**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 14 residents at risk of pressure ulcers. The facility failed to ensure Resident #1 had interventions in place to prevent an Unstageable Pressure ulcer in the thoracic spine (thoracic spine is the middle section of your spine. It starts at the base of your neck and ends at the bottom of your ribs). From 02/28/2025 to 03/04/2025 Resident #1 did not receive wound care treatment or interventions to prevent the abrasion found at admission from developing into an Unstageable Pressure ulcer in the thoracic spine. An IJ was identified on 04/03/2025. The IJ Template was provided to the facility on [DATE] at 05:22 p.m. While the IJ was removed on 04/05/2025, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. This failure placed residents at risk to develop an unstageable pressure ulcer. Findings included: Review of Resident #1's face sheet reflected an 89 -year-old female admitted to the facility on [DATE] with the following diagnoses Pulmonary Hypertension (blood pressure increases in the arteries of the lungs), ADL Needs (activities of daily living), Chronic Kidney Disease (involves a gradual loss of kidney function), Venous Insufficiency (condition in which the flow of blood through the veins is blocked), Diabetes (body doesn't make enough - or any - insulin), and Myocardial Infarction (happens when a part of the heart muscle doesn't get enough blood). Review of Resident #1's Initial MDS dated [DATE] reflected no BIMS score for Resident #1. No indication of skin conditions was listed. Review of Resident #1's MDS dated [DATE] reflected BIMS score for Resident #1 at 14 indicating better cognitive function. Further review of section M revealed risk of pressure ulcer injuries. Review of Resident #1's Admission/Shift Assessment from hospital, dated and timed 02/28/2025 at 08:30 (am), revealed skin alteration as present/exits, other erythema (redness of skin), posterior back. Additional review revealed PT (patient) has kyphosis and has blanchable erythema on her (Resident #1) spine, wound surrounding tissue appearance is blanched/dull. Further review revealed wound cleansing: analgesic/crm (cream)/oint (ointment)/spray, dressing type foam. Review of Resident #1's admission assessment dated [DATE] reflected results opening/abrasion to mid back on spine. Review of Resident #1's Braden assessment dated [DATE] reflected results of 15 indicating high risk for predicting pressure sore. Review of Resident #1's Initial Care Plan dated 02/28/2025 reflected potential for pressure ulcer development, goal will have intact skin, educate resident on skin breakdown, encourage fluid intake, monitor skin changes, out of bed unless contraindicated, weekly head to toe skin at risk assessment. Review of Resident #1's EMR revealed a Skin/Pressure/Ulcer Weekly Assessment, dated 03/04/2025 revealed 12cmx2cm open area, unable to determine depth, location right side of thoracic spine. Further review revealed no Skin/Pressure/Ulcer Weekly Assessment prior to 03/04/2025. Review of Resident #1's Wound Care Physician Surgical Note dated 03/04/2025 reflected: Reason for Visit: Consultation for a wound located at the thoracic spine. Wound from sitting against wheelchair. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 5.04 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was 12 cm x 2 cm x UTD cm (24 sq cm). The post-op wound area was evaluated to be 12 cm x 2.1 cm x 0.2 cm (25.2 sq cm). Wound Description: Odor: None Exudate: Scant, Serous Periwound: Stable Wound Edge: Normal Wound progress: Undetermined: first visit. Operative note: A curettage debridement technique was conducted using a 5 mm surgical steel curette. Hemostasis was managed by dry gauze. Blood loss: less than 5 cc. Honey-based Gel and Dry Dressing were applied to the wound. Review of Resident #1's Physician Orders written and initiated on 03/05/2025 revealed Thoracic Spine: cleanse with NS or wound cleanser, pat dry, apply Medi honey, cover with dry dressing. as needed for Unstageable PI. Review of Resident #1's Wound Care Physician Surgical Note dated 03/11/2025, reflected: Reason for Visit: Evaluation of a wound at the thoracic spine. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 4.34 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was 3 cm x 2 cm x UTD cm (6 sq cm). The post-op wound area was 3.1 cm x 2.0 cm x 0.2 cm (6.2 sq cm). Wound Description: Odor: None Exudate: Scant, Serous Periwound: Stable Wound Edge: Normal Operative note: A curettage debridement technique was employed using a 5 mm surgical steel curette. Hemostasis was achieved using dry gauze. Blood loss was approximately less than 5 cc. Honey-based Gel and Dry Dressing were applied to the wound. Review of Resident #1's Wound Care Physician Surgical Note dated 03/18/2025, reflected: Reason for Visit: To evaluate this patient for a wound located on the thoracic spine. Wound: Thoracic Spine Etiology: Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury Preoperative indications: Slough and Devitalized tissue Procedure Performed: Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 2.5 sq cm of devitalized tissue was debrided with <5 cc estimated blood loss. The pre-op wound area was evaluated to be 1.8 cm x 1.3 cm x 0.1 cm (2.3 sq cm). The post-op wound area was 1.8 cm x 1.4 cm x 0.2 cm (2.5 sq cm). Wound Description: Odor: None Exudate: Mild, Serous Periwound: Stable Wound Edge: Normal Unhealthy granulated tissue identified within the wound! Operative note: A curettage debridement technique was employed using a 5 mm surgical steel curette. Hemostasis was achieved using dry gauze. Blood loss was approximately less than 5 cc. Calcium Alginate with Honey, Dry Dressing, and Skin prep peri wound were applied to the wound. Observation on 04/03/2025 at 9:00 a.m. revealed Resident #1's open wound to thoracic area, surrounding redness, slough to the wound base. Observation on 4/3/2025 at 10:36 am revealed Resident #1 sitting up in her wheelchair with a pillowed positioned between her and the back of her chair. Resident #1 was groomed well and dressed appropriately for the weather with no odors. LVN TN removed the pillow from Resident #1's back area and revealed a covered wound. LVN TN provided wound treatment while Resident #1 was sitting in her wheelchair. Interview on 04/03/2025 at 08:40 a.m. Wound Care Nurse stated he the expectations of the floor nurses are to notify him by phone during after-hours or on the weekends to initiate treatment orders. He initiated a wound care consult the day he was notified of the wound, 03/04/2025. Interview on 04/03/2025 at 12:21 p.m., Wound Care Doctor stated he visits the facility once a week, on Tuesday. He further stated he was doing his rounds on 03/04/2025, and the Wound Care Nurse notified him of Resident #'1s wounds and he confirmed Resident #1 was treated. The Wound Care Doctor stated it was misdiagnosed as it should not have been listed as an abrasion, he further stated based on history it should have been diagnosed as a wound upon admission. Interview on 04/03/2025 at 12:32 p.m., LVN Charge Nurse stated he was tasked with the admission of resident on 02/28/2025 and it was an oversight that he did not put in orders or monitoring of resident's wound and stated he was not properly educated on admission expectations with skin concerns (04/03/2025). Interview on 04/03/2025 at 11:59 a.m. DON stated that the LVN at admission described the wound inappropriately and believes it was a pressure ulcer at admission. She stated, she understands he missed all the steps in place and believes it was a good system in place if everyone follows the process it will work. DON reached out to the hospital and received clinical records on 04/03/2025 at 2:00 p.m. and confirmed in the records that Resident #1 had a wound on the thoracic region. Review of the facility's document titled, Policy/Procedure - Nursing Administration, Admission, undated revealed the following: Provide the resident with information and resources for his care and comfort, as well as federal and state requirements. Initiate any required treatments (oxygen, intravenous) necessary at time of admission per transfer orders. Do a complete assessment of body systems and complete admission assessment form and nursing notes. Include a through skin check. Review of the facility's document titled, Policy/Procedure -Nursing Administration, Wound Management dated 05/2007 revealed the following: A wound flow sheet will be started as soon as a wound is identified. The ADM was notified on 04/03/2025 at 5:22 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 04/04/2025 at 5:40 p.m., and included the following: On 04/02/2025 an abbreviated survey was initiated. On 04/03/2025 the surveyor provided a Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. Action: One on one in service with LVN Charge Nurse to review admission Skin Assessment/ Documentation Treatments and Notification. Overview of Resident #1 and education on expectations of interventions, notification, and documentation. LVNs knowledge and effectiveness of training by conducting quiz, chart audit and feedback given with results of audit, will continue training x4 week. LVN received counseling for insufficient assessment and documentation. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Resident #1's head-to-toe skin assessment completed. Initiated medication review by Medical Provider, Wound Care Provider review of treatment orders for appropriateness. Social Service Assessment conducted to ensure psychosocial well-being. No mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: In service provided to Administrator and DON by Clinical Resource on New admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. In serviced on following up on new admission with chart audits and continue education and counseling as needed by Clinical Resource. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Clinical Resource Action: 100% Charge Nurse In-Service for New admission Skin Assessment/ Documentation Treatments and Notification. PRN nurses in serviced. We do not utilize agency staff. New staff will be in serviced upon hire. Nurses will not work floor until in serviced. 1. Current Protocol: Upon admission the head-to toe skin assessment was to be completed (including staples, bandages, scars, bruising, missing digits/limbs). 2. DO NOT STAGE or measure areas. Only document location, characteristic and odor. 3. Obtain a physician's order for wound care. If you are not sure ask the treatment nurse or call the on-call manager if after hours. 4. DO NOT DOCUMENT TREATMENT NURSE TO EVAL AND TREAT - as admitting nurse you must intervene and ensure orders and treatments are in place. 5. Place appropriate interventions based on Braden score and current wounds. Possible interventions: Low Air Loss Mattress, turning and repositioning program, wedges for positioning, boots for heel protection, float heels, etc. 6. Document all skin tears/skin alterations x 3 days and notify family. Please pass on the need to follow up documentation during the nurse-to-nurse shift change/24-hour report. 7. Notify treatment nurse of all new admission with wounds and any new wounds. Action: 100% Nurse Management in service for New admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing and/or designee Action: Admissions, MDS, DOR, ADOR, Treatment Nurse, ADON informed of IJ, and template reviewed. Start Date: 04/04/2025 Completion Date: 04/04/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Medical Director notified of IJ. Medical Director involved in development of plan and in agreement. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Executive Director, Director of Nursing and/or designee Action: Audit on current residents with pressure ulcers. In process pending completion date. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: Audit on new admissions without Treatment Nurse Assessment. New admission from 04/02/2025 Treatment Nurse Assessments are in place, Treatment in place when appropriate. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: Skin sweep on with residents with wounds and new admissions. Resulted in no new finding. Start Date: 04/03/2025 Completion Date: 04/04/2025 Responsible: Director of Nursing Services or designee. Action: RCA/QIT with IDT and Medical Director. IDT meet to discuss initial admission skin assessments that identify skin issues without treatment orders being placed initially by charge nurse and then a delay in treatment. This was often found on Friday admissions, where the treatment nurse did not see patients until the following week. All nurses being in-serviced prior to working their next shift on admission skin assessment process, implementing orders and interventions and documentation. Treatment nurse was only assessing patient's that it was communicated had wounds. Treatment nurse or designee is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: IDT Action: Treatment Nurse, Admissions Nurse and MDS Resource to conduct in service to nurses trained on New admission Skin Assessment/ Documentation Treatments and Notification and expectation. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Director of Nursing Services or designee. Action: DON or designee to verify nurse knowledge on New admission Skin Assessment/ Documentation Treatments and Notification by quizzing 5 nurses weekly x3m and ongoing for nurse new hires Start Date: 04/03/2025 Completion Date: 07/03/2025 Responsible: Director of Nursing Services or designee. Action: Summary of IJ and corrective action to be reviewed by QAPI Committee monthly x3 months or until substantial compliance established. Start Date: 04/03/2025 Completion Date: 07/03/2025 Responsible: Executive Director, Director of Nursing Services, or designee. Action: Care Plan audit for all residents with pressure/skin alterations. Care Plans update for appropriate interventions. Start Date: 04/03/2025 Completion Date: 04/03/2025 Responsible: Director of Nursing Services or designee. Action: Audit new Admissions within 72 hours of admission for initial skin assessment and treatment nurse assessment, ensuring interventions and orders in place x3 months. Start Date: 04/04/2025 Completion Date: 07/04/2025 Responsible: Director of Nursing Services or designee. The Survey Team monitored the Plan of Removal from 04/04/2025, 4:00 p.m. to 9:15 p.m. and 04/05/2025, 11:00 a.m. to 1:00 p.m. revealed the following: Record review on 04/04/2025 revealed LVN A Charge Nurse received one-on-one in-service on 04/03/2025 with ADM and DON on topics of admission Skin Assessment/ Documentation Treatments and Notification. Further record review revealed LVN A completed quiz to check knowledge and effectiveness of chart audits and feedback given with successful results of audit and received counseling for insufficient assessment and documentation. Record review on 04/04/2025 revealed Resident #1's head-to-toe skin assessment completed, medication reviewed by Medical Provider, Wound Care Provider reviewed treatment orders for appropriateness. Further record review on 04/04/2025 revealed Social Service Assessment was conducted on Resident #1 to ensure psychosocial well-being status., which resulted in no mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1. Record review on 04/04/2025 revealed ADM and DON completed in-services on 4/3/2025 conducted by Clinical Resource on topics of New admission Skin Assessment, Documentation, Treatments and Notifications, Follow-up on new admissions with chart audits to ensure compliance and continued education and counseling with staff as needed. Record review on 04/04/2025 revealed 100% of Charge Nurses and PRN Nurses completed in-services 04/03/2025 and 04/04/2025 conducted by DON, CN, and Clinical Resource on topics of New admission Skin Assessment/Documentation Treatments and Notification. Record review on 04/04/2025 revealed in-services completed on 04/03/2025 and 04/04/2025 for 60 staff on topics of New admission Skin Assessment, Documentation, Treatments and Notification. Further record review revealed 38 Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review on 04/04/2025 revealed Nursing Management staff received in-service training on 04/03/2025 and 04/04/2025 conducted by DON on topics of New admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. Record review on 04/04/2025 revealed ED and DON informed Admissions, MDS, DOR, ADOR, Treatment Nurse and ADON of IJ on 04/03/2025 and template was reviewed. Record review on 04/04/2025 revealed ED notified Medical Director on 4/3/2025 of IJ and he was involved in the development of plan and in agreement. Record review on 04/04/2025 revealed ADHOC QAPI meeting held on 04/03/2025 with the Physician, Administrator, Director of Nursing, Assistant Director of Nursing, Administrator 2, Administrator 3, Director of Nursing 2, Director of Nursing 3, Clinical Market Leader, and Clinical Resource. Meeting included the Plan of Removal and interventions. Record review on 04/04/0205 revealed DON completed audit on current residents with pressure ulcers on 04/04/2025. Record review on 04/04/2025 revealed DON completed audit on new admissions without Treatment Nurse Assessment and new admissions from 04/02/2025 Treatment Nurse Assessments are in place on 04/04/2025. Record review on 04/04/2025 revealed DON completed skin sweep on residents with wounds and new admissions on 04/04/2025. This skin sweep resulted in no new finding. Record review on 04/04/2025 revealed RCA/QIT with IDT and Medical Director was completed on 04/03/2025. IDT met to discuss initial admission skin assessments that identify skin issues without treatment orders, the delay in treatment, all nurses being in-serviced prior to working their next shift, and Treatment Nurse is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate. Record review on 04/04/2025 revealed Corporate Nurse, RN conducted in-services on 04/03/2025 and 04/04/2025 to nurses trained on New admission Skin Assessment/ Documentation Treatments and Notification and expectation. Record Review on 04/04/2025 and 04/05/2025 revealed DON completed Care Plan audit for all residents with pressure/skin alterations and Care Plan updates for appropriate interventions for 14 residents. Phone call interview on 04/04/2025 at 4:43 p.m., CWSP stated that with the additional hospital discharge information provided for Resident #1 he believes, the hospital could have staged P1 incorrectly at the hospital. He stated that sometimes there could be slough on the wound and he doesn't know how deep it goes, and if on the wound belly he would categorize it as unstageable. He stated that a P1 can progress within a day or even in a few hours due to many different factors of the individual. He stated that a healthy-looking wound could be categorized from P1 to unstageable. He stated that based on how much slough he saw on the wound on 3/4/2025 he believes it was going to progress due to her poor health and being very skinny, and he stated he doesn't believe it could have been unavoidable. He stated that, in his opinion as the P1 was incorrectly staged progression could not have been avoided those couple of days treatment was delayed, it was going to progress either way. Interview on 04/04/2025 at 4:55 p.m., LVN W stated that with the additional factors provided to him regarding Resident #1's hospital discharge status and the discussion with the CWSP, he stated for the wound to be an unstageable, P1 was not uncommon, and where the wound was, the fat tissues, more tissue based on body size, doesn't believe it could have been avoided because she was compliant with sideline, aware of the wound, her family was also aware helping reposition her. He stated that she would have had to be completely immobile, moist, friction, other factors to have progressed to a worsening condition. LVN W stated that he has taken in-services conducted by CN and Clinical Resource on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. He stated the expectation moving forward is for him to review all new admissions regardless of receiving wound referral. Interview on 04/04/2025 at 5:32 p.m., DON stated she has taken in-services conducted by Clinical Resource on 04/03/2025 at AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. DON stated she attended an ADHOC QAPI meeting addressing Plan of Removal and interventions. She stated she held a one-on-one in-service with LVN A on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that LVN received counseling for insufficient assessment and documentation. DON stated that she is responsible for following up on LVNs, Charge Nurses knowledge and effectiveness of training by conducting quizzes, completing chart audits, and providing nurses with ongoing training. Interview on 04/04/2025 at 5:42 p.m., ADM stated she has taken in-services conducted by Clinical Resource on 04/03/2025 at AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. ADM stated she notified the MD of IJ and he was involved in the development of Plan of Removal and interventions and agreed. ADM stated she attended an ADHOC QAPI meeting addressing Plan of Removal and interventions. She stated she held a one-on-one in-service with LVN A on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that LVN received counseling for insufficient assessment and documentation. ADM stated she was responsible for following up on new admissions with chart audits and continue education and counseling as needed by Clinical Resource. Record review and interview on 04/04/2025 at 5:53 p.m., LVN A stated that he has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. He stated he taken one-on-one in-services on 04/03/2025 at AM shift with ADM and DON on topics of insufficient assessment and documentation. He stated that now he recalled the expectations of a charge nurse and LVN job description he received as a new hire. He stated that he now remembers why it is so important to follow the processes that are in place with new admissions and skin assessments. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Counseling/Disciplinary Notice signed and dated 4/3/2025 acknowledging insufficient assessment and documentation. Record review and phone call interview on 04/04/2025 at 6:53 p.m., LVN B stated that she has taken in-services on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and Interview on 04/04/2025 at 7:03 p.m. LVN C stated that he has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/4/2025 confirmed completion and knowledge of new admissions. Phone call interview on 04/04/2025 at 7:06 p.m. RN A stated that she stated that he has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:15 p.m. LVN D stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:22 p.m. Interview with LVN E stated that he has taken in-services on 04/03/2025 and 04/04/2025 on AM shift, on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 and 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 7:32 p.m. LVN F stated that she has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Record review and interview on 04/04/2025 at 7:46 p.m. LVN M stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone and on AM shift with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/4/2025 confirmed completion and knowledge of new admissions. Record review and phone call interview on 04/04/2025 at 8:15 p.m. LVN G stated that she has taken in-services on 04/03/2025 over phone with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. Post-test signed and dated 4/3/2025 confirmed completion and knowledge of new admissions. Phone call interview on 04/04/2025 at 8:20 p.m. ADON stated that she has taken in-services on 04/03/2025 and 04/04/2025 over phone and on AM shift with CN and Clinical Resource on topics of new admission skin assessment, documentation, treatments, and notifications. She stated that she was notified of IJ Template via phone on 4/3/2025. The ADM was notified on 04/05/2025 at 01:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is 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 observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not leave the facility with nursing staff being aware as she was found approximately 2.5 hours later and approximately 4.2 miles away (at a store off a major highway - 65 MPH) after being contacted by an outside party 02/16/25. The temperature was approximately 58 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/18/25 at 2:16 PM and an IJ template was given. While the IJ was removed on 02/19/25 at 4:42 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including psychotic disorder with delusions, generalized anxiety disorder, dementia, unsteadiness on feet, and difficulty in walking. She was not her own RP. Review of Resident #1's quarterly MDS assessment, dated 11/08/24, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section E (Behavior) reflected she had not exhibited behaviors of wandering. Section GG (Functional Abilities) reflected she utilized a walker for ambulation. Review of Resident #1's quarterly care plan, dated 01/15/25, reflected she was at risk for impaired cognitive function/dementia or impaired thought process with an intervention of needing supervision/assistance with all decision making. There was no focus area related to wandering or elopement. Review of Resident #1's quarterly Elopement/Wandering Evaluation, dated 01/10/23, reflected a score of 15, indicating she was a high-risk for elopement. Review of Resident #1's progress note, dated 01/14/25 at 1:08 AM and documented by LVN F, reflected the following: [Resident #1] found rummaging through front desk drawers. CN was advised that [Resident#1] has attempted to exit the facility prior to today's date . Review of Resident #1's MD progress note, dated 01/21/25, reflected the following: Discussed with [Resident #1] again upon request from her to talk about her taking the bus, discussed with director of nursing and administrator, that and we all agree that [Resident #1] is safe to go, as long as there is a chaperone with her . Review of Resident #1's progress note, dated 01/30/25 at 5:28 PM and documented by LVN A, reflected the following: [Resident #1] is asking all during shift if can go and take the bus to pick up income taxes. Writer redirected [Resident #1] to speak with social worker or administrator for the ok to leave facility. [Resident #1] is not allowed to leave facility without supervision from stass [sic] or family. Review of Resident #1's progress notes, dated 02/03/25 at 1:50 PM and documented by LVN B, reflected the following: Will continue to monitor for elopement, plan of care ongoing. Review of Resident #1's NP progress note, dated 02/03/25, reflected the following: Otherwise, nursing reporting [Resident #1] has been trying to leave facility . Upon discussion with nursing staff, [Resident #1] often with these behaviors intermittently . Although, [Resident #1] tells me she talked to (name) recently and is discharging tomorrow to a different facility. No discharge plans have been made. Is a wander risk. Alerted staff and DON regarding [Resident #1]'s above statement. (Psychiatric team) is following. Will have (Psychiatric team) follow up. . Mood stable today, thought with intermittent agitation and wandering behaviors . Review of Resident #1's progress notes, dated 02/16/25 at 5:24 PM and documented by LVN C, reflected the following: [Resident #1] signed herself out 2-16-25 at 11:40 am went to the (store) in (town), [Resident #1] returned around 14:00 (2:00 PM) DON aware. After returning back to facility [Resident #1] went to her room. Review of Resident #1's progress note, dated 02/16/25 at 5:49 PM and documented by the DON, reflected the following: [Resident #1] is cognitively intact (BIMS 15) and able to make decisions, although she has had a change in condition and is not making safe decisions and voicing desire to leave and attempting without a safe plan in place . Review of the Out on Pass binder at the desk in the front lobby, on 02/18/25, reflected Resident #1 signed out on 02/16/25 at 11:40 AM but there was no returned time documented. Observations made on 02/18/25 at 9:02 AM revealed an elopement binder with residents that were a high risk located at the Receptionist's desk and each nurses' station. The binders contained Resident #1's information. During a telephone interview on 02/17/25 at 3:48 PM, CNA D stated Resident #1 eloped from the facility on 02/16/25. She stated she was working that day but on another hall. She stated she (Resident #1) left sometime in the morning and was brought back to the facility around 2:00 PM. She stated no one knew how long she had been missing. She stated she did not see her in the dining room at lunch, but that was not unusual because she often ate her meals in her room. She stated the facility received a call from someone at another facility notifying them of where she was located. She stated the ADM went and picked her up and brought her back. She stated the ADM and DON talked to Resident #1's nurse, LVN C, and told her it was not an elopement since she signed herself out. She stated Resident #1 was in their high-elopement binder at the nurses' station and Resident #1 did not have the cognitive ability to sign herself out. She stated she was currently on a 1:1 due to the elopement. During an observation and interview on 02/18/25 at 8:59 AM revealed CNA E sitting in a chair next to Resident #1's bed. She stated Resident #1 was on 1:1 and she was to ensure she stayed with her. She stated she was not sure why she was on a 1:1 but thought it had to do something with an elopement. Resident #1 stated it was because of her shopping trip. She then started crying and talking about the social worker, not getting her money, and missing her family member. She was hard to redirect. During a telephone interview on 02/18/25 at 10:07 AM, LVN C stated she was working Resident #1's hall on 02/16/25. She stated no one knew Resident #1 had left the facility until LVN G received a phone call from the van driver from a facility close by and informed him she was seen at the grocery store in a town approximately five miles way. She stated everyone knew she was not allowed to sign out or leave the facility without someone knowing and going with her. She stated she attempted to leave the facility daily and constantly had to be re-directed. She stated everyone was aware she was not supposed to leave the facility. She stated she immediately called the DON to notify her of Resident #1's location and she and the ADM brought her back to the facility. She stated the DON told her it was not considered an elopement because she signed herself out, she was aware what she was doing, and her mental status was fine. She stated she did sign out at the front desk but as a nurse, she considered it an elopement because no one knew she was gone or where she was. She stated she could have gotten seriously hurt. During an interview on 02/18/25 at 10:38 AM, CNA H stated he worked Resident #1's hall on 02/16/25. He stated it was not his normal hall, so he was not that familiar with her but did know she was ambulatory and liked to sit in the lobby by the Receptionist's desk. He stated he did remember seeing her that day but did not remember what time. He stated he heard a rumor she was missing but he did not see anything. During a telephone interview on 02/18/25 at 11:25 AM, Resident #1's FM I stated she should not have been able to leave the facility on her own. He stated he was very upset she was able to walk out the front door. He stated when he took her out on pass, he had to sign out at two different locations and then get the Receptionist to put the code in to unlock the door, How did she get past all that? He stated he understood she could physically sign herself out, but she had dementia, and it was not safe at all. He stated if she walked out the door and forgot where she was at, then what? He stated she could have gotten ran over or gotten left for dead. He stated he believed the weekend Receptionist (REC J) was a new hire and probably had not been thoroughly trained. He stated the Administrator and DON were aware she had a history of eloping when she was admitted . During a telephone interview on 02/18/25 at 1:13 PM, Resident #1's NP stated it was not safe for her to leave the facility on her own. She stated her psychiatric competency was more complex than most. She stated something would happen, she would get confused, or get lost. She stated if she had signed out, it would still be considered an elopement because the staff did not know she left or her whereabouts. During a telephone interview on 02/18/25 at 1:57 PM, Resident #1's MD stated she had been asking to leave the facility for a long time. He stated they had been trying to do the right thing for her and her safety but also be respectful of her wishes and rights. He stated she was over-all pretty with it in terms of her alertness and orientation. He stated she historically needed to be redirected from the front door. He stated ideally, she would need a chaperone to go out on pass. He stated there was no real reason why she could not go out and it would be against her rights and will. He stated he did expect for there to be a process in place when a resident signed out to leave the facility, but he could not remember what theirs was. He stated generally, staff should be aware when a resident was leaving the facility. During an interview on 02/18/25 at 2:32 PM, the DON stated it was preferred that when a resident wanted to leave, they would sign out and notify their nurse. She stated sometimes residents would forget to notify their nurse. The ADM stated there was a sign out book at the nurses' station and the Receptionist's desk where the residents were supposed to sign out. She stated for a resident to go out on pass alone, it would depend on their cognitive level and their BIMS score. The ADM stated the BIMS score would need to be high - 13, 14, or 15. She stated if a resident had a BIMS score of 10, it would depend and they would need to talk to their provider about it. The ADM stated staff knew which residents were a high-elopement risk by their elopement binders located at the nurses' station and Receptionist's desk. The ADM stated on 02/16/25, REC J told her Resident #1 came to the desk and told her she was going out and signed out in the binder. She stated REC J told her she did not leave, but just sat in the lobby. She stated REC J went to lunch and when she came back Resident #1 was gone. She stated Resident #1 left at some point and was not sure how she left without the code to the door. She stated at that time she was able to be out independently at that time because of her cognitive status and high BIMS score. She stated she was able to answer all of their questions, such as where she had gone and what she had been doing. The ADM stated they did not consider it an elopement because when they found out she was not in the building, they went to the book and saw that she had signed out and, in that moment, they knew where she was. She stated when they got to her location, she was safe and knew everything she was doing. On 02/18/25 at 10:20 AM and 1:14 PM, attempts were made to interview LVN G. A returned call was not received prior to exiting. On 02/18/25 at 10:24 AM and 12:35 PM, attempts were made to interview REC J. A returned call was not received prior to exiting. Review of the facility's Elopement/Unsafe Wandering Policy, revised 12/2023, reflected the following: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Definition: Elopement occurs when a resident leaves the facility premises or a safe area without the facility's knowledge, authorization (i.e. an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so. The ADM and DON were notified on 02/18/25 at 2:16 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/19/25 at 2:39 PM: Action: 100% all staff in service on communication regarding out on pass with nursing approval and elopement process. PRN staff in serviced, we do not utilize agency staff and new staff will be in serviced upon hire. Resident was put on 1:1, psychological evaluation completed by Psychology Services (pending report), neurocognitive testing initiated due to change of condition conducted by Psychological Services (pending report), 100% audit for high-risk elopement residents completed. There were no other residents identified that may display this behavior. Previous protocol: Charge nurse is informed, resident signs out on at reception or nurse's station. Current protocol: Charge nurse to be notified of request and confirms with IDT that resident is appropriate for out on pass independently, Charge nurse completes sign out sheet with resident, informs receptionist if resident is appropriate for out on pass. RP, Resident and Provider to be notified by DON or designee with IDT determination. DON or designee responsible for ongoing compliance. Sign out book has been reviewed as of 2/19/25 and will be audited ongoing in QAPI x90 days to ensure ongoing compliance. Audit on high-risk elopement resident completed by DON and Clinical Resource on 2/18/25. Conducting 100% all staff in service on Elopements. Start Date: 02/18/2025 Completion Date: 02/19/2025 Responsible: Executive Director, Director of Nursing Services or designee. Action: Medical director notified of IJ Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: Director of Nursing Services Action: An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: ED/DON Action: Train the trainer in-service given to ED and DON on communication for out on pass Start Date: 02/18/2025 Completion Date: 02/18/2025 Responsible: Clinical Resource Action: ED or Designee will verify staff knowledge on communication for out on pass with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly following the initial training and knowledge checks Knowledge check will be completed by quizzes and in services. This will continue for 90 days then ongoing for all new hires. Start Date: 02/18/2025 Completion Date: 05/18/2025 Responsible: ED/Designee Action: Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 02/18/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Start Date: 02/18/2025 Completion Date: 05/18/2025 Responsible: ED/DON The Surveyor monitored the POR on 02/19/25 as followed: During an interview on 02/19/25 at 2:45 PM, the ADM stated more than 90% of their staff had been in-serviced on elopement and residents leaving out on pass. She stated no one will work until they get in-serviced. She stated Resident #1 had psychiatric and neurocognitive evaluations conducted the day prior, 02/18/25, and the reports were still pending. During interviews on 02/19/25 from 2:58 PM - 4:21 PM, four LVNs, two CNAs, one MA , and REC K (weekday receptionist) from different shifts all stated they were in-serviced before their shifts on elopement and the process for residents signing out on pass. All were able to describe what the elopement binders were and where they were located. All staff knew to redirect residents to their nurse if voicing a desire to go out on pass. Each staff member was able to define elopement as a resident leaving the facility premises without the staff being aware. The nurses stated they would assess their cognitive status and orientation and would contact the DON for further approval. The nurses stated the log had to be filled out completely whether the resident was leaving with staff and/or family or if leaving independently - name, date, time, location, phone number, and estimated time of return. The nurses stated any time a resident signed out, they would then accompany them to the receptionist area, have them sign out again, and then give the Receptionist the okay to unlock the door. All staff were able to give possible signs and symptoms of residents seeking elopement - pacing to exit doors, voicing wanting to leave, agitation, or actively exit-seeking. All staff stated residents should be rounded on at least every two hours and if they were unable to locate them, the nurse should be notified immediately. Observation on 02/19/25 at 2:42 PM revealed Resident #1 ambulating in the lobby with a CNA closely behind her providing 1:1 supervision. Review of the facility's Ad Hoc QAPI agenda, dated 02/18/25, reflected the ADM, DON, AIT, DOR, ADON, MD, SW, MDSC, and other corporate officials were in attendance. Review of in-services entitled Communication Regarding Out on Pass, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts were in-serviced. Review of Out on Pass quizzes, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts completed the following quiz: 1. If a resident wants to go out on pass, where do they need to be directed for clearance? 2. Who can give the ok for a resident to go out on pass independently? 3. Where is the sign out binder located? 4. How does the receptionist know if a resident can go out on pass? Review of in-services entitled Elopement, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts were in-serviced on their elopement policy. Review of Elopement Inservice quizzes, dated from 02/18/25 - 02/19/25, reflected nursing staff from all shifts completed the following quiz: Location of elopement binder What to do if possible elopement 3 patients that are located in elopement binder Review of the facility's elopement binder, on 02/19/25, reflected fifteen residents that were deemed a high risk. Three residents' EMR's were reviewed to reflect they were a high-risk of elopement. Review of Resident #1's progress note, dated 02/19/25 at 1:22 PM and documented by the SW, reflected the following: Called [FM I] for quarterly care plan meeting. Review of Psychological Evaluation, dated 02/18/25, reflected Resident #1 had a psychological evaluation conducted. The ADM and DON were notified the IJ was removed on 02/19/25 at 4:42 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.