/19/2024 at 1:17 pm, the RNC stated she was providing supervision for the new DON. The RNC stated the Braden Scales was used to identify resident at risk for skin breakdown, less than 12 was high risk, the lower the number the higher the risk. The RNC stated the categories of the Braden scale were, moisture, activity, mobility, nutrition, friction, and shear. She also stated, when a resident was at high risk, a look back at the category that was triggered to determine the intervention. The RNC stated Braden scale were done upon admission, quarterly and with change of condition. She stated Resident #71's Braden Scales scores were 9 throughout her stay in the facility, Resident #71 was contracted and unable to move for a long time. The RNC stated for a resident with weight loss who developed a wound, the dietician needed to be notified of the wound development, but the dietician was not made aware of Resident #71's wound development. She stated Residents with pressure ulcer required supplemented protein to promote wound healing and Resident #71 had nutritional deficit and so she needed more protein. During an interview on 01/19/2024 at 2:01 pm, the NP stated she usually do not order medications or treatments for wounds because there was a wound doctor. The NP also stated for Residents with wounds, were ordered Vitamin C, liquid protein, and zinc. The Dietitian was also made aware to ensure the resident was getting the right intake. The NP stated once the wounds were developed and identified those medications should have started. The NP stated she ordered Remeron (Appetite stimulant) to help with nutrition for Resident #71. Review of Resident #71's MAR reflected no evidence of Remeron being administered. During an interview on 01/24/2024 at 3:05 pm, the Licensed Dietitian stated she visited the facility on 12/20/23, and the wound on Resident #71's foot was identified on 12/15/23, but no one told her about it then. The LD stated she received a wound report from the facility on 12/26/23, and Resident #71's wound was not on it. The Licensed Dietitian stated If she had known Resident #71 had a wound, she would have looked at protein by adding prostat (liquid protein) during medication administration, started multivitamins and seeing if the facility was doing CBC and BMP. Review of facility's policy revised March 2018 titled Abuse and Neglect - Clinical Protocol reflected: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Assessment and Recognition .The nurse will assess the individual and document related findings. Assessment data will include: injury assessment (bleeding, bruising deformity, swelling etc.); Pain assessment; Current behavior; Patient's age and sex; All current medications, Vital signs; Behavior over last 24 hours. All active diagnoses; and any recent labs. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. .The physician and staff will help identify risk factors for abuse within the facility; significant injuries in physically dependent individuals; issues related to staff knowledge and skill; or performance that might affect resident care. .Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention or care of pressure ulcers, inattention to advance directives and resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care, failure to report or evaluate significant weight loss, repeated failure to check for correct application of restraints, etc. Review of facility's policy dated September 2017 titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. Review of facility's policy dated April 2018 titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: the nursing staff and practitioner will assess and document an individual's significant risk actors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). .In addition, the nurse shall describe and document/report the following: .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. .The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. .Beyond trying to maintain a stable weight and providing approximately 1.2-1.5 gm/kg protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. .Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. This was determined to be an Immediate Jeopardy (IJ) on 1/19/2024 at 5:10 pm. The Administrator was notified. The Administrator was provided with the IJ template on 10/19/2024 at 5:10 pm The following Plan of Removal submitted by the facility was accepted on 1/21/2024 at 8:33 am. PLAN OF REMOVAL F600 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on wound prevention and care to include infection control and supplemental incorporation of interventions. 1/19/2024. RNC for facility reinforced and re-educated Director of Nursing and Assistant Director of Nursing on wound prevention and care to include infection control and supplemental incorporation of interventions.1/19/2024. Complete skin assessment of all residents performed throughout facility as well as Braden scales to ensure they match resident status. 1/19/2024 All residents found to have wounds or Braden scores falling within scope of intervention were audited for implementation of supplements, prophylactic skin measures and treatment appropriate orders for wounds or skin issues noted. 1/19/2024 One on one education of all licensed staff members began per DON/ADON and/or designees on areas of wound prevention and treatment to ensure protocols followed as put in place. 1/19/2024. Interventions and Monitoring Plan to Ensure Compliance Quickly: o The facility will ensure infection control education to include hand hygiene and wound care measures on all new hires and at minimum annually or upon audit findings. Initiated: 1/19/2024 Completion: 1/20/2024 o DON/designee will perform random audits of Braden scales for 4 residents 3x/week for 4 weeks to ensure adequate assessment and documentation with appropriate measures in place. Initiated: 1/19/2023 Completion: 1/20/2024 o All residents noted to have current wounds will be audited Q week x4 weeks by DON and/or designee to ensure all supplements, consultations and treatments are in line with standard protocols as ordered by practitioner. Initiated: 1/19/2024 Completion: 1/20/2024 o Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee for any nursing staff receiving re-education or training on competencies not found to be proficient. Staff that are on leave from the facility will be given the competencies check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 1/19/2024 Completion: 1/20/2024. o The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for accurate assessment of resident status in relation to Braden scale and skin monitoring to ensure proper care, training competency and immediate initiation of interventions and treatments are enacted for all residents requiring. This will be relayed to the Administrator during weekly CAR meetings for continuum of care to be documented through signed attendance sheet. Initiated: 1/19/2024 Completed: 1/20/2024 o The policy and procedure for infection control to be reviewed by Regional [NAME] President of Operations and RNC with any changes to policies to be implemented. Initiated: 1/19/2024 Completed: 1/20/2024 o Licensed nursing staff with direct involvement in the resident care in question during the time noted in the immediate jeopardy ruling will receive one on one education if still in employment of facility with return demonstration noted through verbal and written understanding in educational interactions and competency evaluation. Initiated: 1/19/2024 Completed: 1/20/2024 o All licensed staff not on duty during above wound prevention, intervention, and treatment education will be checked as noted above prior to returning to the floor for their next scheduled shift. Initiated: 1/19/2024 Completed: 1/20/2024 o Proper wound care treatment, interventions and prevention as well as staff training competency in wound care and immediate implementation of skin/wound needs will be reviewed by the QAPI committee x 3 months and changes to the plan will be made as needed. Initiated: 1/19/2024 Completed: 1/20/2024 o The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/19/2024 Completed: 1/19/2024 Monitoring of the plan of removal was completed on 01/21/2024 and revealed the following: Review of the facility's POR for F600 reflected: Administrator and DON were both in-serviced by the VP for operation and RNC on prevention of pressure ulcer and infection from developing dated 01/19/2024. In-services initiated on 1/19/2024 for identification of pressure injury risk factor and interventions for risk factors. Documentation of Resident's Braden scale and Resident's skin assessments initiated on 01/19/2024. Post test was conducted on 1/20/2023 covering Infection control, identifying pressure injury risk factors and interventions, Braden Scale, abuse and neglect. During an interview on 01/21/2024 at 12:31 pm, RN I revealed she worked at the facility for five months. RN I also revealed staff have been in-serviced every day. RN I explained staff were in-serviced by the DON, ADON, MDSN, RNC, and TLVN T. RN I revealed staff were in-serviced on wound care, protocols, standing orders, chain of command, what to do when new orders were received, new skin issues, relaying communications to the nurse, nurse relating communications to all reporting parties, and infection control related to handwashing, g-tube medication administration, wound care and orders. RN I revealed staff were required to perform a return demonstration in which they took a test and were scored on performance. RN I also revealed staff took exams on abuse and neglect after given examples of abuse and neglect. RN I explained staff talked about how not catching something could affect a resident, such as nutrition affecting wound healing, not redirecting, and not educating residents. RN I further explained the body would shut down with poor nutrition. RN I also revealed staff were taught how not performing assessments or observing residents could affect the resident. RN I revealed staff were also taught the Braden scale (a scale used to determine who was at risk for developing pressure ulcers) and preparing the scale when there was a change of condition or new change of condition observed during skin assessment. RN I also revealed staff were taught how to locate standing orders for pressure ulcers. RN I revealed she performed a skin assessment on a newly admitted resident and taught a new employee how to perform the protocol. During an interview on 01/21/2024 at 12:50 pm, CNA L revealed staff have been in-serviced by the ADM, DON, and ADON about five times since the surveyors entered the facility on 01/18/2024. CNA L revealed staff were in-serviced on abuse, letting management know if observed something and did not report, skin care, skin change, reporting to nurses when residents did not eat or drink, infection control, such as making sure staff checked residents' skin during showers, immediately reporting any skin changes to the charge nurse, and making sure staff washed their hands when working from one resident to another and performing one task to another. CNA L also revealed nurses were[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for pressure ulcer care. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital 01//2024 due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on 01//2024 and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on 01/16/2024. An Immediate Jeopardy (IJ) was identified on 01/19/2024 at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:10 pm. While the IJ was removed on 01/21/2024 at 4:35 pm the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm that is not immediate jeopardy due to all staff not being trained by 01/21/2024 at 4:35 pm. These failures placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings included: Record review of Resident #71's undated face sheet reflected she was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency (vitamin deficiency), unspecified pain, and type 2 diabetes mellitus with unspecified complications. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 did not have any unhealed pressure ulcers/injuries and no other skin problems. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 had one unstageable pressure ulcer/injury and a diabetic foot ulcer. Staff were required to provide Resident #71 with nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, and application of dressings to feet (with or without topical medications). Record review of Resident #71's acute care plan, dated 12/13/2023, reflected Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Review of Resident #71's comprehensive care plan dated 11/1/2023 reflected Nutritional Status for Resident #71 was at risk for trending weight loss, edited 12/28/2023 reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident #71's Braden scales for predicting pressure sore risk, dated 05/18/2023, 05/25/2023, 06/01/2023, 06/08/2023, 09/08/2023, 11/22/2023, 12/28/23 and 01/12/2024, reflected a score of 9 (with 9 or less indicating very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 at risk for developing pressure ulcer or injuries). Record review of Resident #71's weight reflected the following: 06/02/2023 weight of 160 pounds 09/01/2023 weight of 148 pounds, -5 pounds in a month 10/01/2023 weight of 143 pounds, - 17 pounds in 4 months 11/01/2023 weight of 130 pounds, -13 pounds with 9.9% within a month 12/01/2023 weight of 125 pounds, -5 pounds in 1 month 01/01/2024 weight of 118 pounds, -7 pounds in 1 month Resident had a total of 42 pounds weight loss from 06/02/2023 to 01/01/2024. Record review of Resident # 71's Dietician note, dated 11/03/2023, reflected: Resident with continued weight loss; Significant weight loss -8.33% x 90 days· Record review of Resident #71's wound notes reflected Resident #71's foot wound developed on 12/13/23. Record review of Resident #71's acute Care Plan dated 12/13/2023 revealed Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident # 71's physician orders reflected Resident #71 was not ordered any supplements for wound healing. Record review of Resident #71's wound care notes dated 12/22/2023 reflected: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes dated 12/29/2023 reflected: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes dated 01/02/2024 reflected: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. MAR reflected the medication was given from 01/06/2024 through 01/10/2024. Record review of Resident #71's wound care notes dated 01/09/2024 reflected: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size is 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound noted also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Bactrim was discontinued and Keflex 500mg 1 PO X 10 days started on 01/11/2024. Review of Resident #71's physician orders reflected nutritional supplements to promote wound healing were not stated until 01/10/2024. Record review of Resident #71's Medication administration record reflected the following: Prostat 30ml to promote wound healing 1 x day dated 01/10/2024. Multivitamin with mineral 1 x day dated 01/10/2024. Vitamin C 1 x day dated 01/10/2024. Record review of Resident #71's wound care notes also reflected Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days was discontinued on 01/11/2024 and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated 1/12/2024 reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's progress reflected Resident #71 was discharged to the local hospital ER on [DATE]. Record review of the Resident #71's nurse's notes dated 1/12/24 at approximately 3:51pm written by LVN Y reflected per Resident #71's family's request, Resident #71 was sent to the local hospital ER 1/12/24 for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous, with exudative drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated 1/13/24. Record review of Resident #71's [NAME] blood Cell count (WBC) dated 01/12/2024 reflected a value of 22.0 mm (high), normal range 4.5-11.0 (White blood cells- they defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range is 3.4 to 5.4 g/dL ( If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) During an interview with Resident #71's family member on 1/18/24 at 10:28am, Resident #71's family revealed Resident #71 expired on 1/18/24 at approximately 4:00am. Review of Resident #71's death certificate reflected Resident #71 died on [DATE] with causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Review of Resident # 85's undated face sheet revealed a [AGE] year-old female with admission date of 12/12/2023. Diagnoses include anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) subsequent encounter for closed fracture with routine healing. Review of Resident # 85's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no impairment. It was also reflected Resident #85 was at risk of developing pressure ulcer, dependent for lower body dressing and putting on or removing footwear. Review of Resident # 85's acute Care Plan revealed dated 12/13/2023 reflected Resident #85 had skin issue at left tibia. Record review of Resident #85's wound doctor's notes dated 12/22/2023 reflected: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's wound doctor's notes dated 12/29/2023 reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated 01/02/2024 reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated 01/03/2024 reflected: chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress notes dated 01/08/2024 at 10:00pm written by RN I reflected: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records dated 01/17/2024 reflected Resident # 85 was admitted due to sepsis of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA (Methicillin-resistant Staphylococcus aureus- infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used ), Klebsiella (infections commonly occur among sick patients in healthcare settings who are receiving treatment for other conditions) and pseudomonas on 01/09/2024. Blood culture also positive for MRSA on 01/09/2024. Status post hardware removal, washout, and external fixation on 1/10/2024, wound vac change on 1/12/2024. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done 1/16/2024. Review of Resident # 87's undated face sheet revealed a [AGE] year-old male with admission date of 12/26/2023. Diagnoses include Unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, pain unspecified. Review of Resident # 87's admission MDS assessment dated [DATE] revealed a BIMS score of 15. It also reflected Resident #58 was dependent for upper and lower body dressing, at risk for developing pressure ulcer. Review of Resident # 87's acute Care Plan dated revealed Resident #87 had skin condition on his buttock, middle back and left Achilles. Review of Resident #87's comprehensive care plan dated 01/18/2024 revealed Resident #87 required assistance with ADLs, resident at risk for pressure ulcer, resident is limited in mobility all or most of the time. Review of Resident #87's wound care notes reflected wound on Resident #87 buttocks was first seen on 12/31/2023. Review of Resident #87's wound care notes dated 1/16/2024 reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note dated 01/02/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note dated 01/09/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's clinical records revealed he was not ordered nutritional supplements until 01/12/2024. Record review of Resident #87's physician orders reflected an order dated 01/12/2024 for: Liquid Protein Fortifier (protein hydrolysate, milk) liquid; 1 gram-4 kcal/6 ml; amt: 30ml; oral Vitamin C (ascorbic acid (vitamin c)) tablet; 500 mg; amt: 1 tab; oral Twice A Day Zinc-220 (zinc sulfate) capsule; 50 mg zinc (220 mg); amt: 1 tab; oral Once A Day Record review of Resident # 87's wound doctor's note dated 01/16/2024 reflected: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs. x 7 days pending culture results. During an interview on 01/18/2024 at 10:28 am, Resident #71's family revealed Resident #71 passed away at the hospital on [DATE] at 4:00 am due to sepsis and wound infection. Resident #71's family also revealed Resident #71 had no infections when she was admitted to the facility and developed infections at the facility. Resident #71's family revealed they did not know Resident #71 had wounds on one of her feet. Resident #71's family also revealed they requested staff to send Resident #71 out to the hospital because they felt Resident #71 was in pain, TLVN S informed her that Resident #71 was crying in pain, felt Resident #71 needed pain relief, and did not want to wait for the culture test results to determine if Resident #71 needed to be sent out. Resident #71's family also revealed they observed Resident #71's foot on 01/12/2024, it was black and the tendons were exposed when hospital staff observed her foot. During an interview on 01/18/2024 at 11:06 am, TLVN S revealed she worked at the facility for five years. TLVN S also revealed she was responsible for providing daily wound care, such as changing dressings, daily cleanings, following MD's orders, providing treatment and contacting the NP and/or WCD if there was an infection. TLVN S did not know if Resident #71 had any infections when she was admitted to the facility. TLVN S revealed a nurse informed her that Resident #71 had a spot on her several weeks ago. TLVN S explained Resident #71's heel spot worsened a few days later. TLVN S revealed she tried to apply triad paste to Resident #71's heel and place Resident #71 on the WCD's rounds. TLVN S described Resident #71's wound as boggy. TLVN S revealed Resident #71's wound began to get bigger. TLVN S also revealed the WCD last rounded on Resident #71 on 01/09/2024. TLVN S also revealed she last observed Resident #71's wound when she was treating the heel and necrotic ankle on the right foot on 01/10/2024. TLVN S revealed she observed Resident #71's right foot, from ankle to the front part of the foot, turned into one big wound that was red, sloughy (yellow), boggy, and the skin was macerated white and peeled back on 01/12/2024. TLVN S revealed she did not observe black on Resident #71's wound, but she did observe black on the wound areas treated. TLVN S also revealed Resident #71's family informed her that they were sending Resident #71 out to the hospital on [DATE]. During an interview on 01/18/2024 at 11:39 am, TLVN T revealed she worked at the facility for almost three years. TLVN T also revealed she was responsible for taking care of residents' wounds, notifying residents' families, NP, WCD, and MD of any changes of condition in residents' wounds, and communicating updates with wound care. TLVN T revealed Resident #71 did not have wounds on her bilateral heel, ankle, interior ankle, and left ischium when she was admitted to the facility. TLVN T did not know if Resident #71 had any infections when she was admitted to the facility. TLVN T also did not know when she first observed those wounds. TLVN T revealed Resident #71 started off with wounds on her bilateral heel, ankle, interior ankle, and left ischium. TLVN T revealed daily wound care was given to Resident #71 according to physician's orders. TLVN T revealed she last observed Resident #71's wound on 01/02/2024, which were stable and had some necrotic tissue and slough. TLVN T revealed there were no culture tests taken to determine how Resident #71 developed wounds and infections. TLVN T revealed TLVN S informed her last week that Resident #71's wounds rapidly deteriorated. TLVN T revealed RN I, who covered for wound care nurses during their absence, took a wound culture of Resident #71's foot on 01/11/2024. TLVN T revealed the root cause for Resident #71 developing wounds was due to nutrition. TLVN T was not sure what caused Resident #71's ankle infection. During an interview on 01/18/2024 at 1:20 pm, the WCD revealed he worked for the facility for a little over one year. The WCD also revealed he was responsible for managing residents' wound care and measuring wounds. The WCD did not know if Resident #71 was admitted with wounds and infections. The WCD revealed Resident #71 was very unhealthy, morbidly obese and developed wounds on legs and buttocks. The WCD did not know he started rounding Resident #71's wounds. The WCD revealed Resident #71 had pretty bad wounds and possibly severe PAD. The WCD revealed Resident #71's wounds deteriorated. The WCD also revealed Resident #71 was not eating or drinking well. During an interview on 01/18/2024 at 3:05 pm, RN I revealed she worked at the facility for five months. RN I revealed she was responsible for monitoring and conducting wound care when the wound care nurses were absent. RN I explained TLVN S and the other floor nurses were also responsible for wound care. RN I revealed she was trained in wound care. RN I did not know when she was last in-serviced on wound care. RN I revealed she was in-serviced on dressing changes in November 2023 by TLVN T. RN I also revealed she did not observe Resident #71 had wounds when she started her employment. RN I did not know when Resident #71's wounds developed. RN I revealed Resident's left foot and bottom hip area were treated and the right ankle and right heel wounds were present the first week of January 2024. RN I revealed she observed Resident #71 did not have any odors to her wounds, the wounds were smaller, and had no drainage on either 01/06/2024 or 01/07/2024. RN I did not know who was the wound care nurse who provided care to Resident #71 on 01/04/2024. RN I also revealed she last observed Resident #71's wounds on the right heel, right foot, left ankle, possibly left heel, possibly left knee, and hip sacral area on 01/11/2024. RN I revealed Resident #71's wound had an odor, was bigger, dark colored, saggy and had lots of drainage on 01/11/2024. RN I also revealed she was informed by TLVN T that she had an order to obtain a wound culture from Resident #71's foot on 01/11/2024. RN I revealed Resident #71 had weight loss. RN I explained Resident #71 ate and had an appetite, but she sometimes did not eat because of the food. RN I explained Resident #71 was still losing weight. RN I revealed staff addressed Resident #71's weight loss with the NP, wound care nurses, and family. RN I revealed Resident #71 was given health shakes by medication aides and nurses. An observation of wound care performed by TLVN S on Resident #87 on 01/19/2024 at about 7:45 am revealed TLVN S was assisted by a CNA E. TLVN S gathered supplies outside the room. TLVN S and the CNA E walked into Resident #87's room and performed hand hygiene. Resident #87 was rolled on his right side. TLVN S donned clean gloves, removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively, and had both soiled dressings on her hand. The soiled dressings from both of Resident #87's wounds contained serosanguineous drainages and was dated 01/18/2024. TLVN S did not change her soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and a gauze with her soiled gloved hands and then moved to Resident #87's wound at his buttocks with the same normal saline and gauze. TLVN S again did not change her gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using the same soiled gloved hand fingertips, and then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to the wound bed and back to middle of the back. TLVN S then changed her soiled gloves, did not perform hand hygiene and donned clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. During an interview on 01/19/2024 at 09:26 am, TLVN S said she started about 2 months ago. She rounded with the wound doctor 01/09/2024 and did wound care on Resident #71 on 01/12/2024. TLVN S stated Resident #71's wound had gotten worse, the right foot was macerated, and the dressing was saturated with greenish drainage (like pseudomonas) with foul odor. Resident #71 was not on any supplements for wound healing since her foot wound started two months ago. She also stated the new DON brought to her attention that Resident #71 needed to be on protein supplement and vitamins to aid in her wound healing. TLVN S stated Residents #71, 85, and 87 were at risk for developing pressure ulcers due to her medical conditions such as immobility. TLVN S also stated Resident #71, 85 and 87 should have been on supplements for her wound healing. During an interview on 01/19/2024 at 10:34 am, the DON stated Braden scale assessment should be done upon admission, monthly, when there is check skin issues, nutritional changes to make sure the individual was not declining. The DON stated, if a Resident's Braden scale reflects high risk for pressure ulcer development, the facility should consult the dietician for recommendation for supplement due to increased need for protein. The Resident should be turned/repositioned frequently, staff should ensure the Resident is eating, labs such are albumin levels should be check for wound healing. The DON stated nutrition, turning and repositioning play a big role in wound prevention and healing. She stated when she started work at the facility sometimes after 01/08/2024, while reviewing wound care documents, she realized Residents with wounds were not on nutritional supplements for wound healing and recommended that those Residents be order supplements. She stated she was not sure why those residents were not on nutritional supplements. During an interview on 01/19/2024 at 1:17 pm, the RNC said she was the providing supervision for the new DON. The RNC stated the Braden Scales was used to identify resident at risk for skin breakdown, less than 12 is high risk, the lower the number the higher the risk. The RNC stated the categories of the Braden scale were, moisture, activity, mobility, nutrition, friction, and shear. She also stated, when a resident is at high risk, a look back at the category that was triggered to determine the intervention. The RNC stated Braden scale were done upon admission, quarterly and with change of condition. She stated Resident #71's Braden Scales scores were 9 throughout her stay in the facility, Resident #71 was contracted and unable to move for a long time. The RNC stated for a resident with weight loss who developed a wound, the dietician needed to be notified of the wound development, but the dietician was not made aware of Resident #71's wound development. She stated Residents with pressure ulcer required supplemented protein to promote wound healing and Resident #71 had nutritional deficit and so she needed more protein. During an interview on 01/19/2024 at 4:42 pm, TLVN T revealed she provided wound care to Resident #85. TLVN T also revealed Resident #85 was sent to the hospital on [DATE] because staff thought her wound was infected. TLVN T revealed Resident #85 did not return since being discharged to the hospital. TLVN T also revealed Resident #85 had a wound in her left leg. TLVN T did not know what interventions were implemented for Resident #85's wound care. During an interview on 01/19/2024 at 2:01 pm, the NP stated she usually do not order medications or treatments for wounds because there was a wound doctor. The NP also stated for Residents with wounds, were ordered Vitamin C, liquid protein, and zinc. The Dietitian was also made aware to ensure the resident was getting the right intake. The NP stated once the wounds were developed and identified those medications should have started. The NP stated she ordered Remeron (Appetite stimulant) to help with nutrition as well. During an interview on 01/24/2024 at 3:05 pm, the Licensed Dietitian stated she visited the facility on 12/20/23, and the wound on Resident #71's foot was identified on 12/15/23, but no one told her about it then. The LD stated she received a wound report from the facility on 12/26/23, and Resident #71's wound was not on it. The LD stated If she had known Resident #71 had a wound, she would have looked at protein by adding prostat (liquid protein) during medication administration, started multivitamins and seeing if the facility was doing CBC and BMP. Review of facility's policy dated April 2018 titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). .In addition, the nurse shall describe and document/report the following: .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. .The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. .Beyond trying to maintain a stable weight and providing approximately 1.2-1.5 gm/kg protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer. .Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. Review of facility's policy dated April 2018 titled Prevention and Screening - Clinical Protocol reflected: Where medically indicated and accepted by the resident or a substitute decision-maker, the attending physician will identify primary, secondary, and tertiary preventive and screening measures. .The physician will order lab screening tests that are relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications. .The staff and physician will address ethical issues related to situations where residents decline, to receive, or are unlikely to benefit from screening, preventive measures, or aggressive medical interventions. Review of facility's policy dated March 2020 titled Pressure Injuries Overview reflected: The purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries. .A pressure injury will present as intact skin and may be painful. .A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. .Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Review of facility's policy dated September 2017 titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol reflected: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to ensure dietitian interventions of increased tube feedings and speech therapy were implemented when Resident #71 had a 10% weight loss in November 2023, leading to an overall weight loss of 32% from July 2023 to January 2024. Resident #71 also developed pressure wounds on her foot and hip that worsened, and she died on [DATE]. The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 01/17/24. The facility had corrected the noncompliance before the survey began. The failure placed residents at risk of unplanned weight loss, malnutrition, worsening of wounds, and death. Findings included: Review of the undated face sheet for Resident #71 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), hemiplegia (paralysis on one side of the body), aphasia (loss of speech), dysphagia (swallowing difficulties), diabetes mellitus, and Bell's palsy (weakness or paralysis of facial muscles). Review of the quarterly MDS for Resident #71 dated 12/21/23 reflected she could not participate in the BIMS assessment. The Swallowing and Nutrition section included a trigger for 5% or more weight loss in the previous month or 10% in the previous six months. It reflected she received nutrition by feeding tube and had a mechanically altered diet. It reflected she received 25% or less of her daily nutrition by tube. The section for Skin Conditions reflected she had one unstageable pressure ulcer. Review of the care plan for Resident #71 dated 12/28/23 reflected the following: Category: Nutritional Status Resident is at risk for trending weight loss. Resident will consume 75-100% of meals over the 90-day review period. 1. Serve resident food preferences. 2. Assess resident for food preferences. 3. Monitor dietary intake. 4. Offer supplements between meals to enhance caloric intake. 5. Offer substitute if less than 50% of meal is consumed. 6. Offer oral hygiene before meals. Category: Feeding Tube Resident requires feeding tube R/T PRN use for bolus secondary to poor appetite. Resident will not exhibit signs of complications from feeding tube or enteral feeding solution. Check placement and patency of feeding tube before each feeding or medication administration. Check placement and patency of feeding tube every shift and PRN. If tube should become clogged follow protocol and notify MD. Category: Nutritional Status Resident requires a mechanically altered diet R/T dysphagia/aphasia. Resident will eat 50-75% of meal. Diet: Puree with NTL. Encourage oral intake of food and fluids. Monitor and record intake of food. Review of weights for Resident #71 reflected the following, which constituted a 32% weight loss over the six-month period: 07/01/23 156 lbs. 08/04/23 143 lbs. 09/01/23 148 lbs. 10/01/23 143 lbs. 11/01/23 130 lbs. 12/01/23 125 lbs. 01/01/24 118 lbs. Review of the LD notes for resident #71 dated 11/16/23 reflected the following: Follow up regarding significant weight loss times 30, 90, 180 days; diet: purée NTL (may have moist, minced texture with supervision upon request); has varied 50 to 100%; previously had a nocturnal feeding, but D/C due to being too full from feeding to be able to eat PO. Eats meals in main dining room, sometimes requests for mech soft when nurse present for supervision and set up help; scoop plate added 9/28/23 at all meals; Receives one can ensure daily by mouth. Weight: November weight 132 pounds, down 9 pounds X 30 days; -7.69% X 30 days, -13.16% X 90 days, -18.01 X 180 days; BMI 23.4 within normal limits; this week is down to 128 pounds 11/16/23 Labs 8/16/23 CMP reviewed glucose 115+ Plan: 1. SLP to evaluate and consult family for signing waiver for mechanical 2. Add one can Glucerna 1.2 bolus QID at p.m. between meals, regardless of meal intake. Goal: to halt, weight, loss, maintain weight; improved intake, at least 75% or more daily. Review of the LD notes for Resident #71 dated 12/20/23 reflected the following: December 8 125 pounds, down 5.3% times 30 days, -15.54% times 90 days, -21.88% times 180 days; BMI 22.1 WNL; weight loss of 23 pounds in the past three months. Glucerna 1.2 bolus QID provides 1140 kcal, 57 g PO, 768,CH20+150 CQ shift equals 1368 cc water minimum. Review of the physician orders for Resident #71 dated December 2023 reflected the following: Monitor and document meal intake, breakfast luncheon dinner three times a day after meals if less than 50% of meal eaten give one carton of Glucerna 1.2 Cal via nutrition bolus start date 11/06/23. Review of all the speech therapy notes for Resident #71 from May 2023 through January 2024 reflected she was discharged from services most recently on 07/19/23. Review of the hospital records for Resident #71 dated 01/12/24 reflected she weighed 118 lbs. at hospital admission. The records reflected she had a surgical history of insertion of feeding device into stomach and introduction of nutritional substance into upper GI started 04/27/23. Lab results from the hospital reflected an albumin level of 1.7 g/dl (reference range 3.4-5.4 g/dl), indicating malnutrition. Review of the death certificate for Resident #71 reflected she died on [DATE] in the hospital. Her cause of death was listed as due to or as a consequence of: cerebral vascular accident, sepsis, and infected hip and foot pressure ulcers. During an interview on 01/24/24 at 03:05 PM, the LD stated she had been made aware that Resident #71 had several nursing concerns related to wound care and that she went to the hospital and died. The LD stated she had been stressing with nursing department to get her recommendations to the physician so they could be ordered. The LD stated she frequently recommended interventions, but she was limited in that she could not write orders, so implementation had been a challenge. The LD stated Resident #71 triggered as having significant weight loss over several months with the first occurrence of significant weight loss in November 2023. She stated each week the clinical team met Mondays for weight meetings, and the LD was not in the facility on Mondays, so the LD met the previous Director of Nursing on a different day of the week, depending on the week. The LD said she met with the DON each week and went through everybody with her and asked questions about how her residents had been, and they talked about interventions. The LD stated she had this procedure with the previous Director of Nursing who was on probation and let go. The LD stated Resident #71 would not eat well on pureed foods, and the LD recommended Resident #71 see the SLP to evaluate for mechanical soft meals with one-to-one supervision. The LD stated Resident #71 would have eaten better on that, but she needed to be supervised, as she had some dysphagia. The LD clarified that her recommendations during that period were for Resident #71 to meet with SLP, have her diet upgraded if the family agreed, have the family sign a waiver for an upgraded diet if they need a waiver, and to make sure that regardless of her meal intake, she would get a bolus feeding between meals. The LD stated during interviews with staff, she determined that, when the bolus feedings were dependent on percentage eaten, Resident #71 was not getting them frequently. The LD stated she wanted to make sure Resident #71 received the feedings regardless of intake, because there was still weight loss. She stated she added the recommendation, and it should have become and diet order change on 11/16/23 from based on meal intake to scheduled no matter what. When the LD came back the following month, Resident #71 was still losing weight, as much as 10 lbs per month, so the LD determined Resident #71 should go back on full controlled bolus feedings four times per day. The LD stated she made this recommendation on 12/20/23. The LD stated the facility did not request any additional consults with her in December, and Resident #71 continued to lose weight. The LD stated when the current DON started on 01/08/24, she had to have done an audit immediately, because the LD was called the next day and informed her recommendations had not been implemented for Resident #71. The LD stated in turn, she performed an in-service for all management staff related to the procedure for requesting a consult and the procedure for implementing her recommendations. The LD stated she reminded them about the policy and procedure of contacting her, what issues needed contact and how urgently, and her recommendations: who would be putting them in the system and who was responsible for implementing them. She stated she felt the nursing staff were now on the right page with her. She stated the previous DON seemed burned out, and the LD would go back and check to make sure things had been implemented, and they would not have been implemented. The LD stated the responsibility for placing the orders was with the previous Director of Nursing. The LD stated when she spoke to the previous Director of Nursing and said, hey I've asked you a couple times, this hasn't gone through, the previous Director of Nursing said, don't worry we are placing it. The LD stated the SLP evaluation, and both the increases in bolus feedings for Resident #71 were not implemented when she made the recommendations. She stated she performed an audit of all her recommendations on 01/09/24, and those for Resident #71 were the only ones that had not been implemented. During an interview on 01/25/24 at 09:49 AM, the SLP stated Resident #71 had been on speech therapy from her admission to the facility in May 2023 until July 2023. The SLP stated there had not been another request for an evaluation since then. She stated she was aware from their meetings that the family was unsure whether Resident #71 should upgrade to a mechanical soft diet and finally refused to sign a waiver allowing Resident #71 to eat mechanical soft foods. She stated that was the family's decision and she would have liked the opportunity to educate the family but that did not happen. The SLP said the way she usually found out that she needed to conduct an evaluation for therapy services was that nursing would notify her. She stated no one notified her from any department that the LD had recommended an evaluation for services for Resident #71. During an interview on 01/25/24 at 10:23 AM, the MDSN stated Resident #71 did not like the purée food and wanted to eat regular food. The MDSN stated the family was educated about the risks of upgrading her diet to mechanical soft and did not want to sign a waiver. The MDSN stated they noticed the weight loss at the end of October 2023 and early November 2023. The MDSN stated after the new DON started on 01/08/24, one of the first things she looked at was weight loss in the facility, and they discovered there had been a miscommunication with who was handling the dietitian interventions. The MDSN stated, as a result of the miscommunication, Resident #71 did not receive the interventions recommended by the dietitian. The MDSN stated prior to the new DON discovering this problem, the MDSN's part was to input the weights and report to the rest of the clinical team who triggered for significant weight loss. She stated the former DON was supposed to be doing the rest, which included referring for a dietitian consult, referring to speech therapy, requesting the physician order supplements or additional tube feedings. The MDSN stated since thy discovered the problem, they had developed a plan where the MDSN handled all the communication to and from the dietitian and speech therapy. The MDSN stated the DON would take over if the MDSN was unavailable. The MDSN stated she was responsible for the entire weight loss monitoring program since 01/17/24. She stated the outcome of a failure to identify and address unplanned weight loss for residents could be infection, immunocompromise, skin breakdown, heart failure, kidney failure, or death. During an interview on 01/25/24 at 10:26 AM, the RNC stated she had started working in the facility in July 2023 and began going through several system audits. She stated she quickly discovered unplanned weight loss in the facility was higher than the national average and developed a PIP to address the weight loss. The RNC stated the former Director of Nursing at the time was responsible for the weight loss program and was struggling to maintain oversight on the program. The RNC stated after their PIP was put in place, the former Director of Nursing, who was on a probationary status, was terminated. The RNC stated when they hired the current DON, she began reviewing the systems and paid particular attention to the weight loss program, as there was already a PIP in place. The RNC stated the DON immediately discovered the issue with Resident #71, unfortunately the discovery came after the resident had already lost so much weight. The RNC stated they found dietitian recommendations from November and December 2023 that had not been implemented for Resident #71. The RNC stated when the failure was identified, the LD immediately did in-servicing, they added the failure to the PIP, and assigned the entire weight loss program to the MDSN with the DON as a backup. During an interview on 01/25/24 at 10:43 AM, the DON stated she had started in her position on 01/08/24 and had immediately looked over systems and programs and discovered that Resident #71 had several dietitian recommendations that had not been implemented. She stated after completing her audit, she did not identify any other residents who went without the LD recommendations being audited, but Resident #71 had already lost additional weight at that point. The DON stated the tube feedings for Resident #71 should have increased in November to be scheduled regardless of meal intake and instead the order remained tube feedings between meals only if Resident #71 ate less than 50% of her meal. The DON stated she did not remember exactly how much weight loss Resident #71 had, but it was a lot. The DON stated at that point, she worked with the RNC to develop a new program that had the MDSN responsible for the entire weight loss system. The DON stated the MDSN had already been responsible for inputting weights and communicating to the rest of the IDT if there was significant weight loss, but under the new plan, the MDSN would also be responsible for requesting the dietitian consults, communicating the dietitian recommendations to the physician, and ensuing the orders were entered and started after the physician approved them. She stated the system had been fully in place since 01/17/24 with all pertinent staff in-serviced. She stated she in-serviced the nursing, therapy, and kitchen staff on the new plan as well as several other related in-services such as identifying changes in skin color and turgor, wound care, abuse and neglect protocol, and resident rights. During an interview on 01/25/24 at 03:57 PM, the ADON stated she had been in-serviced on or around 01/17/24 by the LD on the dietitian communication process and by the DON on supplements, nutrition, weight loss, reporting changes, and skin conditions. During an interview on 01/25/24 at 04:01 PM, the MD stated she had been notified of the failures related to Resident #71's nutrition and had participated in creation of the PIP related to weight loss in the facility as well as the additions when it was discovered that Resident #71 did not have her dietitian recommendations ordered. She stated she had reviewed all the dietitian recommendations as part of the plan to correct the issue, and all recommendations had been ordered. She stated she could not think of any recommendations she did not agree with. She stated the plan to correct the failures was effective to the best of her ability to tell, though they would continue monitoring for effectiveness. Review of a PIP dated 10/25/23 with a revision on 01/09/24 and a target date of 02/01/24 reflected the following: Problem We have a high rate of acute weight loss for the month of September. 6.7%. Goals To decrease the rate of weight loss. Benchmark goal is less than 2%. Action 1. Monthly weights to be obtained and analyze by the fifth of each month. 2. Data that meets the significant change criteria will be addressed within variance report with documentation of interventions, notification of RP/family and position. New form created an in-service [NAME] administrative nursing staff. 3. Weekly weights will be reviewed and analyze by DON or designate timely and intervene accordingly. 4. DON or designee to hold a monthly IDT meeting by the 12th of each month. 5. DON to send monthly meeting to Regional Nurse Consultant by the 15th of each month. 6. Admin to ensure monthly meeting is being held. 7. Admin to place action plan in QPI for three months 8. Communication with RD to coordinate recommendations for November, December 9. Weight monitoring to correspond with dietitian and report Review of in-services provided by the LD on 01/25/24 reflected the following two in-services dated 01/17/24, each signed by management staff: 1. Upon completion of the report, the consultant dietitian will email a copy to the facility, staff, as well as the assessments. The report includes: -Cover sheet -Internal compliance -Recommendations -Assessments The entire report will be printed and filed in the designated facility binder under the appropriate month. A copy of the fax recommendations is to be placed in the designated physicians box to be evaluated and signed off on. After the recommendation is signed on by the physician, it is to be ordered and then placed in the resident medical chart under the dietary tab. 2. Facility nursing staff is to notify the consultant dietitian when: -There are physician orders for a dietitian consult -A resident has significant weight loss -Changes in diet or supplementation -A new admission and readmission -A resident has a new area to skin -Any other dietary comments/concerns Ways to contact: Email went not urgent and would like the consultant to review on next visit Examples: -New tube feed patient with orders -Physician order for dietitian consult -Diet or supplementation change -Monthly significant weight loss report -Monthly skin report -Dietary questions/concerns Text or phone call when Examples: -New to feed patient without orders -Family member present at facility with more urgent concern -State surveyors are present Your current consultant dietitians: (Contact information for the LD and an alternative if cannot contact primary for any reason). Review of the facility audits for significant weight loss January 2024 reflected six residents still having significant weight loss. Review of a facility audit performed on 01/10/24 for orders for all six residents still triggering for Weight Loss in January 2024 reflected all dietitian recommendations had been ordered and implemented. Review of the physician orders cross-referenced with dietitian recommendations for the six residents triggering for Weight Loss on the facility CMS-802 matrix dated 01/23/24 reflected all recommendations had been ordered. Review of a facility audit of all residents in the facility with pressure wounds conducted on 01/10/24 reflected three residents with sounds had not been ordered supplements such as protein supplement and multivitamins. Each of these three residents received new orders for supplements between 01/10/24 and 01/14/24. Review of physician orders dated 01/25/24 for all residents with pressure ulcers in the facility reflected they each had orders for protein and vitamin supplements. Review of facility policy dated September 2017 and titled Nutrition (Impaired)/Unplanned Weight Loss reflected the following: Assessment and Recognition 1. The nursing staff will monitor and document, the weight and dietary intake of residents in a format which permits comparisons overtime. 2. The staff and physician will define the individuals, current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight, loss or gain, and significant risk for impaired nutrition. 3. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. 4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline, appetite, or food intake. Treatment/Management 1. The staff and physician will identify pertinent intervention based on identified causes and overall resident condition, prognosis, and wishes. a. Treatment decisions should consider all [NAME] evidence and relevant issues. (e.g. food intake, resident/patient wishes, overall condition and prognosis, etc.) and should not be based solely on lab or diagnostic test results. 2. The physician will authorize appropriate interventions, as indicated. a. This may include tapering, stopping, or switching medications known to be associated with undesirable weight gain or anorexia or weight loss. b. The physician will document specific interventions could not be identified or not feasible. 3. The staff and physician will review and consider existing dietary restrictions and modified consistency diets. Monitoring 1. The physician and staff will monitor nutritional status, and individuals, response to interventions, and possible complications of such interventions. The Administrator was informed the of the past noncompliance at the Immediate Jeopardy level on 01/25/24 at 04:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services in accordance with professional standards of practice for 1 (Resident # 87) of 2 residents observed for wound care by 1 (Wound care nurse A) of 1 wound care nurse reviewed for competency, in that: 1) TLVN S did not perform hand hygiene and change her gloves while performing wound care on Resident #87 on 01/19/2024. TLVN S also performed wound care on Resident #87's two wounds at the same time. The facility failed to ensure TLVN S, TLVN T and RN I had skills and competencies completed to perform wound care on 01/19/2024. An IJ was identified on 01/19/2024 at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:03 pm. While the IJ was removed on 01/21/2024 at 4:35 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices placed residents at risk for infections, sepsis, a diminished quality of life and death. Findings included: Record review of Resident # 87's undated face sheet reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses including unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, and pain unspecified. Record review of Resident # 87's admission MDS assessment, dated 01/02/2024, reflected a BIMS score of 15, which indicated Resident #87 had no cognitive impairment. Record review of Resident # 87's acute care plan reflected Resident #87 had skin condition on his buttock, middle back, and left Achilles. Record review of Resident #87's comprehensive care plan, dated 01/18/2024, reflected Resident #87 required assistance with ADLs, he was at risk for pressure ulcer, and limited in mobility all or most of the time. Record review of Resident #87's wound care notes reflected the wound on Resident #87 buttocks was first seen on 12/31/2023. Record review of Resident #87's wound care notes, dated 01/16/2024, reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note, dated 01/16/2024, reflected the following: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs x 7 days pending culture results. During wound care observation on 01/19/2024 at about 7:45 am by TLVN S on Resident # 87. TLVN S was assisted by CNA E. TLVN S gathered supplies outside the room, both staff walked into Resident # 87's room and performed hand hygiene. Resident # 87 was rolled on his right side. TLVN S donned (put on) clean gloves removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively and had both soiled dressing in her hand. Soiled dressings from both wounds contained serosanguineous (is a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) drainages and dated 01/18/2024. TLVN S did not change soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and gauze with soiled gloved hands then move to Resident # 87's wound at his buttocks with same normal saline and gauze. TLVN S again did not change gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using same soiled gloved hands fingertips, then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to wound bed and back to middle back. TLVN S then changed soiled gloves, did not perform hand hygiene and don clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. During an interview on 01/19/2024 at 9:26 am, TLVN S started by saying, I know I messed up on the first wound care with Resident #87, I read my binder after we were done and know exactly where I messed up. TLVN S stated when performing wound care on a resident with multiple wounds, it should be done one at a time. TLVN S stated going back and forth from one wound to the other was cross contamination. TLVN S stated, after she took the soiled dressing from Resident #87's wounds, she was supposed to remove soiled gloves, perform hand hygiene, and don clean gloves. TLVN S stated every time you remove a gloves hand hygiene was performed because of cross contamination. TLVN S stated, I was just putting the germ back in Resident #87's wounds, I did hand hygiene at the beginning and at the end of the procedure. During an interview on 01/19/2024 at 10:34 am the DON stated hand hygiene was to be done with each resident's contact, with every glove change and when the glove was visibly soiled it should be changed and hand hygiene performed. The DON stated, for residents with multiple wounds, wound care is done one at the time. You address one wound, once you are done, you perform hand hygiene, change gloves, and get to the other wound because you do not want to contaminate the wounds. The DON stated hand hygiene id done for cross contamination prevention and stop infection introduction into the wound. She stated, once there is not one dressing, the expectation is each wound should be treated individually. During an interview on 01/19/2024 at 1:17 pm the RNC she was the providing supervision for the new DON. The RNC stated hand hygiene is done anytime a staff move from clean to dirty, prior to touching the clean, with glove changes to prevent the spread of infection. She stated, after removing the soiled dressing, remove gloves and perform hand hygiene to decrease the risk of infection, once the soiled dressing was removed, staff hands were considered dirty. The RNC stated when doing wound care with a resident with multiple wounds, each location should be treated as a separate treatment. The RNC stated moving from one wound to the other increase the risk of cross contamination. During an interview on 01/19/2024 at 2:01 pm the NP stated when performing wound care on a resident with multiple wounds, the staff should work on one wound complete it before going to the next, wound. She stated if one wound has infection, it will be transmitted to the next wound. The NP stated she expect the wound care nurse to follow the right procedure in wound. Record review of TLVN S, TLVN T and RN I 's personnel files revealed all 3 staff did not have competency skilled completed for wound care or hand hygiene. Interview on 01/19/2024 at 1:17 the RNC stated competencies skills check offs are done upon hiring and annually. She stated the DON or designee was responsible to ensure competencies were done for all staff. She stated competencies were to ensure the nurses were up to date on latest policy and procedure regarding a specific skill. The RNC stated she checked Wound care nurses A, B, and C's personnel's files and did not see competency check off for all 3 wound care nurses. Record review of facility's policy and procedure, revised May 2019, titled, Staff Development Program, reflected: All personnel must participate in initial orientation and regularly scheduled in-service training classes. Staff development is defined as initial orientation, followed by regularly scheduled in-service training. Programs. .The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care. .All Staff Development classes attended by the employee are entered on the respective employee's Employee Training Attendance Record by the Department Director or other person(s) designated by that director. .Records are filed in the employee's personnel file or maintained by the Department Director. Record review of facility's undated competency check off, titled, Clean dressing change check off, reflected: Verify orders and assemble supplies and equipment needed. .Knock - Provide privacy and explain procedure. .Wash hands. .Set up clean and dirty areas. .Put on clean gloves. .Remove soiled dressing and discard. .Wash hands and put on clean gloves. .Clean wound using circular motion starting from the inside working outward. . Remove gloves and sanitize hands. .Put on clean gloves to continue with the dressing. .Discard used items. .Wash hands. . Sign TAR/Document observations. MUST MAINTAIN CLEAN TO CLEAN AND DIRTY TO DIRTY AREAS DURING PROCEDURE. Record review of facility's policy and procedure, dated August 2019, titled, Handwashing/Hand Hygiene, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; Before donning sterile gloves; Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, After removing gloves; These deficient practices resulted in the identification of an IJ on 01/19/2024 at 5:10 pm. The ADM was notified and provided with the IJ template on 10/19/2024 at 5:10 pm. The following Plan of Removal submitted by the facility and accepted on 01/21/2024 at 8:33 am: PLAN OF REMOVAL F726 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Regional Director of Operations re-educated Administrator on ensuring competency of nursing staff completed 1/19/2024. Regional Nurse Consultant for facility reinforced and re-educated Director of Nursing and Assistant Director of Nursing on ensuring competency of nursing staff completed 1/19/2024. Licensed facility personnel to perform completion of competency evaluation as noted by competency skills checklist by 1/19/2024. DON/designee to have completion of competencies with emphasis on wound management on all licensed nursing personnel by 1/19/2024. Re-education of all licensed staff members began per DON/ADON and designees on areas of competencies noting concern following performance of skills checklist 1/19/2024. Interventions and Monitoring Plan to Ensure Compliance Quickly: o o The facility will have policy for competencies for nursing staff to be obtained on hire and at least annually with re-education to be performed as noted by competency check. Initiated: 1/19/2024 Completion: 1/20/2024. o o Audit of all existing and newly hired nursing staff to be performed weekly by DON and/or designee, as well as Human Resources Director to ensure completion of timely competency checks with documented competencies to be placed in employee files. Initiated: 1/19/2023 Completion: 1/20/2024. o o Any nursing staff identified through competency checks to require acute training or re-education will have education performed prior to presenting on shift until such time as competencies are adequate. Initiated: 1/19/2024 Completion: 1/20/2024. o Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee for any nursing staff receiving re-education or training on competencies not found to be proficient. Staff that are on leave from the facility will be given the competencies check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 1/19/2024 Completion: 1/20/2024. o o The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for competencies to include Administrator for continuum of care to be documented through signed attendance sheet in morning stand up. Initiated: 1/19/2024 Completed: 1/20/2024. o o Audit sheets for competencies on nursing staff to be reviewed by DON/ADON for completion at least weekly with indication of last performed check off. Initiated: 1/19/2024 Completed: 1/20/2024. o o The policy and procedure for competencies of licensed personnel to be reviewed by Regional [NAME] President of Operations and RNC with any changes to policies to be implemented. Initiated: 1/19/2024 Completed: 1/20/2024. o o Licensed nursing staff with direct involvement in the resident care in question during the time noted in the immediate jeopardy ruling will receive one on one education if still in employment of facility with return demonstration noted through verbal and written understanding in educational interactions and competency evaluation. Initiated: 1/19/2024 Completed: 1/20/2024. o o All licensed staff not on duty during competency check off will be checked as noted above prior to returning to the floor for their next scheduled shift. Initiated: 1/19/2024 Completed: 1/20/2024. o o The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/19/2024 Completed: 1/19/2024. The survey team monitored the Plan of Removal on 01/21/2024 as followed: Record review of POR FOR 726 reflected the following: MD was notified of the IJ s on 1/19/2024. The Administrator and DON were both in-serviced by the VP for operation and Regional Nurse consultant on the competencies required of all licensed nursing staff to provide safe and proper care of residents. Re-education on proper procedure for wound care. Re-education on proper ways to prevent pressure ulcers and infections from developing. Re-education on abuse and neglect initiated on 01/19/2024. Staff competencies was initiated on 1/19/2024 for hand hygiene and wound care. Staff in-service on wound care, Wound care protocols, hand hygiene, skin and wound resources initiated on 1/19/2024. Infection control posttest initiated on 1/20/2024. During an interview on 01/21/2024 at 12:31 pm, RN I revealed she worked at the facility for five months. RN I also revealed staff were in-serviced every day by the DON, ADON, MDSN, RNC, and TLVN T about wound care, protocols, standing orders, and chain of command. RN I revealed staff were trained on what to do when they received new orders, new skin issues, relaying information to the nurse, and the nurse relaying information to all parties. RN I also revealed staff were trained on infection control concerning hand washing, wound care, and orders. RN I revealed staff also performed return demonstration and took a test that was scored. RN I also revealed staff were taught how to locate standing orders for pressure ulcers. During an interview on 01/21/2024 at 12:50 pm, CNA L revealed staff were in-serviced by the ADM, DON, and ADON about five times since the surveyors were at the facility. CNA L also revealed staff were required to be at the facility on 01/22/2024 for a meeting. CNA L revealed staff were also in-serviced on infection control and taught to wash their hands when working from one resident to another resident and when working on one task to another task. During an interview on 01/21/2024 at 1:04 pm, CNA K revealed she worked at the facility for four months. CNA K stated, We have been in-serviced on a lot of things. CNA K explained staff were in-serviced by the ADM, DON, and ADON on infection control related to keeping hands clean and washing hands with soap and water and using hand sanitizer. CNA K further explained staff had to demonstrate washing their hands while being monitored. CNA K stated, First was your hands before going to the resident and wash your hands after care. During an interview on 01/21/2024 at 1:16 pm, RN Q revealed he worked as a PRN RN for about one year. RN Q also revealed staff talked about the check offs that needed to be done. RN Q explained he completed the check off on hand washing. RN Q also revealed he was provided a handout about infection control that he had not complete yet. During an interview on 01/21/2024 at 1:28 pm, LVN O revealed she worked at the facility for about one year. LVN O also revealed she was in-serviced by the ADM on skin issues and pressure ulcers on 01/20/2024. LVN O revealed staff were also in-serviced by the DON and ADON about the new plan for skin and orders to use for skin. LVN O also revealed the DON and ADON also provided a detailed skin assessment. LVN O revealed the DON and ADON also covered infection control, hand hygiene, using hand sanitizer, washing hands when visibly soiled and using hand sanitizer when not visibly soiled. LVN O also revealed staff did a check off on wound care and hand hygiene. During an interview on 01/21/2024 at 1:40 pm, TLVN T revealed she was in-serviced by the DON and ADON on 01/20/24. TLVN T also revealed the DON and ADON talked about wound care and infection control. TLVN T revealed she also did a return demonstration on wound care and infection control protocols. TLVN T also revealed the DON and ADON also talked about the proper techniques based on the check list and a form for demonstration, wound care protocol, and orders. TLVN T revealed she sent a mass communication to all the nurses. TLVN T also revealed the DON and ADON talked about wound protocol related to nutritional status. TLVN T revealed she was working with the wound doctor to approve the protocol. TLVN T also revealed the DON and ADON reviewed the highlights where the nurses failed, reasons for not going from one wound to the other, better monitoring systems, treatments to suggest to the wound care nurses, changing gloves, hand hygiene, and cross contamination prevention. TLVN T revealed TLVN S and her were both part time wound care nurses. TLVN T also revealed the DON was new and put in place a lot. TLVN T revealed she performed a demonstration with staff on wound care, how to change gloves, when to wash hands, addressing wounds one at a time, and starting the process over when addressing each wound. During an interview on 01/21/2024 at 2:01 pm, the ADON revealed she was in-serviced by TLVN T and the DON on 01/19/2024. The ADON also revealed the DON went over with all the nurse on wound care, hand washing, and infection control. The ADON revealed staff did check offs on wound care and hand washing. The ADON also revealed staff had to also demonstrate to TLVN T on what to do. The ADON revealed staff also talked about the importance of gloving, hand hygiene, treating each wound as a separate entity due to cross contamination and the importance of changing the gloves for cross contamination. The ADON also revealed TLVN T was trained the night shift nurses and aides. The ADON revealed she had a copy of the new wound protocol, interventions and was taught to inform the WCD wounds were stageable. During an interview on 01/21/2024 at 2:18 pm, the DON revealed she was in-serviced by the RNC and trained on infection control during her hiring process and on 01/19/2024. The DON also revealed she started to in-service staff on hand hygiene, infection control, and wound care. The DON revealed hand hygiene was performed before and after resident care. The DON stated, Treat everybody's body fluid as infectious. The DON also revealed hand hygiene was performed when hands were soiled, removing barrels, and coming into contact with body fluid. The DON revealed hand hygiene was also performed before, during and after removing soiled dressings and before donning gloves during wound care. The DON also revealed staff were to use alcohol-based hand rub or soap and water before going to another resident. The DON revealed all nurses at the facility had been given wound care and infection control competency before their work shifts. An observation of 400 hall on 01/21/2024 at 3:20 pm revealed CNA P was sanitizing her hands with hand sanitizer along the hall. During an interview on 01/21/2024 at 3:20 pm, CNA P revealed she was in-serviced by the DON and ADM on 01/20/2024. CNA P explained the DON told her to notify a charge nurse if she saw anything related to skin, bruising, change of condition, or decreased PO intake. CNA P further explained the DON told her to notify the ADM or the DON if nothing is done after bringing the observations to the charge nurse's attention. CNA P revealed she was also trained on infection control and hand hygiene. CNA P stated, Protect yourself and the residents. Touch the residents with clean hands. During interviews on 01/21/2024 from 3:30 pm through 3:42 pm, two residents revealed staff performed wound care and completed a skin assessment. During an interview on 01/21/2024 at 3:59 pm, RN R revealed she worked at the facility for almost one year. RN R also revealed she completed skin assessments on shower days and was taught to inform the DON and perform skin care if she observed any skin changes. RN R revealed she was also taught how to identify residents at risk of developing skin breakdown. RN R also revealed she was taught infection control protocols, such as sanitizing her hands, washing her hands, and changing gloves before, during, and after care and whenever her gloves were soiled. RN R also revealed she was taught to treat one wound at a time to prevent the spread of infection when performing wound care on a resident with multiple wounds. RN R revealed she checked off on wound care, infection control, hand hygiene, and had to demonstrate the protocols and take a test after being in-serviced on the topics on 01/20/2024. During an interview on 01/21/2024 at 4:12 pm, the ADM revealed he was in-serviced by the VPFO and RNC on 01/19/2024 on staff competencies, infection control, pressure ulcer assessment prevention, and wound care. The ADM also revealed the DON, ADON, and TLVN T in-serviced staff on clinical topics and were trying to ensure all staff were in-serviced and trained before their work shift. The ADM revealed all residents had skin assessments and Braden Scales completed and new protocols for wound and skin care were implemented. The ADM also revealed the DON and designee would conduct the audit and he would verify daily. The ADM explained he and the DON would review weekly to make sure protocols and interventions were put in place and effective. The ADM also explained he and the DON decided to change specific treatment plans for each resident because the general care was not effective for all residents. The ADM revealed he notified the MD, and the next meeting was scheduled for 01/24/2024. The ADM was notified on 01/21/2024 at 4:35 pm that the IJ was removed. The facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The survey team returned to the facility on [DATE] to complete a full recertification survey, and the following observations, interviews, and record reviews were conducted. Review of undated Face Sheet for Resident #73 reflected she was admitted to the facility on [DATE] with diagnosis of Klebsiella pneumoniae (a type of gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis), unspecified malignant neoplasm (history of cancer), Depression, Thrombocytosis (a disorder in which your body produces too many platelets), Nutritional deficiency, and Pressure ulcer of sacral region stage 4. Review of Resident #73's Care Plan for Pressure Ulcer/Injury dated 12/06/23 reflected Resident #73's ulcer will not exhibit signs of infection by keeping Resident #73 as clean and dry as possible and minimize skin exposure to moisture, and keep linens clean, dry, and wrinkle free. Review of the Quarterly MDS assessment for Resident #73 dated 12/06/23 reflected a BIMS Score of 12/15, which reflected moderate impairment in mental status. Resident #73 required one-person assistance for ADLs. Observation on 01/24/2024 at 9:52am revealed TLVN S helped turn the resident to the resident's right side. It was observed that resident was laying on an uncovered mattress. TLVN S performed hand hygiene and wore a pair of clean gloves and removed the previous dressing on both the upper back and on the sacrum of the resident. Both dressing was not dated and initialed. Both dressings had trace of drainage on the outer side of the dressing. TLVN S discarded the removed dressing into the trash and disposed the gloves and performed hand hygiene with the use of hand sanitizer. No barrier was placed between the resident and mattress. TLVN S wore new pair of clean gloves and cleansed the upper back wound with saline and gauze. TLVN S disposed the gauze and saline into the trash and did not remove the glove and did not perform hand hygiene and continued to place new dressing onto the upper back wound. TLVN S then disposed the gloves into the trash and did not perform hand hygiene and walked out of the resident's room to gather more supplies to dress the sacrum wound. TLVN S touched the doorknob from inside of the room and touched the treatment cart to gather the supplies. TLVN S returned to the resident's bedside and placed the supplies on the side table with all the previous supplies that was gathered by the TLVN S. TLVN S then performed hand hygiene and wore pair of clean gloves and cleansed the wound on the sacrum. TLVN S dispose the gauze and saline into the trash and removed the gloves and performed hand hygiene with use of hand sanitizer. TLVN S then wore a new pair of clean gloves and dressed the wound and initialed and dated both the dressings. TLVN S repositioned the resident back to the uncovered mattress. In an interview on 1/25/24 at 4:05 PM, TLVN S stated she had worked at the facility consecutively for 1 year. TLVN S stated she had 2 years of additional wound care experience prior to that. TLVN S stated the facility had not initially given her training on the wound care role, and that training happened later. When asked who had provided her job description and responsibilities, TLVN S stated, I am not going to give you that. TLVN S further stated that the 2 old dressings removed from Resident 73's wound did not have a date or initial. TLVN S stated that she had trained another nurse the day before and that nurse had failed to label the dressings. TLVN S refused to name the nurse she had been training. TLVN S stated that she was at the bedside with the nurse in training, but she said, neither of us had a pen on us. TLVN S stated that labeling dressings was really important to know if a dressing was done daily and for drainage amount. TLVN S stated the date would indicate the when the dressing was last changed. TLVN S was asked why she did not remove her gloves between cleaning the wound with saline and applying the new dressing. TLVN S's response was, if you say I didn't, then I didn't, and I did not realize that. When asked why she did not sanitize after removing treatment gloves to go to the supply cart, TLVN S stated she did sanitize before she went to the treatment cart to gather more supplies. TLVN S then stated that before going to the treatment cart she should have sanitized and that I did not know that I didn't. TLVN S stated it is important to complete hand hygiene, so there was no contamination. TLVN S said', you don't know if something is growing in a wound and it can contaminate every surface we touch TLVN S agreed the treatment cart may have possibly been contaminated. TLVN S stated the mattress of the resident did not have a sheet because it was a low air loss mattress. When asked why there was no barrier placed between the draining wound and the mattress, TLVN S stated, I failed to do so and further stated that if copious drainage was on the mattress it could intermingle with the new dressing. TLVN S stated she was provided enough supplies and her last infection control in-service was Friday 1/19/24 with the DON. TLVN S stated the in-service was verbal and reading training with neither observation nor return demonstration completed. TLVN S stated the DON was the infection preventionist. TLVN S stated the initials on her badge were WSOC and that indicates she has a Wound, Skin, Ostomy Care Certification. In an interview on 1/25/24 at 4:25 PM with DON revealed the policy says to provide care and do good hand hygiene. DON stated her staff should use alcohol base hand care between residents or if hands visibly soiled, you should use soap and water. DON stated her expectation was staff should provide good hand hygiene when going from dirty to clean when providing wound care, and if hand hygiene was not done by staff, the potential outcome would be infection to a wound. DON stated infection control was not just for resident but for staff who can take infections home to their family members DON stated there was no excuse not to sanitize hands, as she gives them hand sanitizer. DON stated staff were in-serviced less than a week ago and last month. Interview on 1/26/24 at 11:05 AM with ADM revealed his expectation when wound care is completed, dirty PPE items are removed properly, and hand hygiene, including handwashing or sanitization, occurs. ADM stated once the staff hands were clean and sterile, he expects that they then go to the clean side. ADM stated his expectation is for this to repeat - when going from clean to dirty, they change their PPE, hand wash, or sanitize, and repeat. ADM stated a potential negative outcome of not following this process could be infection or disease. ADM stated staff have been in-serviced previously, and re-educated recently, on wound[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 (Resident #71, #85 , and #87) of 24 residents reviewed for infection control, in that: 1. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on [DATE]. 2. TLVN S did not perform hand hygiene and change her gloves while performing wound care on Resident #87 and performed wound care on two wounds at the same time while performing wound care on Resident #87. 3. LVN M did not wash her hands with soap and water after picking up feces with gloves and discarding the feces and gloves on [DATE] at 9:05 am. 4. CNA C and D failed to perform hand hygiene while serving lunch on [DATE] to Resident #31, 47, 75, 12, 25, 46, 392, 391, and 393. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:10 pm. While the IJ was removed on [DATE] at 4:35 pm the facility remained out of compliance at a scope of pattern no actual harm that is not immediate jeopardy, due to all staff not being trained by [DATE] at 4:35 pm. These deficient practices placed residents at risk for infections, sepsis, and a diminished quality of life and death. Findings included: Record review of Resident #71's undated face sheet reflected a [AGE] year-old female who was originally admitted to the facility on [DATE], re-admitted on [DATE] with diagnoses including history of stroke, cerebral infarction due to unspecified occlusion (blockage or closing) or stenosis (narrowing) of unspecified cerebral artery, pressure ulcer of left hip stage 3, pressure ulcer of unspecified heel unstageable, nutritional deficiency (Vitamins deficiecy, unspecified pain, and type 2 diabetes mellitus with unspecified complications, and discharged on [DATE]. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 did not have any unhealed pressure ulcers/injuries and no other skin problems. Record review of Resident #71's quarterly MDS, dated [DATE], reflected Resident #71 had one unstageable pressure ulcer/injury and a diabetic foot ulcer. Staff were required to provide Resident #71 with nutrition or hydration intervention, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, and application of dressings to feet (with or without topical medications). Record review of Resident #71's acute care plan, dated [DATE], reflected Resident #71 had pressure ulcer at her buttock, right lateral ankle and right knee. Record review of Resident #71's comprehensive care plan, edited [DATE], reflected Resident #71 will not develop skin breakdown related to incontinence. Record review of Resident #71's Braden scales for predicting pressure sore risk, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], reflected a score of 9 (with 9 or less indicating very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 at risk for developing pressure ulcer or injuries). Record review of Resident #71's wound notes reflected Resident #71's foot wound developed on [DATE]. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Left Ischium unstageable measuring 4.6 x 3.4 cm. Left heel diabetic wound measuring 4x4 cm x unstageable. Right heel diabetic wound measuring 4 x 2.5 x unstageable. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Left Ischium unstageable measuring 4.5 x 3.5 cm. Left heel diabetic wound measuring 3.5 x 3.5 cm x unstageable. Right heel diabetic wound measuring 4 x 1.5 x unstageable. Resident #71's wound notes also reflected an order for cipro (Antibiotics are medicines that fight bacterial infections in people and animals) 500mg PO BID X 7 days for wound infection. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Right lateral ankle diabetic wound measuring 3 x 3 cm x unstageable. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 3 x 3 x 2 cm. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable. Resident #71's wound noted also reflected an order Doxycycline (Antibiotics are medicines that fight bacterial infections in people and animals.) 100 mg PO BID X 10 days for wound infection. Record review of Resident #71's wound care notes, dated [DATE], reflected the following: Right lateral ankle diabetic wound measuring 8 x 4.5 x unstageable. (Size was 2.6 times the previous week). note indicated the wound was deteriorating. Left Ischium unstageable measuring 4.5 x 3.5 cm, note indicated the wound was deteriorating. Left heel diabetic wound measuring 2 x 1 cm x unstageable. Right heel diabetic wound measuring 4 x 1.2 cm x unstageable, note indicated the wound was deteriorating. Resident #71's wound care notes also reflected an order Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days for wound infection. Review of Resident #71's wound care notes also reflected Bactrim DS (Antibiotics are medicines that fight bacterial infections in people and animals.) PO BID X 7 days was discontinued on [DATE] and new order for Keflex 500mg 1 tab PO every 12 hours x 10 days, wound culture to right ankle. Resident # 71's wound care notes dated [DATE] reflected, patient seen by facility treatment nurse for daily wound care, left foot has deteriorated a great deal: Record review of Resident #71's progress notes reflected Resident #71 was discharged to the local hospital ER on [DATE]. Record review of the Resident #71's nurse's notes, dated [DATE] at approximately 3:51 pm, reflected per Resident #71's family's request, Resident #71 was sent to the local hospital ER on [DATE] for further assessment of her right foot. Record review of Resident #71's hospital records, reflected Resident #71 was admitted to the local hospital on [DATE] with diagnoses including sepsis secondary to infected left buttock decubitus ulcer and right leg ulcer. Resident #71's hospital records also reflected, integumentary: Warm, Dry, multiple skin ulcers of the bilateral heels of the feet, right knee area medially. 4-inch diameter deep ulcerated wound on the left buttock, which is malodorous (smelling, very unpleasant), with exudative (he slow escape of liquids from blood vessels through pores or breaks in the cell membranes) drainage. minimal surrounding erythema at the wound edges . There was concern for foul-smelling exudate from the left buttock wound and internal medicine was asked to hospitalize. Records also reflected Resident #71 had status post right below-knee amputation dated [DATE]. Record review of Resident #71's WBC, dated [DATE], reflected a value of 22.0 mm (high), normal range 4.5-11.0 (WBC- defend your body against infections and disease. But, when there are too many white blood cells, it usually means you have infection or inflammation in your body): Albumin level 1.7 (low) normal range was 3.4 to 5.4 g/dL (If you have a lower albumin level, you may have malnutrition. It can also mean that you have an inflammatory disease, most cases of low albumin are caused by acute and chronic inflammatory responses.) Record review of Resident #71's death certificate reflected Resident #71 died on [DATE] with the causes of death being cerebral vascular accident, sepsis, infected hip, and foot pressure ulcer. Record review of Resident # 85's undated face sheet reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses including anemia, unspecified, fracture of shaft of left tibia (the shinbone, the larger of the two bones in the lower leg.) and subsequent encounter for closed fracture with routine healing. Record review of Resident # 85's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which indicated she had no cognitive impairment. Record review of Resident # 85's acute care plan, dated [DATE], reflected Resident #85 had skin issue at her left tibia. Record review of Resident #85's wound doctor's notes, dated [DATE], reflected the following: Wound location- Left Tibia sign of infection -none measuring 6.6 x 8.0 cm x 0.2 cm exudate: scant, serous dressing used: Calcium Alginate with Honey, Dry Dressing Record review of Resident #85's wound doctor's notes, dated [DATE], reflected the following: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 x 1.3 cm. exudate: moderate, Serosanguineous, yellow Doxycycline 100mg 1 PO BID x 10 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) Dressing used: Bactroban, Calcium Alginate Record review of Resident #85's wound doctor's notes dated [DATE] reflected: Wound location- Left Tibia sign of infection -drainage measuring 6.1 x 8.1 cm x 2.9 cm. exudate: moderate, Serosanguineous, yellow extend Doxycycline total 14 days. (Antibiotics are medicines that fight bacterial infections in people and animals.) dressing used--Collagen, Bacitracin and Cal alginate. Record review of Resident #85's NP progress notes dated [DATE] reflected the following: Chief Complaint/Reason for this Visit: Follow up on Left lower leg surgical wound infection. Patient was started on doxycycline for surgical wound infection. Wound care following. Vitals are stable per staff. Continue to monitor. Record review of Resident #85's progress noted, dated [DATE] at 10:00pm, reflected the following: Resident complained of increased drainage and warm to touch at wound care sight, upon assessing, removed bandage, wound care sight is red, warm to touch, pus, and has an odor . resident and family requested to go to the hospital. Another note with same date and time reflected the following, Resident family came to the nurses' station and asked if I could assess the resident's leg. The charge nurse from the hall and I assessed the resident, odor and brownish drainage leaking from the wound. After taking dressing out, scopious pus on the wound, this nurse did the treatment as order and charge nurse informed NP and sent Resident to ER. Record review of Resident #85's local hospital records, dated [DATE], reflected Resident # 85 was admitted due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) of left lower extremity and bacteremia (the presence of bacteria in the blood). Resident #85's hospital records also reflected left lower extremity tissue culture was positive for MRSA, Klebsiella, and pseudomonas on [DATE]. Blood culture also positive for MRSA on [DATE]. Status post hardware removal, washout, and external fixation on [DATE], wound vac change on [DATE]. ORIF (Open reduction and internal fixation is a type of surgery used to stabilize and heal a broken bone) and PRS (Plastic and reconstruction surgery) closure was done [DATE]. Record review of Resident # 87's undated face sheet reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses including unspecified open wound of left back wall of thorax without penetration into thoracic cavity, subsequent encounter, and pain unspecified. Record review of Resident # 87's admission MDS assessment, dated [DATE], reflected a BIMS score of 15, which indicated Resident #87 had no cognitive impairment. Record review of Resident # 87's acute care plan, dated, reflected Resident #87 had skin condition on his buttock, middle back and left Achilles. Record review of Resident #87's comprehensive care plan, dated [DATE], reflected Resident #87 required assistance with ADLs, he was at risk for pressure ulcer, and limited in mobility all or most of the time. Record review of Resident #87's wound care notes reflected the wound on Resident #87 buttocks was first noticed by staff on [DATE]. Record review of Resident #87's wound care notes, dated [DATE], reflected an order for Cipro 500 mg (Antibiotics are medicines that fight bacterial infections in people and animals.) PO every 12 hours x 7 days. Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: Mild, Serous measuring 8.0 x 7.1x 0.1 cm Wound location: middle back Sign of infection: None odor: None exudate: none measuring 2.5 x 0.5 cm x unstageable Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: None odor: None exudate: mild, Moderate, Serous measuring 8.1 x 6.8 x 0.2 cm Wound location: middle back Sign of infection: None odor: None exudate: Mild, Moderate, Serous measuring 1.9 x 0.9 x 0.8 cm Record review of Resident # 87's wound doctor's note, dated [DATE], reflected the following: Wound location: Bilateral Buttocks Sign of infection: drainage odor: None exudate: moderate, serous, green measuring 8.1 x 5.1 x 0.3 Wound location: middle back Sign of infection: drainage odor: None exudate: mild moderate, serous, green measuring 2.2 x 0.6 x 0.7 cm Cipro 500mg (Antibiotics are medicines that fight bacterial infections in people and animals.) 1 PO q12 hrs x 7 days pending culture results. An observation of a photograph from Resident #71's family, taken on [DATE] at 9:07 pm, reflected Resident #71's right foot. Resident #71's right foot was black and peeled from the bottom of her heel to above the ankle. Resident #71's right ankle bone was white and yellow and peeled. During an interview on [DATE] at 10:28am, Resident #71's family revealed Resident #71 expired on [DATE] at approximately 4:00 am due to sepsis and wound infection. Resident #71's family also revealed Resident #71 developed wound infections at the facility because she had no infections when she was admitted to the facility. Resident #71's family explained staff contacted them a few months ago (they could not indicate how many months or exact date of contact) and requested permission to treat Resident #71's wounds, which they granted permission. Resident #71's family revealed they did not know Resident #71 had a would on one of her feet. Resident #71's family explained they observed Resident #71's foot in the hospital on [DATE] and described the foot was black. During an interview on [DATE] at 11:06 am, TLVN S revealed she worked at the facility for five years. TLVN S explained she was responsible for providing daily wound care and cleaning, such as dressing changes and treatment, following wound care doctor's orders, and contacting the wound doctor and/or NP if there was an infection. TLVN S revealed a nurse (whose name she did not know) informed her several weeks ago (she could not provide the exact date or how many weeks ago it was) that Resident #71 had a spot on her heel. TLVN S explained Resident #71's spot on her heel worsened a few days later (she could not provide the exact date or how many days later it was). TLVN S explained she tried to apply triad paste to Resident #71's heel and placed Resident #71 on the wound doctor's rounds. TLVN S described Resident #71's heel was boggy (she did not define boggy). TLVN S explained Resident #71's wound began to get bigger. TLVN S revealed she observed Resident #71's right foot on [DATE] and described the ankle to front part of the foot as red, sloughy (yellow), boggy, macerated white skin, and the skin peeled back since her last observation on [DATE]. TLVN S revealed she did not observe Resident #71's wound as black on [DATE]. TLVN S also revealed Resident #71's family informed her on [DATE] that they were sending Resident #71 to the hospital. TLVN S revealed she received a photo from Resident #71's family on [DATE] in which she observed Resident #71's foot was black, and the infection spread from Resident #71's foot up to Resident #71's ankle. TLVN S also revealed she learned Resident #71 was septic and sepsis could cause an infection to spread. TLVN S did not know if Resident #71 had infections when Resident #71 was admitted to the facility. TLVN S revealed she first observed Resident #71's ankle and heel last week (she did not indicate the exact date or day). During an interview on [DATE] at 11:49 am, TLVN T revealed she worked at the facility for more than two years. TLVN T also revealed she was responsible for taking care of wounds and notifying residents' families, NP, and WCD of any changes of condition in residents' wounds. TLVN T revealed Resident #71 started off with wounds on her bilateral heel, ankle, interior ankle, and left ischium and TLVN T did not know when she first observed the wounds on Resident #71. TLVN T also revealed Resident #71 did not have the wounds when she was admitted to the facility. TLVN T did not know if Resident #71 was also admitted with infections. TLVN T revealed Resident #71 received daily wound care according to the physician's orders. TLVN T also revealed she last observed Resident #71 on [DATE], in which Resident #71's wounds were stable and had some necrotic tissue and slough. TLVN T revealed TLVN S informed her last week (she did not indicate the exact date or day) that Resident #71's wounds rapidly deteriorated. TLVN T also revealed the WCD visited the facility once a week. TLVN T did not know what cause Resident #71's ankle wound infection. During an interview on [DATE] at 1:20 pm, WCD revealed he worked for the facility under a contract for over one year. WCD also revealed he was responsible for managing residents' wound care. WCD revealed Resident #71 developed wounds on her legs. WCD also revealed Resident #71's wounds deteriorated. WCD did not know if Resident #71 was admitted to the facility with wounds and infections and when he started visiting and providing wound care to Resident #71. During an interview on [DATE] at 3:05 pm, RN I revealed she worked at the facility for five months. RN I also revealed she was trained and in-serviced on wound care and changing wound dressings. RN I also revealed she was responsible for monitoring and conducting wound care. RN I revealed she last observed Resident #71 on [DATE]. RN I explained Resident #71 had a wound on her right heel, right foot, left ankle, possibly left heel, possibly left knee, and hip sacral area. RN I also revealed she did not observe Resident #71 had wounds when she began her employment. RN I revealed she observed Resident #71 wounds had an odor, were dark colored, saggy, and had lots of drainage on [DATE]. RN I also revealed Resident #71 did not have any odors to her wounds, the wounds were smaller, and had no drainage on [DATE] or [DATE]). RN I did not know who the wound care nurse was who provided wound care to Resident #71 the week before [DATE] because TLVN T was out sick. RN I revealed wound care nurse A, her, and the other floor nurses were responsible for wound care. RN also revealed when she went to get a culture from Resident #71 on [DATE], she observed Resident #71 had drainage and the wound was bigger than on [DATE] or [DATE]. RN I did not know if Resident #71 was prescribed antibiotics and when Resident #71's wound developed. RN I revealed Resident #71's left foot and bottom hip area were treated; the right ankle and right heel wound were still present the first week of [DATE]. RN I also revealed Resident #71's right heel looked bigger when comparing first week of January to [DATE]. RN I revealed the other wounds did not have a change in status or condition when comparing first week of January to [DATE]. An observation of wound care performed by TLVN S on Resident #87 on [DATE] at about 7:45 am revealed TLVN S was assisted by a CNA. TLVN S gathered supplies outside the room. TLVN S and the CNA walked into Resident #87's room and performed hand hygiene. Resident #87 was rolled on his right side. TLVN S donned clean gloves, removed soiled dressing from the wounds on Resident #87's middle back and buttocks respectively, and had both soiled dressings on her hand. The soiled dressings from both of Resident #87's wounds contained serosanguineous drainages and was dated [DATE]. TLVN S did not change her soiled gloves or perform hand hygiene. TLVN S cleaned Resident #87's wound on his middle back with normal saline and a gauze with her soiled gloved hands and then moved to Resident #87's wound at his buttocks with the same normal saline and gauze. TLVN S again did not change her gloves or perform hand hygiene, applied medication med-honey to the wound bed at Resident #87's middle back using the same soiled gloved hand fingertips, and then moved to Resident #87's wound at the buttocks with same gloved hands applying med-honey to the wound bed and back to middle of the back. TLVN S then changed her soiled gloves, did not perform hand hygiene and donned clean gloves, and applied dressings on both wounds and dated the dressings. Both staff positioned Resident #87 in his bed, performed hand hygiene, and left Resident #87's room. An observation of 200 hall on [DATE] at 9:05 am revealed LVN M observed feces on the floor. LVN M put on gloves, picked up the feces, put the feces in a bag, discarded the bag of feces, discarded her gloves, used hand sanitizer, and entered a resident's room. The surveyor stopped LVN M before LVN M made physical contact with the resident in the room. During an interview on [DATE] at 9:05 am, LVN M revealed she worked at the facility for over one year. LVN M also revealed she was trained and in-serviced on infection control by the DON and ADON last week (she did not indicate the exact date). LVN M revealed she thought the hand sanitizer was enough hand hygiene to perform after discarding the gloves and feces. LVN M also revealed she usually washed and sanitized her hands and wore gloves before and after contact with each resident. LVN M explained that typically, if the feces was solid, she would try to wash her hands before and after. LVN M revealed she picked up the feces because she observed it on the ground. LVN M also revealed CNAs were responsible for picking up feces. LVN M also revealed if a nurse did not wear gloves and picked up feces, residents' health and wellbeing could be impacted. During an interview on [DATE] at 9:21 am, TLVN S revealed she was trained and in-serviced on infection control by the DON and ADON. TLVN S also revealed she performed hand hygiene before and after contact with each resident. TLVN S revealed she would wash her hands with soap and water even if she used gloves to pick up a resident's feces and discarded the gloves and feces and used hand sanitizer before contacting another resident. TLVN S also revealed residents' health and wellbeing could be impacted, but it depended on the resident. TLVN S revealed a nurse should have washed their hands with soap and water before touching the next resident after picking up feces with gloves and discarding the feces and gloves. During an interview on [DATE] at 9:26 am, TLVN S stated, I know, I messed up on the first wound care with Resident #87. I read my binder after we were done and know exactly where I messed up. TLVN S explained when performing wound care on a resident with multiple wounds, it should be done one at a time. TLVN S further explained going back and forth from one wound to the other wound was cross contamination. TLVN S revealed after she took the soiled dressing from Resident #87's wounds, she was supposed to remove her soiled gloves, perform hand hygiene, and don clean gloves. TLVN S stated, Every time you remove gloves, hand hygiene is performed because of cross contamination. I was just putting the germ back in Resident #87's wounds, I did hand hygiene at the beginning and at the end of the procedure. TLVN S revealed she started rounding with the wound doctor on [DATE] and performed wound care on Resident #71 on [DATE]. TLVN S also revealed Resident #71's wound had gotten worst; the right foot was macerated (becomes soften by soaking in a liquid), and the dressing was saturated with a greenish drainage (like pseudomonas) with a foul odor. During an interview on [DATE] at 9:31 am, RN J revealed she worked at the facility for three years. RN J also revealed she was trained and in-serviced on infection control by the DON and ADON last week. RN J revealed she performed hand hygiene before and after contact with each resident and after resident care. RN J also revealed she would wash her hands with soap and water if she picked up feces with gloves and discarded the feces and gloves because it was feces and could go through gloves. RN J also revealed residents' health and wellbeing could be impacted if a nurse contacted them after picking up feces with gloves, discarding feces and gloves, and using hand sanitizer. During an interview on [DATE] at 9:37 am, LVN N revealed she worked at the facility for two and a half years. LVN N also revealed she was trained and in-serviced on infection control and hand hygiene by the ADON in [DATE] or [DATE]. LVN N revealed she performed hand hygiene all day and all the time. LVN N also revealed she washed her hands anytime she entered a resident's room and before and after contacting a resident. LVN N revealed she would wash her hands with soap and water if she picked up feces with gloves and discarded the feces and gloves because the feces could have gotten on the hands. LVN N also revealed residents' health and wellbeing could be impacted if a nurse picked up feces with gloves, discarded the feces and gloves, and used hand sanitizer because of the bacteria from the feces and the feces could have contaminated the nurse's hands. During an interview on [DATE] at 9:42 am, the DON revealed she had worked at the facility for 11 days. The DON also revealed she was trained on infection control and hand hygiene annually. The DON was not sure when staff were last in-serviced on hand hygiene and infection control. The DON revealed she expected staff to wash their hands before and after performing resident care and after resident care. The DON also revealed she expected staff to wash their hands with soap and water whenever their hands were soiled. The DON revealed staff were required to wash their hands with soap and water even after picking up feces with gloves, discarding the feces and gloves, and using hand sanitizer. The DON also revealed staff wore one pair of gloves when providing care to residents and were not allowed to wear two layers of gloves. The DON revealed the gloves staff used had the potential for wear and tear during use. The DON also revealed she encouraged staff to perform hand washing. The DON revealed she expected staff to wash their hands with soap and water if staff picked up feces with gloves, discarded the feces and gloves, and used hand sanitizer before entering another residents' room to provide care to another resident. During an interview on [DATE] at 9:43 am, the RNC revealed if a staff member's hands were not visibly soiled and they used gloves to pick up the feces, using alcohol-based hand rub after discarding the feces and gloves would be appropriate. The RNC also revealed staff wore one pair of gloves when providing care to residents and were not allowed to wear two layers of gloves. During an interview on [DATE] at 9:51 am, the ADM revealed he worked at the facility for over one year. The ADM revealed he was trained on infection control. The ADM also revealed he expected staff to wash their hands with soap and water when dealing with bodily fluids and fecal matter. The ADM revealed it was not proper hand hygiene for staff to pick up feces with gloves, discard the feces and gloves, and use hand sanitizer before contacting another resident. The ADM also revealed residents' health and wellbeing could be negatively impacted by a nurse contacting them after picking up feces with gloves, discarding the feces and gloves, and using hand sanitizer. The ADM revealed he expected staff to wash their hands with soap and water after picking up fecal matter. During an interview on [DATE] at 10:34 am, the DON revealed hand hygiene are to be done with each resident contact, with every glove change, and when the glove is visibly soiled, it should be changed, and hand hygiene performed. The DON stated, For residents with multiple wounds, wound care was done one at the time. You address one wound, once you were done, you perform hand hygiene, changed gloves, and get to the other wound because you do not want to contaminate the wounds. The DON revealed hand hygiene was done for cross contamination prevention and to stop infection introduction into the wound. The DON stated, Once there was not one dressing, the expectation was each wound should be treated individually. During an interview on [DATE] at 11:02 am, LVN N revealed she never performed wound care on Resident #71. LVN N did not know about Resident #71's infections. LVN N revealed Resident #71 had wounds. LVN N also revealed Resident #71 had wounds on the right heel, buttocks area, and lower legs. LVN revealed Resident #71's wounds were not deep. LVN N revealed she assessed Resident #71's dressings and made sure the dressings were dry, clean, and intact. LVN N revealed wound care nurses changed dressings and treated Resident #71's wounds. LVN N also revealed she observed Resident #71 on [DATE]. LVN N revealed she did not observe any odors in Resident #71's room on [DATE]. LVN N explained Resident #71 was sent out to the hospital because TLVN S told her that Resident #71's foot wound spread to her necrotic tissue. LVN N also revealed the WCD visited the facility once a week. LVN N revealed nurses documented any change of conditions with wounds and notified the resident's family or responsible party. LVN N also revealed TLVN S treated wounds daily. LVN N revealed she never worked with Resident #85. During an interview on [DATE] at 11:21 am, CNA E revealed she worked at the facility for four months. CNA E also revealed she was trained and in-serviced on infection control by the ADM and former DON. CNA E revealed the wound care nurses performed wound care treatment. CNA E also revealed Resident #71 had different wounds. CNA E did not know when Resident #71's wounds started. CNA E revealed she observed Resident #71 had a wound on her foot and buttocks. CNA E also revealed she last observed Resident #71's foot wound two weeks ago (she did not indicate exact date) and it looked like condition was not okay. CNA E explained Resident #71's foot wound was not healing, and the condition was worse. CNA E also revealed Resident #71's wound started smelling when she worked with Resident #71

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. 1. R#1 was a resident at the facility for approximately 52 hours (08/10/2023 at 2:30 pm admission through 08/13/23 at midnight AMA) and displayed exit seeking, confused, and questionable cognitive behavior during his admission. 2. R#1 eloped two times within a 24-hr. period, and he was discharged AMA without an assessment and without consulting the facility MD or NP or obtaining an order. An (IJ) Immediate Jeopardy was identified on 08/22/2023 at 5:25 pm While the IJ was removed on 08/24/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for accidents, harm, and/or death. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 pm and discharged on 08/13/2023 at 12:00 am. R#1's face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain. The change is often temporary, but can quickly become life-threatening), tachycardia (an irregular electrical signal (impulse) starting in the upper or lower chambers of the heart causes the heart to beat faster), pancytopenia (low levels of red blood cells, white blood cells and platelets), problems - falls and used an electric wheelchair. Elopement was not listed as a problem. Record review of hospital records dated 07/16/2023 reflect that R#1 was admitted on [DATE] found down at a gas station with DX of sepsis (a serious condition in which the body responds improperly to an infection) due to acute colitis (Infections caused by a virus or a parasite) and metabolic encephalopathy (a problem in the brain), homeless and unable to state where he lives. Review of hospital record dated 07/18/2023 of consultation for purposes of capacity to make medical decisions reflected that the patient was very confused, he actually believed he was in Michigan on two occasions in my interaction. He was unable to identify any kind of date time or situation. He was also very confused about events. The record reflected patient showed poor higher level of thinking as well and processing. R#1 revealed he had been having energy difficulties, concentration concerns, sleep disruption, and psychological factors that impacted his functioning. His affect was blunted, and mood appeared depressed. He was oriented to person, place, and time period with no observable signs of psychosis noted. R#1received a 11 out of 30 on PHQ - 9 (PHQ-9 Quick Depression Assessment) which placed him in mild range of depression. He received a 12 out of 30 on the MSE (mental status exam) which indicated moderate cognition. R#1 struggled with any higher-level processing or understanding of recent medical events. A quick review of his medical issues was provided to the patient; however, the patient could not remember any of these issues after a short delay of interference. Record reflected diagnostic impression of 5. delirium secondary to his general medical condition and to rule out dementia/neural cognitive defects 6. anxiety order, not otherwise specified 7. rule out adjustment disorder 8. alcohol use disorder- in full remission per patients report Treatment recommendations. 5. Followed with one-to-one psychotherapy for management of mood while hospitalized . 6. Progress will be assessed with the patient and the staff support. 7. Patient was also assessed for adherence to psychological treatment plan - the patient's mood could impact adherence and consequentially cognitive behavioral therapy will be used to address any issues with adherence 8. The patient is not showing capacity to make medical decisions at this time. Review of hospital record dated 07/24/2023 of psychotherapy one-to-one reflected patient still is as confused as the last interaction and only able to identify he was in the hospital accurately. He still believes he is in Michigan and could not identify place or any aspect time or date. He continued to be confused about why he's in the hospital and recent events. Patient still unable to do any higher-level thinking and could not remember any of the discussion about his medical care after short delay with interference. Mental Status Exam revealed appearance disheveled, oriented to self, mood depressed, affect flat, attitude inhibited, thought content non elicited, insight and judgment both limited and poor. DX assessment plan to rule out Wernicke-Korsakoff syndrome (an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment. It most often happens in people with alcohol use disorder and malnutrition. While there isn't a cure, healthcare providers can recommend treatments to manage your symptoms), apparently patient had a long history of neurocognitive deficits noted at a local homeless shelter and likely patient had at least pre-existing dementia. Patient still not showing capacity make to make medical decisions. Review of hospital progress note dated 08/07/2023 reflected, remains confused. Review of hospital progress note date 08/08/2023 reflected diagnosis assessment of early dementia/anxiety likely a manifestation of B12 deficiency. Patient did not show capacity to make medical decisions, this is likely his baseline cognitive function (measures your brain function in a healthy state). Record review of 08/10/2023 2:20 pm admission nurses note by RN A reflect R#1 had a DX upon admission of altered mental status and was A&O X 3 (alert and oriented to person, place, and time). Record review of 08/10/2023 9:00 pm nurses note by RN A reflect R#1 expressed wanting to leave the facility because of a personal reason. Note reflected he said he would stay the night but would need to leave in the morning. Note reflected that management was notified of his behavior. There are no nurses notes from the facility for 08/11/2023. Interview with RN A revealed on 08/21/23 at 1:10 pm that at 9:00 pm on 08/10/2023, R#1 began to talk about eloping and started wandering and said he had to go but RN A said it was nighttime and it was unsafe for him to leave. She said she texted the ADM that R#1, on admission, did not show any signs of wanting to leave but at approximately 9:00 pm, R1 said he wanted to leave. When asked what ADM's reply was to her text, she said ADM said to redirect him and he would see R1 in the morning. RN A said she does not know if the ADM went to see R1 the next morning. RN A said it is fair to say that there were some concerns about R#1 and elopement. She revealed she did not know about his mental status, but she did try to call the hospital and obtain information, but the hospital did not return her call. When asked why his possession inventory admission sheet was blank, she said he did not have any clothes, he was admitted to the facility from the hospital in a hospital gown and had no belongings to list. Interview with LVN A on 08/12/2023 at 4:32 pm revealed she worked with R#1 on 08/12/2023 in the morning prior to his elopement at approximately 12:30 pm that day. She revealed R#1 was walking around on 400-hallway and pushed up against the bar for the door. She approached him and she said he could not go out. When asked about his mental status she said he was AX3, but he was slow and acted like he did not understand everything she told him. She did not look at his DX but said she thought that he had a DX of dementia or Alzheimer's, and she told the receptionist, who is seated in front of the main entry/exit door, to keep an eye on him. She said all the staff were aware that he was exit seeking. LVN A said she knew he seemed anxious and wanted to leave. LVN A said that when he returned from the first elopement, she texted the NP who ordered labs, to keep him hydrated, issue a WG and conduct Q 15 minutes. When asked again about his mental state, LVN A said R#1 answered all her questions correctly and knew he was in a nursing home but there was something about him that made her think he had cognition issues. Interview with CMA 1 on 08/12/2023 at 11:28 pm revealed she observed R#1 trying to find his way out and when she asked him about why he wanted to leave he said his home was in Michigan and he knew he was not in Michigan. He said that he came to the facility to use the rest room then they would not let him leave. CMA 1 said she felt that he seemed confused she told nurse (nurses name unknown). Interview on 08/25/2023 at 4:14 pm with RN 2 revealed she worked the 2:00 pm to 10:00 pm shift on 08/12/2023, after R#1's first elopement, and had an order from the NP for a WG for R#1. RN 2 revealed she asked permission from R#1 to place the WG (there was no policy in place for the resident or RP to sign for WG) on his R leg by his ankle and R#1 agreed. RN 2 revealed NP also placed an order for labs, to make sure he was hydrated, and for Q15-minute checks. RN 2 said each time she checked R#1 she said she confirmed he was wearing the WG. Interview on 08/22/23 at 11:41 am with the RNC said there was absolutely concern about R#1 eloping and he exhibited clear wandering and exit seeking behaviors. She feels the WG could have helped with his safety. She said that if he agreed to wear the WQ, it would not feel like his rights were being violated. If he eloped once, particularly because they were not sure how he eloped the first time, he could elope a second time. Interview on 08/21/2023 at 10:23 pm with ADM revealed R#1 eloped from the facility on 08/12/2023 between12:30 pm and 1:00 pm. Facility elopement policies were followed and approximately 2.5 hrs. R#1 was located about 2 miles away, in a heavy metropolis area, by a facility nurse, who was looking for him in her car. R#1 returned to the facility at approximately 3:00 pm. ADM told him that it is not okay to leave without telling someone. R#1 was assessed and was fine. ADM said they suspected R#1 followed someone out of the facility. ADM revealed that they checked the fire exit doors, and they were all working. R#1 eloped again at approximately 9:45 pm on 08/12/2023, facility elopement policies here followed, and R#1 was located approximately 1.75 hrs. later approximately 1.2 miles away in a heavy metropolis area. He was returned to the facility by the police. ADM revealed that he told R#1 if you want to leave, that's fine. R#1 signed AMA papers at midnight on 08/13/2023 and left the facility. ADM revealed that when he eloped the second time on 08/11/2023, he was not wearing a WG. ADM said that he consulted with his superiors who said that R#1 was fine to sign AMA paperwork and let him be on his way. ADM revealed he was not assessed the 2nd time he was returned by the police to the facility because he just came into the facility from outside with the police to AMA paperwork. Interview on 08/24/2023 at 9:08 pm with the ADM who revealed, when asked what could happen if a resident was improperly discharged , ADM said the resident could become injured or possibly die. When asked if ADM was aware that R#1 had a DX of altered mental status and hospital records repeatedly, over several days, revealed R#1 thought he was in the state of Michigan he said he was not very familiar with reading clinical records, so he sent them to his corporate office for review and asked for guidance from his corporate bosses. When asked who is responsible for the residents at the facility where he is the ADM, he revealed he was responsible for the safety of the residents, and he might have made some assumptions about R#1's cognition. When asked why he allowed R#1 to leave AMA, he said that he relied on the advice of his bosses at the corporate office. When asked if he called the NP or MD and asked them about R#1 leaving AMA, he said he did not. Interview on 08/23/2023 at 2:14 pm with DON revealed she said she was not informed that R#1 left AMA and she would have liked to have been given notice of the situation because she is the main care giver and wants to know what is going on with the patients. When asked to see the order from the NP or MD for the AMA as is required by facility policy, the DON revealed that is no order from either the NP or the MD because neither were consulted or informed about the AMA until after R#1 discharged AMA. Interview on 08/22/23 at 9:45 am with the ADM revealed he did not communicate with the NP or MD if it was okay for R#1 to be discharged AMA if R#1 requested, but the ADM did ask his corporate nurse. ADM said he sent all the hospital and clinical referral information to the CP asked if R#1 could be discharged AMA. He revealed that he explained to the CP that R#1 eloped and his concerns, anytime a resident went missing or eloped, was the resident's BIMS score and cognitive level. He revealed he sent the hospital and clinical records to the CP to review and evaluate because he is not familiar with hospital paperwork. When asked if ADM was aware that R#1's medical records contained the name and a location to obtain R#1's daughter's name and telephone number as an SDM information (SDM a process whereby clinicians collaboratively help patients to reach evidence-informed and value-congruent medical decisions. This process is especially relevant in screening for conditions in which there is a close trade-off between harms and benefits) ADM revealed he searched the initial few pages of R#1's admission hospital records but did not see R#1's daughter's name listed as a SDM. The ADM revealed that he notified the NP and MD after the AMA was signed and did not call either the NP or the MD to discuss R#1 and a possible AMA after R#1's elopements. The ADM revealed his is not sure why he did not notify either the NP or the MD sooner, he would have to look into that, and no response was given. When asked why no BIMS was conducted, the ADM replied, he would have to look into that, and no response was given. ADM revealed he did not either contact or notify the ombudsman about R#1's AMA discharge. Interview on 08/24/2023 at 9:08 am with the ADM revealed he does not know why there is no physical order for the WG. He revealed that he knew there was an order for the WG when the investigation began because RN 2 told him she put a WG on R#1. ADM was not aware that the NP was phoned when R#1 eloped the 1st time, but he did know that the NP should be notified if a resident elopes. ADM said he initially told staff to conduct 30-minute safety checks, but they were already doing 15-minute safety checks as ordered by the NP. ADM revealed he communicated to RN 2 that the WG was not necessary to give R#1. The ADM never personally asked R#1 if it was okay for him to get a WG. R#1 did tell the ADM that he was sad, and he wanted to go for a walk. The ADM revealed that he told R#1 that if he wanted to leave, to let someone know and he could leave. ADM revealed that R#1 was eating his lunch during this conversation and R#1 seemed content and receptive of the conversation. ADM revealed to R#1 that it was probably best if he stayed but he was welcome to leave. ADM revealed that the total amount of conversation with R#1 was probably ten minutes. ADM revealed he did not ask the staff who had cared for him what they thought about his mental capacity and did not talk to his staff about R#1's exit seeking behaviors. ADM revealed he was not aware that RN 2 asked R#1 permission to place a WG on R#1. ADM revealed that the CP and RVPO made the assumption, even though they did not speak to R#1 about a WG placement, that it was against his rights to put a AG on R#1. ADM revealed his superiors said it would be some form of resident restraint. ADM believed that R#1's cognition was the key factor regarding the WG placement. The ADM and his superiors felt that R#1's cognition was intact, and the ADM relied on the information of his superiors who had never seen or spoken to R#1 when making the judgment of a WG placement after R#1 had already eloped from the facility. ADM revealed he was not aware that he needed to talk to the MD or NP before considering a resident AMA. ADM revealed that when R#1 was told he could leave AMA, the ADM said he did not ask R#1 if he had a place to obtain his prescribed medicine or if he was homicidal or suicidal. Interview on 08/23/2023 at 12:20 pm with MD revealed he did not learn about R#1's discharge AMA until 08/23/203 from the facility NP. Interview on 08/23/2023 at 12:20 pm with NP revealed she was told at 2:20 pm that R#1 eloped, they found him, and he returned. She gave verbal orders for STAT labs, for a WG, and Q-15-minute checks. She revealed the facility did not communicate to her R#1's exit seeking behavior prior to his elopement. She revealed she would have liked to have known about R#1's exit seeking behaviors because, had she known, she might have been able to prescribe a medication to relieve R#1's anxiety or other arrangements to keep him safe. NP revealed that, of course R#1's elopement was a safety concern. When she was informed of R#1's second elopement she said she thought to herself, how did this happen again particularly because he had a WG. NP revealed she did not know about R#1's AMA discharge until Monday, 08/14/2023 when she went to the facility for her regular visit. She revealed she did not write an AMA order. She revealed that R#1's discharge was not the most safe or appropriate and should have been kept more in the loop at to what happened. NP said R#1 would be homeless with no stable housing and no knowledge or how to get his medications and because his cognitive status was unknown, R#1 was unable to understand the risks. Record review of R#1's hospital records dated 08/07/2023 revealed that R#1's daughter's name and telephone number was in the EMR records. Record review of R#1's orders reflect no NP order for the WG. Record review of R#1's orders reflect no order from the NP or MD for AMA approving R#1's release from the facility AMA. Record review of R#1's nurses notes reflect not records indicating any communication with the NP or MD involving R#1 leaving AMA. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by LVN A for R#1's first elopement reflected R#1 was A&OX2 and revealed cognitive factors of memory impairment and decision making impaired. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by the DON for R#1's second elopement reflected under Type of Injury other, no Head-to-Toe assessment and that physician was notified on 08/12/2020 (believe the 2020 is a type and should be 2023) at 9:45 pm. Review of Release of Responsibility for Discharge Against Medical Advice dated 08/13/2023 reflected, This is to certify that I, R#1, wish to discharge myself from this facility at my own insistence and against the advice or authority of my physician. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/13/2023 completed for R#1's first and second elopements and signed by the ADM reflected Head to Toe Assessment A&Ox3 and NP was notified on 08/12/2023 with no time of notification documented. Record revealed R#1 left building at around 12 pm and was found by staff member and brought back. Then at around 9:30 R#1 left again and was found. Record review of facility policy Review of Risk of Elopement/Wandering Review undated in R#1's paper file and completely blank revealed: Instructions Complete upon admission, thirty days after admission, quarterly and at significant change, or per facility policy. Review potential risk factors and resident status including is the resident cognitively impaired with poor decision-making skills, does the resident have a history of leaving the facility without informing staff, has the resident expressed a desire to go home, and admitted or readmitted and not accepting the situation. Record review of facility Discharging a Resident without a Physician's Approval dated October 2012 revealed a physician's order should be obtained for all discharges unless a resident or representative is discharging himself or herself against medical advice. The order for approved discharge must be signed and dated by a physician and recorded in the resident's medication record not later than seventy-two (72) hours after the discharge. Record review of facility Wandering, and Elopements dated March 2019 revealed Policy Statement - The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure: If the resident is not located in the building or premises notify the Attending Physician, and the DON services, the resident's legal representative, when the resident returns to the facility, the DON or charge nurse shall examine the resident for injurie, contact the attending physician and report findings and conditions of the resident, document relevant information in the resident's medical record. Review of facility admission Criteria dated March 2019 reflected Policy and Interpretation and Implementation - 1. The objectives of our admission criteria policy are to: a. Admit residents who can be cared for adequately by the facility. e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. 5. Prior to or at the time of admission, the resident's Attending Physician provides the facility with information needed for the immediate care of the resident, including orders covering at least: routine medical care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. 6. Residents are admitted to this facility as long as their needs can be met adequately by the facility. Review of facility Nursing Services Policy and Procedure manual for Long-Term Care Behavior, Mood, and Cognition dated April 2018 reflected all new admissions are screened for mental disorders, intellectual disabilities or delated disorders per the Medicaid Pre-admission Screening and Resident Review Process. On 8/22/2023 at 5:25 pm, the the ADM and the DON were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 08/24/2023 at 10:51 am: Table of Contents F 600 On 8/22/23, [NAME] Woods 1 Nursing Center failed to adequately supervise and prevent accidents for one resident. The facility inappropriately discharged R1 with notifying MD or obtaining AMA discharge order. All residents are at risk for inappropriate discharge. 1. Regional [NAME] President of Operations performed education on 8.22.23 for Administrator on discharge processes including discharging AMA and the requirements. 2. Regional Nurse Consultant performed further education on 8.22.23 for Director of Nursing on discharge processes including discharging AMA and the requirements 3. The DON/Designee immediately in-serviced licensed nurses on the discharge process on 8.22.23. Education includes to start discharge planning upon admission, the information required in the medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval. All present and newly hired licensed nurses and agency staff will complete education prior to beginning a shift. 4. DON/designee presented posttests 8/23/23 for knowledge retention after the education was presented. All staff who scored <80% will be reeducated by DON /designee. 5. DON/designee to monitor all discharges for documentation and notification of physician 3xwk for 4 wks. then 1xw for 3 months. Start 8.22.23 and end 12.12.23. Any issues with the discharge process will be immediately addressed and corrected by DON/designee. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director during QAPI and implement new interventions if needed 3 times a week for 4 weeks then once a week for 3 months which started 8/23/23 6. DON/designee will have a weekly at-risk meeting, a meeting with IDT to review fall, skin, weight, infection, and discharges, with interdisciplinary team to include review of all discharging residents. Start date is 8.22.23 and will be ongoing. Any issues with the discharge will be immediately addressed and corrected DON/designee. 7. Admin/designee will hold a QAPI meeting with the interdisciplinary team q week for 3 weeks to discuss discharge process. Any issues found within the meeting will be immediately addressed and corrected which includes further education by DON/designee. Start 8.22.23 and end on 9.12.23. 8. Electronic notification of Medical Director notification of IJ and QAPI meetings given 8/22/23 at 5:43 p.m. Medical Director attended meeting. Ad Hoc meeting held 8/23/23 at 2:00 p.m. discussing the citations received and process of POR. 9. Admin/designee will keep the discharge process in QAPI meeting with the interdisciplinary team for 3 months following the initial 3-week meetings. Start 8.22.23 and end 12.12.23. Any issues found within the meeting will be immediately addressed and corrected DON/designee which includes further education and replacement of equipment if needed. Monitoring of the plan of removal from 08/25/2023 through 08/25/2023 included the following: 1. Confirmed the Regional [NAME] President of Operations performed education on 08/22/2023 for Administrator on discharge processes including discharging AMA and the requirements. 2. Confirmed the Regional Nurse Consultant performed further education on 08/22/2023 for Director of Nursing on discharge processes including discharging AMA and the requirements. 3. Reviewed the in-service on for licensed nurses on the discharge process on 08/22/2023 with education that included to start discharge planning upon admission, the information required in the medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval and interviewed LVN and charge nurse on understanding. 4. Reviewed the staff posttests 08/23/2023 for knowledge retention after the education was presented. 5. Interviewed LVNs regarding the education received on in-services for discharges including when to start discharge planning and the information required from medical record including obtaining a physician's order for all discharges, and the process of discharging a resident without a physician approval. 6. Facility had no discharges for the start date of 08/22/2023 to document for notification of physician. 7. Reviewed QAPI meeting notes 08/22/2023 with the interdisciplinary team to discuss discharge process. The ADM and DON were informed the Immediate Jeopardy was removed on 08/24/2023 at 6:30 PM., however the facility remained out of compliance at a scope of isolated nd a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. 1. On 08/10/2023 resident was admitted by ambulance to the facility after an acute hospital stay with a diagnosis of altered mental status. 2. On 08/12/2023 at approximately 12:30 pm resident R#1 eloped from the facility. R#1 was returned by a staff member to facility on 08/12/2023 at approximately 3:00 pm. Resident was assessed, and no injuries found. 3. On 08/12/2023 at approximately 9:45 pm R#1 eloped a 2nd time from the facility. He was found by police who returned him to the facility. R#1 was not assessed for injuries, and he left AMA. An (IJ) Immediate Jeopardy was identified on An IJ was identified on 08/22/2023. While the IJ was removed on 08/25/2023 at 6:30 PM, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for accidents and harm. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 pm and discharged on 08/13/2023 at 12:00 am. R#'s face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain. The change is often temporary, but can quickly become life-threatening), tachycardia (an irregular electrical signal (impulse) starting in the upper or lower chambers of the heart causes the heart to beat faster), pancytopenia (low levels of red blood cells, white blood cells and platelets), problems - falls and used an electric wheelchair. ElopementBased on interview and record review the facility failed to ensure adequate supervision to prevent accidents for 1 (Resident #1 ) of 5 residents reviewed for accidents and supervision. - On 08/12/2023 at approximately 12:30 p.m. Resident #1 (R#1) eloped from the facility. R#1 was returned by a staff member to facility on 08/12/2023 at approximately 3:00 pm. Resident #1 was assessed, and no injuries found. - On 08/12/2023 at approximately 9:45 p.m., R#1 eloped a 2nd time from the facility. He was found by police who returned him to the facility. R#1 was not assessed for injuries, and he left AMA. An (IJ) Immediate Jeopardy was identified on 08/22/2023 at 5:25 pm While the IJ was removed on 08/24/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk for harm requiring hospitalization and/or death. Findings included: Review of R#1's undated face sheet reflected R#1 was a [AGE] year-old male, admitted to the facility on [DATE] at 2:04 p.m. and discharged on 08/13/2023 at 12:00 a.m. R#1's face sheet did not list a diagnosis. Review of R#1's Baseline Care Plan reflected an admitting DX of altered mental state (Altered mental status is a change in mental was not listed as a problem. Record review of hospital records dated 07/16/2023 reflected that R#1 was admitted on [DATE] found down at a gas station with DX of sepsis (a serious condition in which the body responds improperly to an infection) due to acute colitis (Infections caused by a virus or a parasite) and metabolic encephalopathy (a problem in the brain), homeless and unable to state where he lives. Review of hospital record dated 07/18/2023 of consultation for purposes of capacity to make medical decisions reflected that the patient (R#1) was very confused, he actually believed he was in Michigan on two occasions in my interaction. He was unable to identify any kind of date time or situation. He was also very confused about events. The record reflected patient showed poor higher level of thinking as well and processing. R#1 revealed he had been having energy difficulties, concentration concerns, sleep disruption, and psychological factors that impacted his functioning. His affect was blunted, and mood appeared depressed. He was oriented to person, place, and time period with no observable signs of psychosis noted. R#1received a 11 out of 30 on PHQ - 9 (PHQ-9 Quick Depression Assessment) which placed him in mild range of depression. He received a 12 out of 30 on the MSE (mental status exam) which indicated moderate cognition. R#1 struggled with any higher-level processing or understanding of recent medical events. A quick review of his medical issues was provided to the patient; however, the patient could not remember any of these issues after a short delay of interference. Record reflected diagnostic impression of 1. delirium secondary to his general medical condition and to rule out dementia/neural cognitive defects 2. anxiety order, not otherwise specified 3. rule out adjustment disorder 4. alcohol use disorder- in full remission per patients report Treatment recommendations. 1. Followed with one-to-one psychotherapy for management of mood while hospitalized . 2. Progress will be assessed with the patient and the staff support. 3. Patient was also assessed for adherence to psychological treatment plan - the patient's mood could impact adherence and consequentially cognitive behavioral therapy will be used to address any issues with adherence 4. The patient is not showing capacity to make medical decisions at this time. Review of hospital record dated 07/24/2023 of psychotherapy one-to-one reflected patient (Resident #1) still is as confused as the last interaction and only able to identify he was in the hospital accurately. He still believes he is in Michigan and could not identify place or any aspect time or date. He continued to be confused about why he's in the hospital and recent events. Patient still unable to do any higher-level thinking and could not remember any of the discussion about his medical care after short delay with interference. Mental Status Exam revealed appearance disheveled, oriented to self, mood depressed, affect flat, attitude inhibited, thought content non elicited, insight and judgment both limited and poor. DX assessment plan to rule out Wernicke-Korsakoff syndrome (an unusual type of memory disorder due to a lack of thiamin (vitamin B1) requiring immediate treatment. It most often happens in people with alcohol use disorder and malnutrition. While there isn't a cure, healthcare providers can recommend treatments to manage your symptoms), apparently patient had a long history of neurocognitive deficits noted at a local homeless shelter and likely patient had at least pre-existing dementia. Patient still not showing capacity make to make medical decisions. Review of hospital progress note dated 08/07/2023 reflected, remains confused. Review of hospital progress note dated 08/08/2023 reflected diagnosis assessment of early dementia/anxiety likely a manifestation of B12 deficiency. Patient did not show capacity to make medical decisions, this is likely his baseline cognitive function (measures your brain function in a healthy state). Record review of 08/10/2023 at 2:20 pm, admission nurses note by RN 1 reflect R#1 had a DX upon admission of altered mental status and was A&OX3 (alert and oriented to person, place, and time) and had no other concerns at that time. Record review of 08/10/2023 at 9:00 pm nurses note by RN 1 reflect R#1 expressed wanting to leave the facility. R#1 expressed he needed to leave because of a personal reason. Note reflected that R#1 was redirected back to his room and assured that there would be additional assistance in the morning. Note reflected he said he would stay the night but would need to leave in the morning. Note reflected that management was notified of his behavior. There are no nurses notes from the facility for 08/11/2023. Interview with RN 1 revealed on 08/21/23 at 1:10 pm that at 9:00 pm on 08/10/2023 R#1 began to talk about eloping and started wandering and said he had to go but RN 1 said it was nighttime and it was unsafe for him to leave. She said she texted the ADM that R#1, on admission, did not show any signs of wanting to leave but at approximately 9:00 pm, R#1 said he wanted to leave. When asked what ADM's reply was to her text, she said ADM said to redirect him and he would see R#1 in the morning. RN 1 said she does not know if the ADM went to see R#1 the next morning. She revealed she told the charge nurse for the next shift that R#1 wanted to leave and to keep an eye on him. RN 1 said it is fair to say that there were some concerns about R#1 and elopement. She revealed she did not know about his mental status, but she did try to call the hospital and obtain information, but the hospital did not return her call. When asked why his possession inventory admission sheet was blank, she said he did not have any clothes, he was admitted to the facility from the hospital in a hospital gown and had no belongings to list. Interview on 08/12/2023 at 5:05 pm with LVN 2 revealed LVN 2 observed R#1 walk the 300-hallway on the 08/11/2023 and he looked confused. LVN 2 revealed R#1 was walking the hallway and the nurses' station near the dining area and when LVN #2 last saw R#1, he was in his bed. Interview with LVN 1 on 08/12/2023 at 4:32 pm revealed she worked with R#1 on 08/12/2023 in the morning prior to his elopement at approximately 12:30 pm that day. She revealed R#1 was walking around on 400-hallway and pushed up against the bar of the front door. She approached him and she said he could not go out. When asked about his mental status she said he was AX3, but he was slow and acted like he did not understand everything she told him. She did not look at his DX but said she thought that he had a DX of dementia or Alzheimer's, and she told the receptionist, who is seated in front of the main entry/exit door, to keep an eye on him. She said all the staff were aware that he was exit seeking. LVN 1 said she knew he seemed anxious and wanted to leave. LVN 1 said that when he returned from the first elopement, she texted the NP who ordered labs, to keep him hydrated, issue a WG and conduct Q 15 minutes. When asked again about his mental state, LVN 1 said R#1 answered all her questions correctly and knew he was in a nursing home but there was something about him that made her think he had cognition issues. Interview with CMA 1 on 08/12/2023 at 11:28 pm revealed she observed R#1 trying to find his way out and when she asked him about why he wanted to leave he said his home was in Michigan and he knew he was not in Michigan. He said that he came to the facility to use the rest room then they would not let him leave. CMA 1 said she felt that he seemed confused she told nurse (nurses name unknown). Interview on 08/25/2023 at 4:14 pm with RN 2 revealed she worked the 2:00 pm to 10:00 pm shift on 08/12/2023, after R#1's first elopement, and had an order from the NP for a WG for R#1. RN 2 revealed she asked permission from R#1 to place the WG (there was no policy in place for the resident or RP to sign for wander guard placement) on his R leg by his ankle and R#1 agreed. RN 2 revealed NP also placed an order for labs, to make sure he was hydrated, and for Q15-minute checks. RN 2 said each time she checked R#1 she said she confirmed he was wearing the WG. Interview with maintenance manager on 08/24/2023 at 10:34 pm revealed that he has worked at the facility for approximately seven years and every Monday he opened the doors that are alarmed with both regular alarms and combination WG and regular alarms and confirmed that they alarmed for at least 20 seconds. He also revealed that after R#1 eloped, he checked all the door alarms and the facility windows and screens. He revealed that he thinks R#1 walked out with facility visitors because he has no clue how else R#1 eloped. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by LVN 1 for R#1's first elopement reflected R#1 was A&OX2 and revealed cognitive factors of memory impairment and decision making impaired. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/12/2023 and signed by the DON for R#1's second elopement reflected under Type of Injury other, no Head-to-Toe assessment and that physician was notified on 08/12/2020 (believe the 2020 is a type and should be 2023) at 9:45 pm. Record review of facility Accident/Incident Report for Falls, Injury, Elopement, Behaviors, Allegation dated 08/13/2023 completed for R#1's first and second elopements and signed by the ADM reflected Head to Toe Assessment A&Ox3 and NP was notified on 08/12/2023 with no time of notification documented. Record revealed R#1 left building at around 12 pm and was found by staff member and brought back. Then at around 9:30 R#1 left again and was found. Record review of facility policy Review of Risk of Elopement/Wandering Review undated in R#1's paper file and completely blank revealed: Instructions Complete upon admission, thirty days after admission, quarterly and at significant change, or per facility policy. Review potential risk factors and resident status including is the resident cognitively impaired with poor decision-making skills, does the resident have a history of leaving the facility without informing staff, has the resident expressed a desire to go home, and admitted or readmitted and not accepting the situation. On 8/22/2023 at 5:25 pm, the the ADM and the DON were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 08/24/2023 at 10:51 am: Table of Contents F689 On 8/22/23, [NAME] Woods 1 Nursing Center failed to adequately supervise and prevent accidents for one resident. The facility failed to prevent R1 from eloping from the facility two times in less than a 24-hour period. All resident at risk for elopement. 1. Regional [NAME] President of Operations performed education on 8.22.23 for Administrator on accidents and hazards processes including elopement program. 2. Regional Nurse Consultant performed further education on 8.22.23 for Director of Nursing on accidents and hazards processes including elopement program. 3. The DON/Designee immediately assessed all residents for elopement risk on 8/22/23. 4 Residents who were found to be high risk for elopement and care plan and orders were updated by DON/designee. No new residents were found at risk. Elopement Assessments were dated and signed by evaluator. 4. MDS coordinator reviewed and updated Comprehensive care plan for all residents who scored yes in the Risk of Elopement/Wandering Review on 8.22.23. 5. The DON/Designee immediately in-serviced all staff on the elopement program and exit seeking behaviors on 8.22.23. If behaviors are noted, report to DON/designee. Education included licensed nurses to complete elopement risk assessment upon admission, quarterly and change of condition. All staff education on when and how to respond to door alarms and what to do if a resident leaves the facility and what to do when the resident returns. All staff not present, including agency, shall be in-serviced by DON/Designee before start of shift and new hires will be educated by DON/designee. 6. DON/designee presented post tests on 8/23/23 for knowledge retention after the education was presented. All staff who scored <80% was re-educated. 7. Administrator/designee to perform random checks of residents with wander guard bracelets, wander guard door system, and fire exit alarms via one-on-one observation 3x/week for 4 weeks and 1x/week for 3 months to assure wander guard system and doors are working properly. This shall be documented on the administration's audit sheet for wandergaurd, fire door exit alarm. Start 8.22.23 and end 12.12.23. Any issues with the system or doors will be immediately addressed and corrected Administrator/Designee. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director in QAPI and implement new interventions if needed. Results of the audits will be reviewed and discussed by the interdisciplinary team and medical director during QAPI and implement new interventions if needed 3 times a week for 4 weeks then once a week for 3 months. Started 8/22/23. 8. DON/designee will have a weekly at-risk meeting with interdisciplinary team to include review of the incident and accident reports and interventions including elopements. Start date is 8.22.23 and will be conducted 3 times a week for 4 weeks then once a week for 3 months and once a month there after. Any issues with the reports and interventions will be immediately addressed and corrected. 9. Admin/designee will hold a QAPI meeting with the interdisciplinary team q week for 3 weeks to discuss elopement program progress. Any issues found within the meeting will be immediately addressed and corrected by DON/designee which includes further education and replacement of equipment if needed. Start 8.22.23 and end on 9.12.23. 10. Electronic notification of Medical Director notification of IJ and QAPI meetings given 8/22/23 at 5:43 p.m. Medical director attended via telephone conference. 11. Admin/designee will keep the elopement system in QAPI meeting with the interdisciplinary team for 3 months following the initial 3-week meetings. Start 8.22.23 and end 12.12.23. Any issues found within the meeting will be immediately addressed and corrected which includes further education and replacement of equipment if needed. Monitoring of the plan of removal from 08/25/2023 through 08/25/2023 included the following: 1. Confirmed that the Regional [NAME] President of Operations performed education on 08/22/2023 for Administrator on accidents and hazards processes including elopement program. 2. Confirmed Regional Nurse Consultant performed further education on 08/22/2023 for Director of Nursing on accidents and hazards processes including elopement program. 3. Confirmed the DON/Designee immediately assessed all residents for elopement risk on 08/22/2023. 4. Confirmed MDS coordinator reviewed and updated Comprehensive care plan for all residents who scored yes in the Risk of Elopement/Wandering Review on 08/22/2023. 5. Reviewed in-service attendance sheet and materials dated 08/22/2023 given by the DON and ADM to staff subjects WG protocol, admission protocol, incident/accident protocol, exit searching, and discharge. 6. Reviewed in-service attendance sheet dated 08/22/2023 given by the DON and ADM on head count for residents on all shifts incoming and outgoing, check when you put your eyes on the residents, nurses check your residents when you come in from your shifts. 7. Reviewed in-service given by DON on wanderguard Use Protocol to check placement of WG, check and ensure skin integrity, and document every shift. 8. Reviewed in-service given by DON and ADM to all staff on abuse and neglect, elopement/wandering, and wanderguard. 9. Interviewed LNV, LVN nurse manager, and CMA from different shifts who stated they participated, understood, and felt comfortable with the information given regarding WG, admissions, incidents/accidents and discharge, and keeping eyes on the residents. The ADM and DON were informed the Immediate Jeopardy was removed on 08/24/2023 at 6:30 PM., however the facility remained out of compliance at a scope of isolated nd a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.