**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure residents had adequate supervision and assistance devices to prevent accidents for 1 (resident #51) of 10 residents reviewed for accidents and hazards. The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall and fracture to the right femur. This has led to anxiety around shower times, and a reduced quality of life. An IJ was identified on 05/02/2025 at 4:30 PM. The initial IJ template was provided to the facility on [DATE] at 4:38 PM. While the IJ was removed on 05/04/25 at 12:21 pm, the facility remained out of compliance at the scope of isolated and a severity of no actual harm due to the injury sustained by Resident #51. Findings Included: Record review of Resident #51's face sheet dated 04/16/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right femur, chronic obstructive pulmonary disease(a disease that makes it hard to breath and causes lung deterioration, morbid obesity, fall from non-moving wheelchair, and osteoarthritis (arthritis of the bones which causes widespread generalized pain.) Record review of Resident #51's care plan revised 02/12/25 reflected Resident #51 has impaired visual function related to legal blindness, had a right femur and right tibia fracture related to fall with interventions to initiate PT, OT, and pain treatment as indicated by MD. Record Review of Resident #51's MDS dated [DATE] indicated a BIMS score of 15 indicating intact cognition, a mood interview score of 5, and extensive assistance for bed mobility, transfers, and toilet use. He required two person assist for transfers between surfaces; MDS states this excludes to/from bath and toilet. Resident #51 had received 150 minutes of physical therapy starting on 01/22/25 and ended 02/28/25. Review of Resident #51's incident report dated 01/17/2025 at 11:12 am reflected the following, This nurse seen when resident fell out of the shower chair while shower aid was bringing him back to his room from just receiving a shower. EMS has been called and are here at the facility as the resident states he thinks he broke his right knee. (Family) has been contacted a few times without success will attempt to contact later. MD aware. Incident and vitals initiated at this time. Resident stated, I think I heard a loud pop. I think I broke my right knee. A section within the incident report titled, Other Info, reflected the following, Resident was being transported to a room after a shower. Resident states he adjusted himself in chair and although he was not completely settled, he told CNA he was ready to go back to his room. Resident and staff educated on importance of sitting properly in chair prior to transporting. Review of Resident #51's discharge placement sheet from hospital dated, 01/18/25 reflected, Resident #51 is a [AGE] year old right-hand dominant male with a past medical history reported by the patient to have morbid obesity, CHF, Afib, congenital hydrocephalus (blindness), HTN, OSA who presents with a right distal shaft femur fracture after falling out of the shower chair at the nursing home today. He said that the while sitting on the chair the wheels broke down and he fell to the ground with his knee bent underneath him. Injury occurred at (name) nursing home. He reports experiencing immediate pain, gross deformity, and inability to bear weight about his right distal thigh after the accident. Patient was initially taken to the (name) emergency room where x-rays were obtained and then a decision was made to transfer the patient by ambulance to hospital for further evaluation and care. Preliminary x-rays were obtained revealing the above-mentioned fracture(s)/injury(s) and Orthopedic surgery was consulted. It stated Resident #51's weight was 575 lbs. During an interview on 04/14/25 03:47 PM, Resident #51 stated that he fell out of the shower chair in January of 2025. He stated he was in the hospital for 3 days and came back to receive physical therapy that had been working. The accident occurred after his shower while he was still wet. The wheels were crooked the CNA they rounded a corner and the CNA to pushed him forward, his leg got caught underneath his body. When he fell, and he heard a pow. He stated he was embarrassed because his covering came off, he was naked on the floor. The staff ended up covering him up. He did have a pending litigation with the facility. He believed they are using the same shower chair, and it causes his anxiety around shower time. He stated he only trusts one specific CNA to shower him because the CNA is strong enough to handle him. He did have a pending litigation with the facility. If the facility had been more apologetic to what happened to him, he would not bring legal action against the facility. During an interview with the Corp N. on 04/16/25 10:28 AM revealed they completed an in-house investigation to rule out neglect. She stated they checked the wheelchairs and did an in-service to retrain everyone. She stated the fall was witnessed so they ruled out abuse. They ruled out neglect earlier and major bodily injury was not sign of neglect according to her policies. During an interview with LVN A on 04/16/25 at 12:12 pm, she was a witness to the incident, and she did not suspect abuse or neglect. She stated the wheel of the chair just gave out and he slid forward onto the floor out of the chair. She saw his leg get twisted underneath him and was apart of the team that helped him get situated correctly. She stated she knew the wheelchair was ok for him and normally had one person wheeling him. She stated she thought maybe in that situation he should have been wheeled backwards, but was unsure of anything that could have been done differently to prevent the situation. During an interview with DON on 04/16/25 at 2:30 pm. She stated the event with Resident #51 happened on her second day and she was not involved in the incident. She did not have any further comments about the accident. During an interview with ADM on 04/16/25 at 3:01 pm revealed that she did not report to the stated because she believed the fall was witnessed and the facility had done their due diligence ruling out abuse and neglect within the two-hour period. They had checked that the weight limit was under his weight and verified that the aide had not done anything wrong. They were able to clear it in-house. According to her it was not suspicious. The investigation was reopened on 05/02/25. Observation of the shower chair as identified by the resident on 05/2/25 at 10:15 am revealed it was properly working and had a weight limit of 600 lbs. Interview with CNA at 05/02/25 at 10:21 am revealed that she had showered him three times before. She was sure that the shower chair's weight was certified for him. She stated she was confident the wheelchair was working because she looked at it and pushed it from the shower room to his room to transfer him. She stated when they went around the corner the wheel got stuck and I pushed him at a different angle. When I pushed the chair forward it tipped forward and was unable to catch him. He had fell on his right leg. She waited with him until EMS arrived. Interview with MAINT on 05/02/25 at 11:09 am, stated that he is up to date on most of the maintenance and he had looked at the shower chairs that month and saw nothing unusual. He stated he looked at the chair after the fall and saw no issues with the chair. He stated he didn't know if they had replaced the shower chairs. Interview with RP from the manufacturing company on 05/2/25 at 11:56 am said the shower chairs were able to be used for transportation. Record review on 05/02/2025 at 12:30 pm revealed shower chair maintenance had been completed January 7, 2025. Record review of shower chair's owner's manual states, Always abide by weight capacity. Never allow the user to suddenly shift weight in any way creating a tipping hazard for the user and the equipment. Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment. Record review of facility policy titled, Policy for Resident Incident and Visitor Accident Reports dated 07/23/18 stated, The facility will conduct an investigation of all incidents involving residents of the facility. Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations. Any employee witnessing or having knowledge of an incident or accident involving a resident or visitor must immediately report such occurrence to his/her supervisor. The supervisor and/or employee must immediately notify the charge nurse to ensure proper medical attention can be provided. Regardless of how minor an incident/accident appears to be, it must be reported to the Department Supervisor, Administrator, or DON /designee. As soon as possible after becoming aware of an incident/accident, the Witness Form must be completed by any person witnessing the incident or any person thought to have witnessed the incident. An Incident Report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. The Investigation must be initiated by the Department Supervisor or Charge Nurse and completed by the Administrator or DON/designee. Record review of facility policy titled, Abuse Prohibition Policy, reviewed May 17, 2024. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries. a.Initial Reporting i.Facility must provide sufficient information to describe the alleged violation and indicate how residents are being protected. Information should include, but is not limited to: 1.Basic facility information 2.Allegation type 3.When the facility became aware of the incident 4.Information about the alleged victim and perpetrator 5.Witnesses 6.Details about the allegation, including outcomes to the alleged victim 7.Notifications that were made to law enforcement or other agencies 8.Steps taken immediately to ensure resident(s) are properly protected 9.Who is submitting the report An IJ was identified due to the above findings on 05/02/25 at 4:30 PM The POR was as follows: On 5/2/2025 an abbreviated survey was initiated at Nursing Facility. On 5/2/2025 the surveyor an immediate jeopardy (IJ) Template notification that the regulatory Services has determined that the condition of the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide safe transport for Resident #51 on 01/17/25 that resulted in a fall from his shower chair and fracture to the right femur. Action: Resident #51 was assessed on 5/2/2025 for safety during bathing, including the use of the bariatric shower chair which was confirmed for continue use by DON. Other options were explored to include bed bath per resident preference and caregiver preference per resident preference. If assistance is needed, staff knowledgeable on how to stop and ask for support during transport. As changes arise, care plan and Kardex will continue to be modified and staff will receive education tailored to mobility needs of individual residents. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON Action: Audit completed with other residents, no other residents identified to be using the bariatric shower chair. As is standard protocol and nursing procedures, unless a resident is self-ambulatory, a resident is transported in a shower chair or gurney. Resident #51 was noted to be the only resident utilizing the bariatric shower chair. Also, during transport, caregivers will continuously remind resident of safety awareness such as placement of feet, arms, etc. to mitigate accidents during transport. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON Action: Corporate Clinical Nurse in-serviced ADM, DON, Maintenance Director, and ADON on accidents and hazards to include safe transport practices (intact, free of debris, functionality) including navigating shower chairs and responding to concerns. Verbal quiz was given to ensure competency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Corporate Clinical Nurse Action: All nursing staff in-serviced on accidents and hazards to include safe transport practices, including navigating shower chairs and responding to concerns, process if issue is identified, who to report to, and when to report. Verbal quiz was given to ensure competency. If resident is noted to shift weight or become unstable during transport, then staff is trained to stop transport and request assistance. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: DON/Designee Action: All training material will be incorporated into the new hire orientation. The training material to be included for all current nursing staff, new hires, PRN, and agency to show they were in-serviced on accidents and hazards to include safe transport practices, including navigating shower chairs and responding to concerns, process if issue is identified, who to report to, and when to report. If resident is noted to shift weight or become unstable during transport, then staff is trained to stop transport and request assistance. No employee will be allowed to work without completion of this training. Competency will be validated by verbal quizzing which will be recorded in an in-service and a copy placed in their employee file. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Administrator Action: Maintenance director in serviced by Regional Nurse on proper navigation and handling of shower chairs, accidents and hazards to include safe transport practices (intact, free of debris, functionality) including navigating shower chairs and responding to concerns. Maintenance Director conducted full audit of all shower chairs on 5/2/25 to ensure safety and integrity. No negative findings noted. Maintenance director will continue to monitor and audit shower chairs through TELS monthly tasks. Any issues to be reported to Administrator and Director of Nursing/designee and shower chair to be taken out of service until issue is resolved. Any issues and their coordinating resolution to be documented in TELS work orders. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible: Maintenance Director Action: DON/designee will observe shower completion and transportation 3x a week x 4 weeks to validate compliance and safety. Findings will be documented on audit tool. DON/designee looking to identify appropriate transport device and validate the plan of care per individual resident and staff transports are conducted appropriately. Start Date: 5/2/2025 Completion Date: ongoing Responsible: DON Action: The DON/designee will review incident reports weekly to detect trends, intervene promptly, complete root cause analysis, implement interventions, and present findings to the QA Committee for review and necessary revisions. Start Date: 5/2/2025 Completion Date: ongoing Responsible: DON THE POR WAS MONITORED AS FOLLOWS: Initial facility walk-thru on 05/03/2025 at 11:00 am revealed 7 residents up in wheelchairs to be sitting in common area next to nurse station watching television. All residents appeared neatly groomed. Further observation revealed 2 residents in wheelchairs near medication cart. One resident having vitals taken by RN A second resident receiving medications from MA G . CNA I sitting outside of room [ROOM NUMBER] for resident providing one to one sitting. CNA I stated she has provided one-to-one yesterday and today. Observation of resident coming down 200 hall walking with rolling walker to common area to watch television. Observation of housekeeping staff on 300 hall cleaning rooms. Record review of in-service of Safe Transport Practices-Shower Chair Safety and Response on 05/03/25 revealed 37 staff members have documentation of receiving in-service. In an interview on 5/3/25 at 2:41 PM with CNA J revealed CNA J stated she has received ANE in-service recently. CNA J states ANE is reported to the charge nurse and the ADM. CNA stated any suspicion of ANE is to be reported. CNA J stated if a resident falls either witnessed or unwitnessed then that is also to be reported to the charge nurse and the ADM. CNA J stated she recently received an in-service on safe transporting with the shower chairs. CNA J stated the shower chair needs to be inspected prior to use by the staff member and if the chair does not roll properly or is any form of disrepair then it should not be used and it should be reported to the charge nurse and maintenance. CNA J states if a resident shifts or slides while in shower chair then the staff member should get help from another staff member to readjust resident before continuing transport. In an interview on 5/3/25 at 3:00 PM with CNA I revealed CNA I stated she had recently received an in-service about abuse neglect and exploitation and who to report to. CAN I stated any concerns would be reported to the ADM. CNA I stated all falls are reported to the charge nurse and the ADM. CNA I stated she had received an in-service about safe transport with the shower chairs. CNA I states the shower chairs are to be inspected for safety before using with a resident. CNA I states if the shower chair is unsafe then it is to be reported to the charge nurse and the ADM. CNA I stated she thinks there is a book where it is documented and reported to maintenance, but she is not positive as she has never had to complete a work order or document on any unsafe equipment. CNA I stated if she had a resident in a shower chair and they started to slide out or readjusted and became unstable she would stop and try to secure the resident and call out for assistance from another staff member if needed. Observation on 05/04/25 at 11:13 am revealed no foul smells, the building was clean, residents in were in TV area watching TV, all residents interviewed for safety in showers chairs had call lights close to them. During interviews on 05/04/25 from 11:30 am - 5:15 pm 2 RNs, 8 LPN/LVN, and 20 CNAs from different shifts all stated they were in-serviced before working their shift. Their in-service included assessing shower chairs for safety before they were used, what to do if a resident shifts their weight, reporting unsafe shower chairs, and abuse and neglect. Interview with Corp N. on 05/04/25 at 2:30 pm she stated that she in-serviced the ADM, DON, ADON, MAINT on shower chairs and equipment, reminding residents of their safety, who to report shower chairs to and how to take it out of service and replace it. Interview with MAINT on 05/04/25 at 2:41 pm, he stated he was in-serviced by the Corp. N. about abuse and neglect, auditing the shower chairs, reviewed shower chair safety, and how to remove unworking shower chairs from service. Interview with ADON on 05/04/25 at 2:55 pm, she state that she was in serviced on abuse and neglect, safe transport in the shower chair, how to assess shower chairs for safety and how to assess resident safety in the shower chairs. Interview with DON on 05/04/25 at 3:05 pm revealed she was in-serviced on abuse and neglect, shower chair safety, inspections of shower chairs, reporting broken equipment to ADM and how to take broken shower chairs out of service. Record review of Shower Chair Inspection Audit document on 05/04/25 completed by MAINT revealed Shower chairs were audited on 02/02/25 and passed the audit. Record review of Staff In-service training record on 05/03/25 revealed that ADM, ADON, DON, and MAINT were in serviced by Corp. N on safe transport practices on 05/02/25. Record review of progress notes dated 05/03/25 at 12:55 am stated, Resident transferred to bariatric shower chair via lift and assist of 2 staff for purpose of assessing the resident' seated balance and positioning outside the scheduled shower time. Resident remained seated in chair without difficulty. Resident did not display any signs of leaning, instability, or distress during this assessment. No concerns identified at this time. Finding are consistent with safe use of current equipment and staff assistance. Record review of statement submitted on 05/04/25 stated, this is a written statement verifying that [Resident #51] is the only resident who currently uses the bariatric shower chair at [Facility name] in [City, State] as of this date. Record review of New Hire Orientation paperwork packet on 05/04/25 revealed safe transport practices for shower chairs were a part of the education and orientation. Record review of statement provided on 05/04/25 revealed an AD HOC QAPI plan meeting took place on 05/02/25 that included ADM, DON, ADON, and Medical Director. The ADM was informed the IJ was removed on 05/04/25 at 12:12 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm that was not immediate threat, 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes that met a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan which reflected Resident #1's Advanced Directive was full. Resident # 1 expired at the facility on [DATE] and there was no CPR performed . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 3:11 pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of injury, harm, impairment or death to a resident receiving care in this facility. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included heart failure (heart does not pump as well as it should), diabetes (body have trouble controlling blood sugar energy) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Resident #1 could make himself understood and was able to understand verbal content. Record review of Resident #1's care plan, dated [DATE], did not reflect an Advance Directive. Record review of Resident #1's care plan meeting notes, dated [DATE], signed by the SW reflected under the Advanced Directive section: Want to change to full code, currently DNR. Record review of Resident #1's progress notes, dated [DATE] at 10:20 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented, [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his needs/wants. [Resident #1] stated that he had been doing okay but he was having a hard time breathing, gaining weight so he may be overeating and feeling depressed because of his heart. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident #1] wishes to change from DNR to full code. Record review of Resident #1's progress notes, dated [DATE] at 10:32 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented. [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his need/wants. [Resident #1] stated that he has been doing okay but still gets depressed because of his health condition. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident # 1] wishes to remain full code. During an interview with the SW on [DATE] at 4:05 PM, the SW stated the MDS Coordinator would have been responsible for making sure Resident #1's code status was updated in the care plan. The SW stated that it was expected for the care plan to be reflected with Resident #1's code status so his wishes would have been followed. During an interview with the MDS Coordinator on [DATE] at 10:25 PM, stated she was not working as MDS Coordinator when Resident #1 changed his code status from DNR to full code at the care plan meeting [DATE]. The Prev MDS Coordinator would have been responsible for making sure Resident #1's code status was updated. The MDS Coordinator stated the MDS Coordinators were responsible for making sure the care plans were updated. The MDS Coordinator stated it was expected for Resident #1's code status to be included on the care plan. The MDS Coordinator stated without the care plan being updated there was no way to know what care to provide and the care would not have been provided . During an interview with the DON on [DATE] at 6:22 PM, she stated she was not working at the facility when Resident #1 changed his code status on [DATE]. The DON stated there was a Prev MDS Coordinator who was no longer at the facility who would have been responsible for developing Resident #1's care plan to show an Advanced Directive of Full Code. The DON stated it was expected for Resident #1's Advanced Directive to be developed in the care plan. Resident #1's wishes were not followed, and his rights were not followed. During an interview with the ADM on [DATE] at 6:48 PM, the ADM stated it was the Prev MDS Coordinator who would have been responsible for implementing and changing the code status on the care plan for Resident #1. The ADM stated it was expected for the code status to be documented in Resident #1's care plan. The ADM stated the Prev DON would have been responsible for making sure the care plans were correct. The ADM stated without the code status being documented in the care plan Resident #1 was not provided CPR and his wishes were not followed. Interview attempted with the Prev MDS Coordinator on [DATE] at 1:28 PM was unsuccessful. Left voice message for the Prev MDS Coordinator to return call. The Prev MDS never returned call . Interview attempted with the Prev DON on [DATE] at 1:30 PM was unsuccessful. Left voice message for the Prev DON to return call. The Prev DON never returned call. Record review of the facility's policy, dated [DATE], reviewed [DATE], titled Care Plans, Comprehensive Person -Centered reflected, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 7:42 PM. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 7:42 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: [DATE] F657 - The facility failed to ensure Resident #1 code status was care planned. The following actions were immediately put into place: A comprehensive review of all residents was conducted to verify code status and to ensure care plan status reflects resident current choices by DON, ADON, and Corporate Clinical Specialists on [DATE] . An Ad Hoc QAPI was held on [DATE], to include Medical Director, DON, Administrator and Corporate Clinical Specialist. A care plan training session was successfully conducted by Corporate Clinical Specialist with the interdisciplinary team, focusing on the detailed process of updating code status within the care plan, as well as providing clear instructions on how to effectively implement and modify any necessary changes. During the training, the participants demonstrated their ability to competently identify the Interdisciplinary Team (IDT), showcasing their understanding of the collaborative roles involved on [DATE]. DON/Designee will be responsible for oversight of the IDT process for updating code status within care plan . The above information will be included in new hire orientation, by the Administrator effective [DATE]. Monitoring and Audits: The DON/designee will ensure advance directive care plans are updated immediately following a status change and will conduct audits of advance directive care plans to ensure accuracy in electronic medical records (E.M.R.) weekly x 4 weeks. After 4 weeks, the DON/designee will follow the above process twice a month for 8 weeks, then monthly thereafter. The facility QA Committee will meet weekly starting [DATE], for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: Record review of the comprehensive audit of all residents to verify care plan reflected residents current Advanced Directive choice was completed on [DATE] . Record review of care plan training in service with facility nursing staff was completed on [DATE] . During an interview with the ADON on [DATE] at 12:30 PM, she stated she was trained on [DATE] with the CCS on care plans. The ADON stated care plans would need to be updated by any nurse. The ADON stated no one person was responsible for updating the care plans. The ADON stated the DON would be responsible for making sure the care plans were correct. During an interview with RN B on [DATE] at 12:57 PM, she stated she received her training on [DATE] with the ADON on care plans. RN B stated changes to care plans would need to be made immediately. RN B stated the DON would be responsible for checking the care plans for accuracy. During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over care plans. RN C stated she trained on making sure care plans were updated immediately when there was a change or change in condition. RN C stated any nurse could update the care plan and the DON would be responsible to make sure the care plans were correct. During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on care plans with the DON. LVN D stated care plans could be updated by any nurse and would need to be updated immediately. LVN D stated when a code status changed it would need to be updated immediately. During an interview with LVN E on [DATE] at 1:29 PM, stated the CCS trained her on [DATE] over care plans. LVN E stated care plans were updated immediately, and any nurse could update. LVN E stated the care plans would be checked by the DON. During an interview with the DON on [DATE] at 2:30 PM, she stated she received her care plan training on care plans on [DATE] with the CCS. The DON stated there was not one person responsible for updating care plans and all nursing staff could update or implement. The DON stated care plans would be updated immediately at the change or change in condition. The DON would be checking for accuracy on care plans and it also could be delegated to a nurse. The DON stated all nursing staff completed their care plan training on [DATE] and any new hires would receive their care plan training at new hire orientation. During an interview with the ADM on [DATE] at 2:45 PM, stated she completed her in service on [DATE] with the CCS over care plans. The ADM stated all nursing staff were trained on care plans as of [DATE]. The ADM stated all nursing staff were able up implement and update care plans. The ADM stated the DON or designee would be responsible for making sure the care plans were correct. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:11 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel and related physician orders and the residents advance directives for one of seven (Resident #1) residents reviewed for CPR . The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, which included CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 fell back in his bed while talking to Emergency Medical Services and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 3:11 pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, harm, impairment or death. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included heart failure (heart does not pump as well as it should), diabetes (body have trouble controlling blood sugar energy), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Resident #1 could make himself understood and was able to understand verbal content. Record review of Resident #1's care plan, dated [DATE], did not reflect an Advance Directive. Record review of Resident #1's care plan meeting notes, dated [DATE] , signed by SW reflected under the Advanced Directive section: Want to change to full code, currently DNR. Record review of Resident #1's progress notes, dated [DATE] at 10:20 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. Resident #1 appears to be alert and oriented, [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his needs/wants. [Resident #1] stated that he had been doing okay but he was having a hard time breathing, gaining weight so he may be overeating and feeling depressed because of his heart. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. Resident #1 wishes to change from DNR to full code. Record review of Resident #1's progress notes, dated [DATE] at 10:32 AM, written by the SW, reflected SW met with [Resident #1] at bedside to conduct MDS assessment. [Resident #1] appears to be alert and oriented. [Resident #1] hearing is minimal difficulty, but vision is adequate with glasses, impaired without them. [Resident #1] has clear speech and able to voice his need/wants. [Resident #1] stated that he has been doing okay but still gets depressed because of his health condition. [Resident #1] discharge plan is to remain at the facility LTC. [Resident #1] is his own RP. [Resident # 1] wishes to remain full code. Record review of Resident #1's progress notes, dated [DATE] at 8:00 PM, written by RN A, reflected [Resident #1] presented to nurse with chest pain and shortness of breath, swearing, anxious. Saturations 84% on room air. Oxygen 2 liters applied. Blood pressure 214/110, heart rate 88. One sl not given. Rated pain 10/10. 8:10 B/P 210/116, hr 89. 2nd sl not given. 8:15 B/P 214/128, hr 76. Aspirin 81 mg po given, EMS, DON, Family. EMS arrived at 8:23 pm. Record review of Resident #1's progress notes, dated [DATE] at 8:30 PM, written by RN A, reflected EMS placed resident on monitor. Talking to resident, all of a sudden resident fell back in bed and became non-responsive. Monitor showed PEA(without pulse). Patient was pronounced at 8:36 PM. No pulse, no respirations, no signs of life. Family arrival pending. Funeral home notified. Record review of Resident #1's DNR form, dated [DATE], reflected a form signed by Resident #1 and two witnesses. During an interview with the SW on [DATE] at 4:05 PM, the SW stated Resident #1 requested at the care plan meeting on [DATE] that Resident #1 requested his code status of DNR to full code. The SW stated the MDS Coordinator was responsible for updating the care plan from DNR to full code. The SW stated after the care plan meeting on [DATE], she removed the DNR from the binder at the nurse's station. The SW stated she met with Resident #1 on [DATE] to conduct his Quarterly MDS and Resident #1 had expressed he wanted to remain full code . During an interview with the MDS Coordinator on [DATE] at 10:25 AM, she stated she started in [DATE] date not recalled as the MDS Coordinator. The MDS Coordinator stated she was not the MDS coordinator when Resident #1 requested his code status be changed from DNR to full code. The MDS Coordinator stated the MDS Coordinator would be responsible for updating the code status to reflect the change of the DNR to full code . During an interview with the NP on [DATE] at 1:00 PM, the NP stated she was not told about Resident #1's code status was an error until after he expired on [DATE]. The NP stated her records reflected Resident #1's code status was DNR. The NP stated it was expected for the directive to have been updated and Resident #1's code status be followed per his wishes. The NP stated with no attempt to provide life saving measures Resident #1's wishes were not followed. During an interview with RN A on [DATE] at 1:29 PM, RN A stated Resident #1 came out of his room to the nurse's station on [DATE] around 8:00 PM and she immediately noticed Resident #1 was in distress. RN A stated Resident #1 was sweating and she started assessing Resident #1 's blood pressure and it was elevated. RN A stated she gave Resident #1 oxygen, a nitro, and called 911. RN A stated when EMS arrived and talked to Resident #1, he fell back in the bed and became nonresponsive. RN A checked in PCC, and it had DNR for Resident #1 and that was followed. RN A stated no CPR was performed because the code status in PCC showed DNR . During an interview with RN B on [DATE] at 2:19 PM, she stated she was finishing up on notes in the evening time not recalled on [DATE] when Resident #1 walked up to the nurse's station to state he did not feel well. RN B stated RN A assessed Resident #1 and called 911. RN B stated the last thing she knew, Resident #1 was DNR. RN B stated it was expected to follow the resident's wishes of the directive. RN B stated PCC showed DNR and that was followed. During an interview with FM #1 on [DATE] at 2:00 PM, FM #1 stated RN A stated to her when Resident #1 expired that he was DNR. The FM stated the last she knew Resident #1 was DNR and he did not tell her he was a full code. The FM stated all along she thought DNR was what Resident #1 had wanted. The FM stated she was blown away that EMS was right there with Resident #1 and could have possibly saved him. The FM stated RN A told her Resident #1 died immediately and there was nothing they could have done for Resident #1 because he was DNR. The FM stated she was so upset the facility had messed up and did not grant Resident # 1 his wishes he had requested. The FM stated the facility dropped the ball with Resident #1. During an interview with the DON on [DATE] at 6:22 PM, she stated she started with the facility on [DATE]. The DON stated she was not at the facility when Resident #1 had expired. The DON stated the current MDS Coordinator was not working in the facility during the time of the incident with Resident #1. The DON stated the MDS Coordinator would have been responsible for making the change of the DNR to full code. It was expected for the MDS Coordinator to make the change to make sure Resident #1's wishes were honored. The DON stated Resident #1's rights were not honored when his code status of DNR to full code were never changed after Resident #1 requested. During an interview with the ADM on [DATE] at 6:48 PM, the ADM stated the Prev MDS Coordinator would have been responsible for changing Resident #1's code status after the care plan meeting on [DATE]. The ADM stated Resident #1's code status was never changed from DNR to full code when Resident #1 had changed it from DNR to full code. The ADM stated it was expected for Resident #1's code status to be changed from DNR to full code when he requested at the care plan meeting. The ADM stated with the code status not being updated Resident #1's wishes were not get granted. Interview attempted with the Prev MDS Coordinator on [DATE] at 1:28 PM was unsuccessful. Left voice message for the Prev MDS Coordinator to return call. The Prev MDS never returned the call. Interview attempted with the Prev DON on [DATE] at 1:30 PM was unsuccessful. Left voice message for the Prev DON to return call. The Prev DON never returned call. Record review of the facility's policy, dated [DATE], revised [DATE], titled Advance Directives reflected. Advanced directives will be respected in accordance with state law and facility policy. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 7:42 PM. The ADM was notified. The ADM was provided with the IJ template on [DATE] at 7:42 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: F678- The facility failed to ensure Resident #1 was provided CPR. [DATE] The following actions were immediately put into place: A comprehensive review of all residents was conducted DON, ADON, and Corporate Clinical Specialists to verify code status, medical orders, care plan, and DNR documentation on [DATE]. Care plans were checked to ensure alignment with advance directive documentation DON, ADON, and Corporate Clinical Specialists on [DATE]. Advance directive binders at the nurses' station were cross-checked, with necessary adjustments made to DNR documentation by DON, ADON, and Corporate Clinical Specialists on [DATE]. DON/Designee will keep binders updated on ongoing basis. All staff were in-serviced on binder's kept at nursing station. An Ad Hoc QAPI was held on [DATE], to include Medical Director, DON, Administrator and Corporate Clinical Specialist. Inservice DON and ADON was completed by Corporate Clinical Specialist on [DATE] on the following: How to document, identify and update code status on residents. CCS/DON/Nursing Administration will in-service licensed staff on the following: How to document, identify and update code status on residents. Competency was validated by verbal quizzes. Any staff that were no in-serviced will not be able to work the floor until training and competency is validated by DON/Designee. Inservice was provided to all staff on how to identify code status by nursing admin on [DATE]. Competency validated by verbal quizzes. The above information will be included in new hire orientation by Administrator effective [DATE]. Monitoring and Audits: The Administrator /designee will conduct audits of advance directive documentation to ensure accuracy in electronic medical records (E.M.R.) weekly x 4 weeks. After 4 weeks, the Adm/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. Mock Code Drills: DON/designee will perform quarterly mock code drills for 1 year to ensure staff can effectively identify code status and respond correctly to emergencies . The facility QA Committee will meet weekly starting [DATE], for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: During an interview with the ADON on [DATE] at 12:30 PM, she stated she had in serviced over advanced directives with CCS on [DATE]. The ADON stated after she received her training, she assisted with training staff. The ADON stated a short quiz was conducted after the training and she passed the quiz. She stated she was trained making sure the Advanced Directive was in place, make sure the code status was entered in PCC under the resident's name, and to make sure the binder at the nurses' station stayed updated. During an interview with RN B on [DATE] at 12:57 PM, she stated she had received her training on [DATE] with the ADON over advanced directives. The ADON stated the Advanced Directives training included making sure code status was entered in PCC and making sure the binder at the nurse's station was updated with the code status. During an interview with RN C on [DATE] at 1:03 PM, she stated she was trained on [DATE] with the ADON over Advanced Directives. RN C stated the training was over code status and where you can find the code status in PCC. RN C stated the code status could also be found in the black binder at the nurse's station. During an interview with LVN D on [DATE] at 1:20 PM, she stated she was trained on [DATE] on advanced directives with the DON. LVN D stated she was trained on the location of finding the code status and making sure the code status was updated. LVN D stated code status would be located in the black binder at the nurse's station and in PCC . During an interview with LVN E on [DATE] at 1:29 PM, she stated the CCS trained her on [DATE] over advanced directives. She was in serviced on knowing the difference between DNR and full code. LVN knew code status was able to be located in PCC and in the black binder at the nurse's station. During an interview with Med Tech F on [DATE] at 1:40 PM, she stated she completed the training on Advanced Directives on [DATE] with the ADON. Med Tech F stated she was trained on finding the code status. Med Tech F stated the code status could be found in PCC and in the black binder at the nurse's station. During an interview with CNA G on [DATE] at 1:55 PM, she stated she completed the code states training on [DATE] with the ADON. CNA G stated the training was on the location of finding the code status. CNA G stated the code status could be located in the black binder at the nurse's station and in PCC. During an interview with CNA H on [DATE] at 2:00 PM, he stated he was trained on the code status on [DATE] with the ADON. CNA H stated he was trained on how to find the code status in PCC. CNA H stated the code status could also be found in the black binder at the nurse's station. During an interview with Med Tech I on [DATE] at 2:05 PM, he stated he was trained on the code status on [DATE] with the DON. Med Tech I stated he learned where to find the code status at the nurse's station in the black binder. Med Tech I stated he also learned where to find the code status in PCC. During an interview with the DON on [DATE] at 2:30 PM, she stated she was trained on Advanced Directives on [DATE] by the CCS. The DON stated all facility staff training was completed on Advanced Directives on [DATE]. The DON stated all staff were trained on the location to find the code status on residents. The DON stated the comprehensive audit of all residents to verify code status, medical orders, and DNR documentation was completed on [DATE]. The DON stated all staff knew every resident had a right to have their wishes followed . During an interview with the ADM on [DATE] at 2:45 PM, she stated she completed her in service on [DATE] with the CCS over code status. The ADM stated all facility staff were trained on code status as of [DATE]. The ADM sated the code status audit were completed on [DATE], on all residents. The ADM stated the DON or a designee would be responsible for the audits and mock trials that will be conducted. The ADM stated any new staff will be trained at the new hire orientation. Record review of the comprehensive audit of all residents to verify code status, medical orders, and DNR documentation was completed on [DATE]. Record review of how to document and verify code status in service with all facility staff was completed on [DATE]. The ADM was informed the Immediate Jeopardy was removed on [DATE] at 3:11 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, inter, and record review, the facility failed to ensure a 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 three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pressure ulcers. The facility failed to: 1) - Provide treatment and services to heal Resident #2's PUs on the gluteus, sacrum, and left heel and the wounds became larger. - Provide treatment and services to prevent infection to Resident #2's sacral PU and it became infected. An IJ situation was identified on 03/18/24.L The IJ template was provided to the facility on [DATE] at 2:40 PM. While the IJ was removed on 03/19/24 the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. 2) - Provide treatment and services to heal Resident #1's three pre-existing stage 2 PU for nine days when he returned from a brief stay at the acute care hospital. - Provide treatment and services to heal Resident #1's stage 2 pressure ulcer acquired on 3/15/24. - Provide treatment as ordered on 03/04/24, 03/06/24, 03/09/24, and 03/12/24 to Resident #3's stage 2 PU These failures could place residents at an increased risk of complications such as pain, acquiring new ulcers, worsening of existing ulcers, and infection. Findings included: 1) Review of Resident #2's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected resident is a [AGE] year-old female originally admitted to the facility 07/28/23 and readmitted [DATE] after an admission to an acute care hospital. Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected resident was dependent on staff for all ADL care including, eating, hygiene, dressing, rolling left and right, and transfers. Section I (Active Diagnoses) reflected hypertension (high blood pressure), orthostatic hypotension (blood pressure drops when changing position from sitting to standing), renal insufficiency (poor kidney function), neurogenic bladder (lack of bladder control due to nerve or spinal cord problem), septicemia (blood infection), quadriplegia (paralysis of arms and legs), malnutrition, anxiety disorder (intense and excessive worry and fear), depression (feeling of sadness and loss of interest), osteomyelitis of vertebra sacral and sacrococcygeal region (bone infection of the tailbone), and other lack of coordination. Section M (Skin Conditions) Reflected resident had one Stage 2 PU (a break in the top two layers of skin), one Stage 3 PU (the injury goes through the layers of the skin into the fatty tissue), and one Stage 4 PU (deep injuries that may go into the muscle, tendons, ligaments, and bone) all at the time of admission/entry or reentry. Review of Resident #2's Physician Order dated 01/19/24 reflected, Gluteus Rift Distal Wound (in the crease between the buttocks)- Cleanse the wound with Dakin's Sol 0.25% using gauze sponges. Do not scrub. Allow Dakin's to remain on wound bed for 10 minutes. Then rinse with N/S using gauze sponges. Then apply Triple Helix to the wound bed - fill remaining cavity with xerofoam and the cover with sacral foam dressing (3x week M-W-F. External foam dressing should be changed prn if soiled). Review of Resident #2's Physician Order dated 03/11/24 reflected, Per wound care clinic: calcaneus wound left lateral: Cleanse wound with Dakin's solution 0.25%. Apply iodosorb gel. Apply calmoseptine ointment to peri-wound. Apply Mepilex Heal AG dressing every M, W, F x 30 days. An order dated 03/10/24 reflected, NPWT to Right Distal Gluteus at 150 mm/hg pressure. Prisma to wound bed, black foam. Check Wound vac q shift. Wound Care will apply the wound vac. If wound vac become dysfunctional and is not able to restore to proper functioning within 2 hours, please follow previous dressing orders. ***Check wound vac q shift. An order dated 3/12/24 reflected, Medial Sacral Wound (Wound #1) NPWT to wound continuously at 150 mm/hg Black foam. (NPWT is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate and promote wound healing) Review of Resident #2's care plan initiated 12/12/23 reflected, The resident has a stage 3 to the right buttock wound #2 related to disease process and Resident has a stage 4 to the sacrum/coccyx wound #1 related to disease process. Care plan initiated 03/16/24 reflected, I have a stage 3 pressure injury/ulcer (Left posterior calcaneus wound #5) r/t disease process. An intervention for the calcaneus wound included Turn and reposition when direct care provided and PRN. Review of Resident #2's wound clinic notes from 03/14/24 visit reflected: Wound #8 left calcaneus wound was acquired 02/05/24. Measurements as follows: 02/09/24 1 cm x 1 cm x 0.1 cm 02/23/24 1.5 cm x 1cm x 0.1cm 3/8/24 2.5 cm x 2.5 cm x 0.2 cm 3/14/2024 2.1 cm x 2 cm x 0.2 cm. Wound #4 acquired 07/05/23 Pressure ulcer gluteus, right distal measurements included: 03/01/24 1 cm x 0.9 cm x 1 cm 03/08/24 1.5 cm x 2 cm x 2 cm 3/14/24 2 cm x 2 cm x 3 cm Wound #1 acquired 11/01/22 Pressure ulcer sacrum medial measurements included: 03/04/24 2.5 cm x 2.7 cm x 1.5 cm 3/8/24 3 cm x 3 cm x 3 cm 3/14/24 2.5 cm x 2.7 cm x 2.5 cm. Review of Resident #2's wound care clinic noted dated 02/23/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, she states the staff hasn't been dressing it NPWT was initiated today and wound vac with black foam applied to both sacral and gluteal pressure ulcers Review of Resident #2's wound care clinic noted dated 03/01/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, and even more there was no dressing to ANY of her wounds . the right buttocks seems to have additional depth today. Patient also indicates that the staff are not turning her routinely for off-loading. Orders attached to the note reflected in part, .Calcaneus, left cleanse with Dakin's Solution . peri-wound calmoseptine ointment . Iodosorb gel, primary dressing mepilex heel Ag Dressing . 3 x per week/30 days. Turn and reposition every 2 hours. Review of Resident #2's wound care clinic noted dated 03/08/24 reflected, Upon arrival there is, again, no dressing to the left calcaneal decubitus ulcer, and even more there was no dressing to ANY of her wounds .She reports that she has been asking the staff about her dressing changes and has not gotten anyone to perform the care. Upon exam, the calcaneal heal has more non-viable tissue to the wound bed . The right gluteal ulcer has increased drainage and increased size to the sacral ulcer with some deeper red color to portion of wound bed that is suspicious for deep tissue injury. Culture obtained and will follow up with sensiva report next week. Review of Resident #2's wound care clinic noted dated 03/14/34 reflected, Patient present to her f/u appointment .She is noted to have unfortunately developed a new wound to right hip - skin tear from dressing possibly. Dressing to heel was not as ordered. She has started the antibiotics prescribed per sensiva report after culture last week. Upon exam the calcaneal heal has more non-viable tissue .The right gluteal and sacral ulcers again have increased drainage and increased size . Review of Resident #2's Order Summary Report of active order printed on 03/18/24, reflected and order written 10/11/23, Completely float bilateral heels off the bed with pillows and apply egg crate to bilateral feet. Only remove to do wound care and showers then replace every shift. There were no orders to turn or reposition the resident. Review of Resident #2's Treatment Administration Record for March 2024 reflected no treatment orders for the calcaneal wound from 03/01/24 through 03/10/24. The treatment record reflected the gluteal wound and sacral wound treatments were not completed on 03/04/24 and 03/06/24. Review of Resident #2's evaluations/assessments reflected wound assessments were not completed weekly for each identified wound: 02/02/24 for wounds #1, #2, #4, and #5 02/14/24 for wounds #1, #2, #4, and #5 02/23/24 for wounds #1, #2, and #5 03/01/24 for wound #1 03/14/24 for wounds #1 and #2 03/16/24 for wound #5. During an observation and interview on 03/16/24 at 2:10 PM, with Resident #2, resident was observed lying in bed with the head of the bed elevated. Resident was observed with boots on her feet but no pillow under her legs. Resident stated she had been at the facility since July 2023. She stated she was in a motorcycle accident in 2022. As a result of the accident, she was quadriplegic and had an infection in her tailbone from a piece of asphalt. She stated she had received several rounds of IV antibiotics for the infection. She stated she came to this facility because the wound clinic nearby had a great reputation and success rate and she hoped to get her wounds healed. She stated the staff did not reposition her regularly and she often had to ask for a pillow to float her heals. She stated the facility did not perform wound care daily and had not done the treatments to her feet all week. She stated one day the facility took off all the dressings to assess the wounds but they never put the dressings back on. Resident stated NPWT dressing were on her back side. NPWT machine observed near bedside table, fluid was visible moving through tubing. During an interview on 03/16/24 at 2:00 PM, with LVN C, she stated they did not have a wound care nurse so the nurse assigned to the resident was responsible for performing wound care. She stated RN A often did all the treatments on the weekend. She stated weekly skin assessments are completed by the assigned nurse and weekly wound assessments were done by the RN supervisor, ADON, or DON. During an interview on 03/17/24 at 12:36 with ADON, she stated the RN or DON was responsible for measuring wounds. She assisted by entering the data collected by the RN on to the weekly wound report. She stated she usually entered the data a couple days after it was collected. She stated she did not enter the data as a late entry so the assessment appeared to be done on the day the data was entered. She stated if there had been a new wound or a wound had worsened, the RN would have been responsible for contacting the doctor or NP on the day the wound had been observed. During an interview on 03/17/24 at 3:33 PM, the DON stated the on-duty nurse was responsible for calling the doctor or NP to obtain new orders. She stated it was her expectation that residents were turned/repositioned at least every two hours unless otherwise ordered. During an interview on 03/17/24 at 3:55 PM, the ADM stated the nurse assigned to the hall was responsible to complete wound care. She stated it was her expectation that treatments were completed as ordered. She stated not treating the resident could cause more wounds or make current wounds worse . During a telephone interview on 03/18/24 at 8:07 AM with the clinical nurse manager from the wound care clinic, she stated the team at the clinic is concerned about the care provided at the facility as the resident's wounds have been getting worse. She stated the resident was in her right mind and she was able to speak to the care provided. She stated she would re-send notes from the most recent visits to the facility. During an observation and interview on 03/18/24 at 10:54 AM, Resident #2 was observed lying on her back with the head of the bed elevated. Resident #2 had a pillow under her legs. She stated, They only put the pillow under my legs if I ask them to do it. During an interview on 03/18/24 at 12:53 PM with RN B, she stated Resident #2 has wound care to her left foot daily. She stated she had not done the treatment to the gluteus wound in a long time. After looking at the TAR, she stated she signed for the treatment on 03/08/24 because the NPWT machine was turned off for an undetermined amount of time, so she removed the NPWT dressing and she replaced it with the dressing ordered in case the NPWT dressing came off. She then stated the resident was not receiving NPWT on 03/08/24. During an interview on 03/18/24 at 1:02 PM with CNA G, she stated, Resident #2 was turned every two hours. She stated sometimes they get busy so she may not have been turned every two hours but she tried. She stated the resident is supposed to have a pillow under her legs. She stated she used a pillow under the draw sheet to help position and off-load pressure. She stated by not turning residents, they could get wounds or the wounds could get worse. During an interview on 03/18/24 at 1:13 PM with LVN D, she stated she worked intermittently at the facility but she was somewhat familiar with Resident #2. She stated she did not remember what specific devices the resident used for pressure ulcer prevention but knew the resident had pressure ulcers. She stated she had not performed wound care on Resident #2 in quite a while. When asked why she had signed for the treatment to the gluteus wound on 03/13/24 she stated, We don't do any treatment on her butt because she has the NPWT treatment. During a telephone interview on 03/18/24 at 1:35 PM with the wound clinic nurse manager, she stated the NPWT had been discussed in January 2024 then reordered on 02/16/24. She stated the facility used their own contracted company to provide the machine. The machine was finally provided and the dressing applied to the resident on 03/08/24. The clinic changed the NPWT dressings every Monday, Wednesday, and Friday to both the sacral and gluteus wounds. Review of the facility's in-service records reflected an in-service dated 02/03/24, At any time any skin issues that is seen/arises, report to nurse, report to medical doctor, to obtain orders and give treatment to resident. Ensure to document at all times and follow up with proper documentation. [sic] Review of the Facility Skin Integrity Prevention and Treatment Program, last revised 01/23, reflected in part, Skin Essentials Assessment and Documentation Standards include but no limited to: Braden Skin Risk Assessment Skin Risk Analysis and Interventions Developed Weekly Skin Integrity Checks Weekly Wound assessment a. Each identified skin issue/area is assessed weekly in electronic medical record. b. If treatment or interventions change or wound presentation is reclassified update care plan d. Physician updated. Wound Care Review of the Pressure Injury Prevention Program Procedure last revised 01/23, reflected in part, Standard - All Residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. Procedure - 1. Braden Skin Risk Assessment 2. Skin Risk Analysis and Interventions Developed 3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries a. Frequent turning and positioning b. Do not massage over any reddened areas c. Keep residents clean and dry d. Provide incontinent care as appropriate e. Monitor resident's nutritional intake f. Pad between bony prominences g. Keep linens clean and wrinkle free h. Utilize pressure reducing devices as needed (ex. Cushions, Therapeutic Support Surfaces, Positioning Devices) . 4. All residents will have a head-to-toe assessment (shin check) completed on a weekly basis . 5. If a pressure injury/skin breakdown is identified, the following will be done - a. If new area found .complete new wound evaluation/ assessment b. Assessment must include Size Stage Location Drainage amount . c. Notify MD - obtain treatment orders d. Notify RP/ or family . e. Update care plan . This was determined to be an Immediate Jeopardy (IJ) on 03/18/24 at 2:43 PM the Administrator and Director of Nurses were notified. The Administrator was provided with the IJ template on 03/18/24 at 2:43 PM and a Plan of Removal was requested The following Plan of Removal submitted by the facility was accepted on 03/19/24 at 10:37 AM: F686 - The facility failed to provide treatment and services, consistent with professional standards of practice to Resident #2 with pressure ulcers to promote healing, prevent infection and prevent new ulcers from developing. Six Residents with current pressure injuries had potential to be affected by this failure. The following actions were immediately put into place: Resident #2 was evaluated, and wound treatment orders verified and completed per MD orders and plan of care updated by DON on March 18, 2024 An Ad Hoc QAPI was held on March 18, 2024, to include Medical Director, DON, Administrator and Corporate Clinical Specialist. A complete head to toe skin sweep was initiated and completed on all residents on 3/18/2024 and completed by DON, ADON, RN Weekend Supervisor include updated assessments which includes pressure and non-pressure assessments, measurements, staging and description of wound appearance updating/initiating treatment orders if indicated, notification of MD/ family, care plans update. On 3/18/2024 reassessment of residents with pressure and non-pressure wounds was completed by DON/Designee, to include current measurements and staging as well as any required treatment changes. An audit was completed of Braden Scales, for all current residents /current treatment/wound orders, and care plans to ensure accuracy. Audit was completed by CCS/DON/Designee on March 18, 2024. Inservice for nursing administration was completed by CCS on 3/18/2024 on the following: Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out physician orders. Competency was validated for DON, ADON and MDS by CCS on March 18, 2024. On March 18, 2024, the DON/Designee completed in servicing of all nurses on the skin policy and protocol to include reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out of physician orders. All nurses will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. On March 18, 2024, an Inservice for certified nursing assistants was completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice was completed on March 18, 2024. No CNAs will be allowed to work their scheduled shift until they complete the Inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation, by Administrator effective March 18, 2024. In order to monitor current residents for potential risk, DON/Designee will conduct a skin sweep weekly x 4 weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON compliance weekly. The facility QA Committee will meet weekly starting March 18, 2024, for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. The Surveyor monitored the Plan of Removal on 03/19/24 as followed: During an interview on 03/19/2024 10:37 AM with CNA/MA E, she stated she had worked in the facility for about a year. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/2024. She stated they called and in-serviced her on the phone on 03/18/2024 and she signed the in-service today. She stated she observed and checked all of her resident's skin daily during showers and incontinent care when she is working as a CNA. She stated when she is working as a medication aide, she also looks at the resident's visible skin. She stated if a resident had a new skin issue, she would go immediately and report it to the nurse. During an interview on 03/19/2024 at 11:18 AM with RN B, she stated she had worked in the facility for about 2 years. She stated she had been in-serviced on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders when she first began working here and also just this week. She stated they were in-serviced on how to stage wounds and how to do treatments correctly and follow wound care doctors' orders also. She stated all the residents have weekly skin assessments and if there is something found in between that time they would write up a new report. She stated they have a nurse practitioner that is on call 24 hours a day and they would report any new skin concerns to her or the resident primary physician. She stated if a resident had a new skin issue, she would do a basic assessment, full skin assessment, vital signs, and a skin report, call and notify family, DON, and doctor, and follow doctor's orders. During an interview on 03/19/2024 at 12:00 PM with LVN C, she stated she had worked in the facility for about a year and 5 months. She stated she had been in-serviced on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders on 03/17/24. She stated skin assessments are done on a weekly basis on residents scheduled shower days and they check to see if there are any changes to residents' skin. She stated if a resident had a new skin issue, she would notify her DON, ADON, doctor, family and hospice if resident is on hospice services, receive new orders for treatment to area, and follow through with the doctor's orders. During an interview on 03/19/2024 at 12:06 PM with CNA G, she stated she had worked in the facility for about 2 years. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would report it to the nurse immediately. During an interview on 03/19/2024 at 12:12 PM Interview with CNA H, she stated she had worked in the facility for about 1 month. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24 and also this morning. She stated she also was in-serviced on the phone 03/17/24 plus a few more times. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would immediately write it on the shower sheet and report it to the nurse. During an interview on 03/19/2024 at 12:19 PM with CNA I, she stated she had worked in the facility for about a year. She stated she had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/19/24. She stated she observed and checked all of her resident's skin daily during showers and incontinent care. She stated if a resident had a new skin issue, she would let the nurse know right away. During an interview on 03/19/2024 at 12:34 PM with CNA/MA F, he stated he had worked in the facility for about a year. He stated he had been in-serviced on notifying the charge nurses of any issues with residents' skin on 03/18/24 and one other time but he cannot remember the date. He stated he observed and checked all of his resident's skin daily during showers and incontinent care. He stated if a resident had a new skin issue, he would report it to the nurse and the DON/ADON. During an interview on 03/19/2024 12:41 PM with the DON, she stated she had worked in the facility for 1 week today. She stated she had been in-serviced by corporate and she had in-serviced nurses on skin policy and protocol, reporting skin changes, process of assessment and documentation of all skin concerns, how to conduct skin assessments, notifying resident's doctor and family, and carrying out physicians' orders on 03/17/24 - 03/19/24. She stated she in-serviced CNA's on notification to nurses about any skin concerns on 03/17/24 - 03/19/24. She stated all staff were in-serviced on pressure ulcer prevention and turning and repositioning on 03/17/24 - 03/19/24. She stated all nursing staff have been in-serviced. She stated education on skin assessments and protocol for new skin issues would be included in new hire orientation from here on out. She stated she would be performing skin sweeps on all residents weekly for 4 weeks and then as planned in the facility plan of correction. She stated if a resident had a new skin issue, the CNA should go immediately to her and the charge nurse. She stated if she found a new skin concern, she would report it to the resident's nurse, call the doctor and family to inform them, and get some type of treatment to prevent further injury to that wound and something to treat the wound as well. She stated they had a QAPI meeting on 03/18/2024 with Medical Director, the Administrator, herself, and a regional nurse, regarding the plan of removal and they went over all wounds in the facility and how to take care of and treat and also to prevent other wounds from occurring. She stated they also discussed the plan of removal with the medical director so he would be aware of the plan. During an interview on 03/19/2024 at 1:51 PM with Resident #2, she stated she was doing fine, and the staff had been taking care of all of her wound care needs and she had received a shower today. She stated she had a concern about her Medicare or Medicaid benefits which was passed on to the DON. Resident was sitting up in wheelchair with blankets covering her up to chest area. Resident was in no sign of pain or distress and her call light was in reach. Reviewed QAPI meeting held on 03/18/2024 which included medical director, Administrator, DON, and Corporate Clinical Specialist and regarded abatement plan for immediate jeopardy citation. Reviewed records on skin sweep performed for all residents on 03/18/2024 with a Skin Monitoring: Comprehensive CNA Shower Review sheet. Reviewed in-servicing for nursing management and nurses completed on 03/18/24 which covered skin policy and protocol to include reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out of physician orders. Reviewed in-servicing for CNA's completed on 03/18/24 which covered immediate notification to their licensed nurse of any skin concerns or dressing soiled or dislodged that they observe. Reviewed in-servicing for all staff completed on 03/18/24 which covered turning, repositioning, and off-loading. Reviewed nurse and CNA skin quizzes all completed on 03/17/24 and 03/18/24. Record Review of Resident #2 admit date - 07/28/2023 DX - Quadriplegia, Osteomyelitis of Vertebrae (Infection of bone in spine), Dysphagia (difficulty swallowing), Chronic Pain Syndrome Full Code BIMS - 14 Care plan updated - 03/17/24 Braden Scale completed - 02/03/2024 Record Review of Resident #3 admit date - 05/12/2023 DX - COPD, Diabetes, Dementia, Osteoarthritis Full Code BIMS - 07 Care plan updated - 03/17/24 Braden Scale - 02/01/2024 Record Review of Resident #4 admit date - 11/30/2023 DX - Dementia, Osteoarthritis, Hypertension, Muscle Weakness DNR BIMS - 99 Care plan updated - 03/17/24 Braden Scale - 03/17/2024 Record Review of Resident #5 admit date - 06/12/2023 DX - Colon Cancer, Anxiety, Dementia, Rheumatic Tricuspid Valve (a condition that affects a valve in the heart) DNR BIMS - 10 Care plan updated - 03/16/24 Braden Scale - 03/17/2024 Record Review of Resident #1 admit date - 04/21/2018 DX - Lobar Pneumonia (infection that affects a lobe of the lung), Atrial Fibrillation, Dementia, Cerebrovascular Disease DNR BIMS - 08 Care plan updated - 03/17/24 Braden Scale - 03/17/2024 Record Review of Resident #6 admit date - 05/02/2023 DX - Fibrosis, Anxiety, Dementia, Catatonic Disorder (a complex behavioral syndrome characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal) Full Code BIMS - 99 Care plan updated - 12/12/2023 Braden Scale - 02/01/2024 On 03/19/24 at 10:37 AM, the Administrator and Director of Nurses were informed the IJ was removed however the facility remained out of compliance at a severity of potential for more than minimal harm that was not Immediate Jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2) Review of the facility pressure injury report dated 03/16/24 reflected Resident #1 had the following pressure injuries: One un-staged pressure injury measuring 2 cm x 0.2 cm x 0.2 cm (wound #2) acquired 03/01/24 located on middle buttock left. One Stage 2 pressure injury measuring 2 cm x 2 cm x 0.1 cm (wound #3) acquired 03/01/24 located on right medial buttock. One Stage 2 pressure injury measuring 0.5 cm x 0.4 cm x 0.1 cm (wound #4) acquired 03/15/24 located on right wound. One Stage 2 pressure injury measuring 1 cm x 0.8 cm x 0.1 cm (wound #1) acquired 03/01/24 located on right buttock lateral. Review of the facility pressure injury report dated 03/16/24 reflected Resident #3 had the following pressure injury: One Stage 2 pressure injury measuring 1.6 cm x 0.5 cm x 0.2 cm (wound #1) acquired 03/10/24 located on the coccyx. Review of Resident #1's 5-day MDS assessment, dated 12/30/23, Section A (Identification Information), reflected an [AGE] year-old male originally admitted to the facility on [DATE]. Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was independent for most [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for (Resident #1) of 5 residents reviewed for accidents and supervision. Resident # 1 eloped from facility on 2/5/2023 and fractured her left rib. An (IJ) Immediate Jeopardy was identified on 4/12/2023 at 4:45PM. While the (IJ) Immediate Jeopardy was removed on 4/13/2023 at 6:00PM, the facility remained out of compliance at a level of actual harm that was not immediate Jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their corrective systems. This failure could place all residents at risk for accidents and harm. Findings included: Observation on 4/11/2023 at 3:00PM, reflected the facility is located on a main highway that had high traffic. The highway was approximately 50feet from the facility. The facility had a fence around one side of the building where Resident # 1's room was located. The fence was observed with no lock it was able to be pushed open with no resistance, no alarm noted on the fence, the fence lead to the west side of the parking lot and then to the main highway. The police station where Resident # 1 eloped to was approximately 1.1 miles from the facility driving and located on a busy street. Observation on 4/12/2023 at 3:15PM of Resident # 1 room window room [ROOM NUMBER], the window was observed to be low about 2feet from the floor. The window had 2 hinges that lock the window, both hinges must be pressed at the same time to open the window. All the windows in the facility have the 2 hinge lock. During a phone interview on 4/11/2023 at 11:45AM with LVN A, stated she was one of the nurses on duty the night Resident # 1 eloped from the facility. She stated she gave Resident # 1 her night medication about 9:30pm. She stated Resident # 1 was observed walking around the facility and in the common area watching television with others the night of the incident. LVN A stated she last saw Resident # 1, around 1:00AM walking down 600 Hall. She stated then around 4:30A, she was in the process of admitting another resident back into the facility when the local law enforcement showed up at the facility asking if they had a resident and gave Resident # 1 name. LVN A stated when she spoke with the police, she was advised that Resident # 1 had walked to the police station and that she had been held captive by some men in an apartment. She stated the police reported that Resident # 1 complained of pain and fell in their lobby floor, she stated she was then transported to the hospital for further treatment and examination. LVN A stated when they went and checked Resident # 1 room, they found the window up and screen pushed out, she stated she was not aware that the resident was missing. LVN A stated they usually make rounds every two hours or when the residents turn on their call light. During a phone interview with LVN B at 12:07PM, revealed she worked the night Resident # 1 eloped from the facility, she stated she worked from 6:00PM to 6:00AM. LVN B stated she remembered seeing Resident # 1 walking around the facility throughout the night. She stated Resident # 1 asked her a few times that night for the number to the police department. LVN B stated the last time she saw Resident # 1 was around 12midnight and 1:00AM. She stated when she took her break outside is when the police showed up around 4:30AM asking if they had a resident and gave Resident # 1 name. LVN B stated, she and LVN A went down to Resident # 1 room and noticed that her window was wide open, and the screen was off. She stated the police reported that Resident # 1 complained of pain and was transported to the local hospital. LVN A stated she was not aware that Resident # 1 was missing from the facility. She stated they make rounds every two hours and reported that she tried to coordinate her rounds with the aides, so checks are completed ever hour. LVN B stated she had never seen Resident # 1 try to elope before but stated she would often get her to dial the police for her. She stated Resident # 1 would walk all the time around the building. In an interview on 4/11/2023 with CNA A, stated she worked another hall when Resident # 1 eloped from the facility. She stated they usually make their rounds every two hours and reported they make their last rounds about 3:30AM. CNA A stated around 4:00AM the police showed up at the facility asking if they were missing a resident and gave Resident # 1 name. She stated they immediately went down to Resident # 1 room and observed Resident # 1 was gone. CNA A stated earlier that day Resident # 1 was walking around asking for different phone numbers for different people. CNA A stated they were not aware that Resident # 1 was gone from the facility. She stated she had been in-serviced on elopement process and procedures, abuse and neglect, she stated the ADM was the abuse/neglect coordinator. In an interview on 4/11/2023 at 4:30pm with DON, stated she received the call about 4:30am from LVN A, who was on duty. She stated the police were still at the facility when she called and advised her that Resident # 1 had eloped from the facility and walked to the police station. DON stated the resident was able to elope from the facility by raising her window and pushing the screen out. She stated Resident # 1 had never tried to elope before, she stated Resident # 1 would often check doors, and go out the dining room door and pull on that gate, but that gate has a lock. DON stated she just thought Resident # 1 likes the security of checking doors but had never seen her actually try to elope from the facility. The DON stated the fences around that side of the building did not have any locks. DON stated after Resident # 1 elopement she was placed on one-on-one supervision until she was able to be placed in another facility on a secure unit. The DON stated once Resident # 1 arrived at the new facility she continued to complain about pain in her back a side, stated the facility completed more x-rays and saw that Resident # 1 had a fractured left rib, from her recent fall when she eloped. Record review of facility incident report dated 2/5/2023 reflected, on 2/5/2023 at approximately 4:30am the facility was notified by the local police department that Resident # 1 had eloped and walked to the police station. The facility was advised that Resident #1 reported she fell and hurt her back/left rib area Resident # 1 was transported to the local hospital. Record review of police report dated 2/5/2023, reflected Resident # 1 entered the police lobby at around 3:38AM. The report reflected at 3:44AM, EMS was contacted due to Resident # 1 complaining of pain on left side. The report stated Resident # 1 fell in the lobby and had labored breathing. The report reflected Resident # 1 claimed that she had been held against her will for several days and escaped. The report reflected law enforcement made contact with the facility at 4:26AM and learned that Resident # 1 had been a current resident. Record review of hospital records dated 2/5/2023, reflected Resident # 1 was admitted to on 2/5/2023 for rib/trunk pain- swelling. The report reflected Resident # 1 stated she was drugged with a cloth over her mouth and tripped while escaping hitting her left flank on a curb. The report reflected CT (computerized tomography) scan of the head/brain reflected no intercranial abnormalities, X-Ray of chest -No acute cardiac or pulmonary abnormalities, vitals HB (heart- beat)-78 bpm (beats per minute), Oxygen saturation -96%, respiratory rate-18 br (breathes/ per minute), temp.- 97.8 BP (blood pressure) 133/82. Discharge disposition: Good, stable oriented x 2 (to place and time), to return resident to ER (emergency room) if any new or worsening symptoms. Review of Resident #1 face sheet dated 4/12/2023, reflected Resident # 1 was a 94- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with Unspecified Dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and to solve problems), psychotic disturbance (severe mental disorder that causes abnormal thinking and perceptions), Mood disturbance (feelings or distress, sadness or symptoms of depression and anxiety) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #1 quarterly MDS dated [DATE] reflected a BIMS score of 03 which indicated severe impairment. Section E of MDS (behavior) reflected, Resident # 1had a behavior of wandering. Review of Resident # 1 care plan dated 10/17/2022, reflected the following: Problem: Resident is unaware of safety needs, Gait/balance problems, cognitive deficits with Dementia. Interventions: Bed in low position, floors free from clutter, glare free light, call light within reach personal items within reach. The care plan did not reflect any interventions regarding elopement or wandering. Record Review of quarterly Wander assessments dated10/25/2022 reflected, Resident # 1 was at a high risk for wandering with a score of 14. assessment dated , 1/25/2023 reflected, Resident # 1 was a moderate risk for wandering with a score of 8. Wander assessment dated [DATE] reflected, Resident # 1 was at a high risk for wandering with a score of 21. Record Review of progress notes dated 9/2022- 1/2023 reflected since admittance to the facility Resident #1 often spoke of leaving the facility. Resident#1 often talked about family members and friends coming to get her to take her home to live in Dallas or Mexico. Record Review of facility one on one monitoring for Resident # 1 dated 2/5/2023 -2/7/2023 reflected, the facility provided 30min. monitoring starting when Resident # 1 initially returned to the facility. 2/6/2023- 2/7/2023 monitoring reflected 24-hour monitoring of Resident # 1 until she discharged on 2/7/2023 to another facility with a secure unit. Record Review of facility Wander Management, Monitoring System & Resident Elopement Protocol policy dated: 1/2023 reflected: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. To provide a system to alert staff that a resident may be attempting to leave the facility All staff is responsible to ensure resident safety Record Review of facility Abuse/Neglect policy 12/12/2019 reflected: Neglect is the failure of the facility, to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record Review of facility in-services dated 2/5/2023, reflected all staff have been in-serviced on Elopement, abuse/neglect, how to supervise, monitor, and redirect residents, Notifications to responsible parties and emergency contacts for incidents/accidents Record Review of QAPI - (Quality Assurance and Performance Improvement) held quarterly dated-September 2022- February 2023 to address elopement. An (IJ) Immediate Jeopardy was identified on 4/12/2023 at 4:45PM. The ADM was notified on 4/12/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/12/2023 at 4:45PM. A Plan of Removal was first submitted by the ADM on 4/13/2023 at 11:31am. The Plan of removal accepted on 5/3/2023 at 4:00pm Plan of Removal April 12, 2023 Immediately on Regional Director of Operations conducted a post incident huddle with, prior Administrator, DON/RN to conduct a root cause analysis and to develop a list of actions. During the post investigation huddle and Administrator were in-serviced on Elopement Policy to include Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. Upon review of the IJ template written on 4/12/2023, it was noted that Resident #1 would often check doors and pull on doorknobs. Immediately we spoke to DON regarding this notation. DON explained that the conversation she had with the surveyor was regarding behaviors of the resident prior to the elopement on 2/5/2023. When the elopement occurred on 2/5/2023, DON was trained on the elopement policy along with how to identify exit seeking behaviors as notated above by, RDO. On 4/12, Regional Director of Operations, Regional [NAME] President and Chief Operating Officer re-in-serviced the Interim Admin and DON on the elopement policy with a focus on identification of elopement risk to include exit seeking behaviors, verbalizations of a plan to exit the facility as well as how to intervene when these behaviors are noted to include 1:1 supervision and discharge to an appropriate setting. Resident #1 remained on 1:1 supervision from time of elopement until she was discharged [DATE] to a secure unit in Copperas Cove. Resident #2 was place on 1:1 supervision as a result of a suicidal ideation on March 9, 2023 until discharged for further psychiatric evaluation and treatment to Oceans Behavioral hospital on 4/24/2023. On 4/12/2023 Maintenance Director rechecked all exit doors for functionality and closure/locking. The facility put a precautionary lock on the fence on 4/12/2023. Maintenance Director checked all windows to ensure the locks were functional 4/12/2023 Wander /elopement risk assessments were updated by Nursing admin on 4/12/2023, for all residents to ascertain risk for wandering, and appropriate interventions implemented. Elopement binder was checked and up to date on 4/12/2023. On 4/12/2023, The DON/designee initiated in-servicing of department heads and staff on the policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. Additional in-servicing done 4/12/2023 on policy and procedures of elopement which included but does not limit to: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement. On 4/12/2023, Administrator/Designee initiated training with department managers on the roles of the nursing department and non nursing departments when a resident is exit seeking and when a resident elopes, and our elopement policy. The department managers trained staff on the roles of the nursing department and non nursing departments when a resident is exit seeking and when a resident elopes, and our elopement policy. Each role was discussed in the scenario of an active elopement occurrence. In addition, the Administrator, Maintenance Director, and DON verbally conducted an elopement drill where each role was discussed in different active elopement occurrence scenarios. Staff was able to verbalize understanding. Additional elopement drills were completed 4/12/2023 The elopement mitigation policy is part of new hire orientation. In order to monitor current residents for potential risk, IDT team will review and discuss all wander risk residents daily for 30 days to identify any potential behavior changes. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year for. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of Plan or Removal on 4/13/2023 is as follows: Observation on 4/13/2023 at 3:00pm walk around with Maintenance director, checked locks on the outside fence, observed nails placed in the windows 6inches up. Observation on 4/13/2023 at 3:30PM, random check on rooms on 600 hall this hall is still under construction rooms observed screw in window 6inch up, maintenance man measured to ensure placement. Observation on 4/13/2023 at 3:45PM random check on rooms 306, 605, 406 observed screws in each window. In an interview on 4/13/2023 at 5:00PM with interim ADM, stated on 4/12/2023 she verbally advised the MD of the IJ (Immediate Jeopardy) concerns identified. In an interview on 4/13/2023 at 3:33PM with Maintenance director, stated he would put a nail in all the windows at facility. He stated he would continue to check the locks and alarms of the doors and use the Tels system (maintenance system that electronically tracks checks on the facility alarm system). to document these checks and any irregularity. He stated he would develop a form to document the checks made on the fence and all the windows. In an interview on 4/13/2023 at 4:45PM with CNA D, stated they had a resident on one- to- one supervision for behavioral issues. Observed on 4/13/2023 aide sitting at door, resident observed in room asleep. CNA D stated she was trained on the elopement process and procedure. She stated she was trained on abuse/ neglect and reported that abuse neglect coordinator was the ADM. In an interview on 4/13/2023 at 5:00PM with LVN C, stated she completed the elopement drill and was in-serviced of on the policy, procedures and steps to take when there was a missing resident. LVN C, stated she was in -serviced on abuse/ neglect, elopement, and documentation. She reported the ADM was the abuse/neglect coordinator. LVN C was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:10PM with LVN D, stated she participated in the elopement drill today. She stated she was in-serviced on abuse/neglect, elopement, and resident documentation. She stated she understood the process when they have a resident missing, she stated she contacted the ADM immediately if she suspected abuse/ neglect, and that she understood the importance of charting on residents. LVN D was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:20PMwith CNA C, stated she participated in the elopement drill. CNA C stated She stated she was trained on the elopement process and procedure. She stated they made rounds every two hours or when the resident turned on their call light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they saw or suspected abuse/neglect. CNA C was able to identify elopement behavior as attempting to go out doors, sitting close to doors. In an interview on 4/13/2023 at 5:30PM with CNA D, stated she was agency staff, she stated she had not yet completed the elopement drill yet. She stated she was trained on the elopement process and procedure. She stated they made rounds every two hours or when the resident turned on their light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they saw or suspected abuse/neglect. In an interview on 4/13/2023 at 5:40PM with CNA E, stated she participated in the elopement drill. CNA C stated she was trained on the elopement process and procedure. She stated they make rounds every two hours or when the resident turned on their call light. She stated she was trained on abuse/ neglect and documentation, she stated the ADM was the abuse/neglect coordinator and they needed to report immediately if they had seen or suspect abuse/neglect. In an interview on 4/13/2023 at 6:00PM with DON, stated she and most of the staff were trained on the elopement drill and what to do when they have a missing resident. She stated any staff that have not been trained had been contacted and advised of the required training. DON stated the rest of the staff even agency staff when they came to work were trained over the elopement process, abuse/neglect, and documentation. In an interview on 4/13/2023 at 5:30PM with ADM, stated 55 of 80 staff were trained on the elopement process. She stated the day staff participated in the elopement drill skills test on what to do if they had a missing resident. She stated evening and night staff were contacted to advise them of the required training. She stated the elopement mitigation policy would be a part of the onboarding for new hires packet. The ADM advised agency staff would be trained as they use them. She stated was their responsibility to ensure that all the residents in the facility were safe. The ADM stated The IDT would review and discuss all wander risk residents daily in the morning meeting starting 4/14/2023. Records review on 4/13/2023 of Root cause analysis dated 2/5/2023 reflected, the facility completed a Root cause analysis regarding missing resident and interventions. Intervention identified was to add a screw to the window for further protection. Record review on 4/13/2023 of POR binder, reflected all residents had wander elopement assessment completed on 4/12/2023. All assessments reflected no wander or elopement risk residents in facility. Record review on 4/13/2023 of wander assessment, reflected the resident who was at a high risk of elopement and still at facility was re-assessed on 4/12/2023 for wander elopement risk and determined to be a moderate risk at this time, no longer high risk for elopement. Record review 4/13/2023, at elopement binder checked all resident wander elopement assessments in the binder had been updated to reflect current elopement status. Record review on 4/132023 of in-services completed by 60% of staff for the following: Identification & Prevention of elopement, interventions, and documentation, at risk for elopement; monitoring, interdisciplinary interventions, procedure for missing residents/elopement, what to do when resident is found, and actions post elopement Record review of Elopement drills completed with staff by ADM and department managers. Dates of drills noted were 4/13/2023, 2/5/2023, 2/18/2023. The ADM was informed the (IJ)immediate Jeopardy was removed on 4/13/2023. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.