**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 2 of 6 residents (Resident #1 and Resident #2) reviewed for a change of condition. The facility failed to follow their skin and wound policy by not notifying the Medical Director of the changes to Resident #1 and Resident #2's wounds. Resident #1 was admitted to the hospital on [DATE] with sepsis (infection in the blood) and osteomyelitis (bone infection). Resident #2 had an unstageable pressure ulcer wound that was identified on 11/10/2024. An Immediate Jeopardy was identified on 11/10/2024 at 11:15 AM. While the Immediate Jeopardy was removed on 11/11/2024 at 2:15 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than mininal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and death. Findings included: 1.Record review of an admission Record dated 11/9/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, heart failure (heart's inability to pump blood effectively), and benign prostatic hyperplasia (enlarged prostate). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he has severe impairment in thinking with a BIMS score of 1. He was dependent on staff for all ADLs except for upper body dressing which he required substantial/maximal assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries. He did not have any unhealed pressure ulcers/injuries. Other ulcers, wound and skin problems indicated he had moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Treatments included applications of ointments/medications. Record review of an admission MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 6. He required supervision or touching assistance with toileting hygiene and personal hygiene. He was always continent of urine and bowel. He was not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Record review of a care plan for Resident #1 dated 2/28/2024 indicated he had pressure ulcer or potential for pressure ulcer development related to impaired mobility with interventions to notify nurse immediately of any new areas of skin breakdown. Record review of a Consultation Note for Resident #1 dated 11/1/2024 from the hospital indicated he had been admitted to the hospital on account of worsening changes involving his sacrococcygeal wound (a pressure injury also known as a bedsore that occurs in the sacrum) with features suggestive of an infected stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) sacrococcygeal decubitus ulcer (bedsore). Record review of a Nurse Progress Note for Resident #1 dated 10/31/2024 indicated, .patient out of the facility, went to appointment with Infectious Disease Specialist on this AM, and transportation received notice per RP that patient was being admitted to the hospital . Record review of a History and Physical for Resident #1 dated 10/31/2024 from hospital indicated, Resident #1 was sent to the hospital from Infectious Disease Specialist office for infection sacral decubitus ulcer. Assessment and plan of treatment revealed infection with some necrosis decubitus ulcer sacral . Record review of a skin evaluation for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, .excoriation to sacral region (bottom of spine) and bilateral buttock, stage 3 (loss of tissue) to sacrum 3.8 x 4.4, stage 3 to left ischial tuberosity 3.0 x 3.0 x 0.2 . Record review of a Skin/Wound Note for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, sacrum has deteriorated now presents as a stage 3 measures 3.8 x 4.4 x 0.2 with serous exudate small amount no odor wound bed 50% non-granulated tissues 50% yellow slough peri wound pink and stage 3 to left ischial tuberosity measures 3.0 x 3.0 with serous exudate small amount no odor wound bed 70% granulated tissues 30% yellow slough peri wound pink excoriated. C/o pain during treatment. No new orders at this time. NP notified. RP notified . Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2, updated 10/29/24, now a stage 3. Interventions included air mattress, clean sacrum with normal saline, pat dry and apply calcium alginate to wound bed, and cover with dry dressing daily. Multivitamins with minerals, zinc sulfate, and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 to right ischial tuberosity. Interventions included air mattress, cleanse left ischial tuberosity (bone that makes up the bottom of the pelvis) with normal saline, pat dry, and apply exuderm (thin protective dressing to provide a protective barrier for wounds) q 3 days. Multivitamins with minerals, zinc sulfate, and vitamin c to be given daily for wound healing. Record review of a Skin/Wound Note for Resident #1 dated 10/18/2024 by the Treatment Nurse indicated, Excoriation to sacrum had deteriorated and presented as a stage 2 (top layer of skin is broken) measures 3.0 x 4.0 x 0.2 with serous (bloody) exudate (drainage) small amount no odor wound bed pink and stage 2 to left ischial tuberosity measures 2.7 x 3.0 with serous exudate small amount no odor wound bed pink peri wound pink excoriated (redness). C/o pain during treatment. Pain meds given. NP notified. New order: cleanse left ischial tuberosity ulcer with normal saline, pat dry, apply exuderm q3 days. Exuderm to left ischial. RP notified. Record review of skin evaluations for Resident #1 dated 9/12/2024 to 10/17/2024 by the Treatment Nurse indicated he had excoriation to bilateral buttock and no other skin issues noted. During a phone interview on 11/8/2024 at 4:55 PM, RP for Resident #1 said he was at the hospital. She said he was admitted to the hospital on [DATE] from an appointment with an infectious disease physician. She said the facility had been checking labs for him and he had elevated WBC's and the facility Medical Director was giving orders. She said on 8/31/2024 he was admitted to the hospital with altered mental status, and it was documented the beginning of a wound. He discharged from the hospital 9/6/2024 back to the nursing home. She said he was on antibiotics, and they sent him to see a blood physician and was told by her she could not find anything and was told he needed to see an infectious disease doctor. She said he saw the infectious disease doctor on 10/31/2024 and he immediately saw an area on Resident #1's bottom and sent him to the hospital and said that was the source of his infection. She said there was a huge hole that you could place your fist in it, and she did not see it until Resident #1 was at the hospital. She said she was told by the nursing facility that they were using some type of saline spray in the wound. She said she visited her father daily and the last time she saw the wound before the last hospital stay it looked like raw meat. She said it was not open at that time, but it looked bad. She said he had one debridement (surgical removal of damaged tissue) of the wound since admission to the hospital and he had a colostomy (a surgical opening in the large intestine for stool which collects into a bag outside of the body) to keep feces from getting into the wound. She said they were planning on another debridement sometime next week. 2. Record review of an admission Record for Resident #2 dated 11/9/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, malignant neoplasm of prostate (cancer of the prostate), and atherosclerosis (buildup of plaque in the artery walls that can block blood flow). Record review of a Quarterly MDS Assessment for Resident #2 dated 9/30/2024 indicated he had severe impairment in thinking with a BIMS score of 1. He was dependent on staff with all ADL's except for eating which he required supervision or touching assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Other ulcers, wounds, and skin problems indicated moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Skin and ulcer/injury treatments were nutrition or hydration intervention to manage skin problems and application of ointments/medications. Record review of a care plan for Resident #2 dated 7/18/2023 indicated he had pressure ulcer and potential for pressure ulcer development related to poor mobility and weakness. Interventions included to encourage fluid intake and assist to keep skin hydrated. Record review of active physician orders dated 11/9/2024 for Resident #2 indicated an order to cleanse scar tissue to sacrum with normal saline, pat dry, and apply exoderm q3 days every day shift every 3 days that started on 10/18/2024. Record review of a facility Skin Report for the month of October 2024 did not have Resident #2 listed as having a wound or other skin issues. During an interview on 11/9/2024 at 3:56 PM, the Treatment Nurse said she had been the treatment nurse at the facility for 8 ½ years and was an LVN. She said she was responsible for skin assessments weekly and responsible for surgical and pressure wounds, venous stasis wounds, and the charge nurses were responsible for the other ones. She said if a new wound were observed if the nurse aide found it during the day, they would notify her. She stated if it were after she left for the day, the nurse aides would let the charge nurse know and put it on the 24-hour report. She said it depended on the type of wound and the severity for if she would be notified the same day or not. If it were a skin tear, she may not be notified until the next day but if it were pressure, they would notify her immediately. She said if a new wound were present for pressure, she would contact the physician, and notify them. She said excoriation looked like redness, scratches, or some type of minor injury without any skin breakage. She said pressure wounds varied according to the stage, stage 1 was non blanchable skin (when touched stays red), stage 2 top layer of skin was missing, stage 3 slough might be present, or it could be a stage 4. She said she staged the wounds. She said she had a lot of education on it and had been to different classes and seminars. The DON would come behind her and look at the wounds and then would notify the physician. She said she would assess the wound, stage it, and let the DON and physician know. She said they did not have a wound care physician that visited the facility and had not had one since she had been employed for 8 ½ years. She said she was responsible for all the pressure wound treatments for the residents in the facility. She said Resident #1's buttocks started as a scratch from the hospital with excoriation, had small opens on his bottom that were sporadic, and they were using barrier cream after incontinent care episodes. She said the wound was close to his rectum and he continued to have frequent bowel movements throughout the day. She said the interventions started as barrier cream, then an order for exuderm to keep feces out of it, then got wedges to turn q2 hrs, and chair cushion when up. She said she noticed slough, it was a stage 3, and it was about a size of a 50-cent piece. She said he had an appointment in Houston in October, he was gone all day, and noticed he started getting slough on his bottom. She said when the slough started, she got an order for an air mattress to try and relieve pressure on his bottom and a wheelchair cushion, supplements for wound healing, and wound care treatment order changed. She said the treatments were being done daily. She said the wound had gotten worse before he left the faciity on [DATE]. She said the wound was so close to his rectum and it was hard to keep the feces out of it. She said they used waterproof nonadherent bandages, but when he had a bowel movement, it would get underneath the bandage, and she had a hard time keeping it out. She said they were contacting the NP and the Medical Director about the wound for Resident #1. She said the NP and the Medical Director would make rounds at about 6 am in the facility and never made rounds with her to see the wound on Resident #1 or any of the other residents. She said if they asked to see the wound it would have been with the charge nurses. She said she was not wound care certified. She said there was a RN weekend supervisor that performed wound care on the weekends. She said there were standing orders for certain types of wounds, if stage 2 would use exoderm, if stage 3 with minimal drainage would use collagen, moderate drainage calcium alginate, if it had depth she could pack, and use collagen powder. She said there was a book that was kept at the nurse desk. During an interview on 11/9/2024 at 4:29 PM, RN A said she was one of the weekend supervisors and worked every other weekend for the past 2 ½ years. She said she was responsible for everything that went on in the facility except for staffing. She said she performed wound care on the weekends for the residents. She said she had Resident #1 for daily wound care before he discharged to the hospital. She said the last time she saw Resident #1's wound on his sacrum it was macerated with a dressing, noted the skin looked splotchy, some bleeding, some skin breakdown, and the top layer of skin was missing. She said his left ischium seemed to be deeper about a quarter size in diameter and was open about 1-2 cm. There was no bleeding, he had an exuderm and dressing on the sacrum with collagen, a dry dressing daily, and exuderm every 3 days. She said the sacral wound was right by his rectum and it was very hard to keep the area clean. She said she had been notified before and was told not to stage or classify the wounds because she was not the Treatment Nurse, and the Treatment Nurse would be the one to measure and stage them. She said she could get an order for a dressing for the wound but could not stage it. During a phone interview on 11/9/2024 at 5:06 PM, the PT said he had been employed at the facility for 5 years. He said part of his duties of physical therapy would be administering wound care. He said he did not perform wound care often. He said he used the Ultramist on several patients in the past and it worked well for them. He said he used it recently on Resident #1 who had several pressure wounds. He said he focused on his sacral and coccyx area which were common areas for wounds. He said he had a stage 3 pressure ulcer that had necrotic tissue that was too painful to debride, so the Ultramist was another form of wound care that he could do. He said he performed 5-6 treatments on his wounds before his hospital admission on [DATE]. He said initially the entire wound was necrotic and the goal was to decrease the necrotic areas and increase granulated tissue that looked nice and was beefy red with good blood flow. He said the goal was for new skin growth. He said the machine was a small ultrasound machine, if the wound were close to a pacemaker or located close to a cancerous nodule it would be contraindicated. He said it could treat any wounds or ulcers. He said there were subtle changes on the outside of the wound, as it started to have granulation buds that you could visibly see and that was how granulation started. He said when you started to see buds on the skin that was a good thing. He said the location of the wound was close to feces. He was incontinent of bowel/bladder and that could slow things at times. He said the Ultramist was in addition to traditional nursing care, changing dressings, pat dry, and the nurse would apply a new dressing after the treatment was completed. He said due to the location, it always had a foul odor because it was near the rectum but could be a combination of dead tissue or feces and had to be cleaned prior to treatment. He was not sure if he was on antibiotics. He said he gets the wound information from the nurses. He had a stage 3 that ate through the skin, subcutaneous fat, and tissue but no bone was exposed. Record review of Physical Therapy Notes dated 10/21/2024, 10/23/2024, 10/25/2024, 10/29/2024 and 10/30/2024 for Resident #1 indicated .an additional skill of initial treatment of MIST therapy (low frequency, non-contact, non-thermal ultrasound) using sterile water to patient's sacrococcygeal wound due to sharp debridement being contraindicated in order to facilitate perfusion to ischemic areas of wound and decrease risk for infection . During an interview on 11/9/2024 at 5:27 PM, CNA B said she had been employed at the facility for September 2023 and worked 6 am - 6 pm and worked on all halls in the facility. She said on the weekends she helped with wound care by holding and positioning with the weekend RN supervisor. She said she found a wound on Resident #1 about a month ago and informed the weekend RN that he had a bad wound. It started out as two small red, circled areas in the butt crack on the weekend and she told the weekend RN and a charge nurse about it. She said the weekend RN put a bandage on it and put a note for the Treatment Nurse about the wound. She said sometime after observing the new area on Resident #1, she had been off for a few days, and came back and observed no bandage on his buttocks and the wound had started getting bigger. She said the area was bigger than the size of a 4 x 4 gauze. She said the last day she saw the wound was on 10/31/2024 before he left for a physician appointment, and he did not come back. She said the wound on 10/31/2024 was bad, both sides of his buttocks were open, he could put at least three fingers inside, and it smelled like dying flesh that was yellow and green in color. She said a charge nurse put a dressing on the wound before he left for that appointment on 10/31/2024. During an observation on 11/10/2024 at 8:55 AM, Resident #2 was in his room in bed with CNA B and CNA C present to provide incontinent care. CNA B and CNA C removed a dressing to his sacrum as the dressing had stool present that had gotten underneath the dressing to the wound. The DON entered the room and said she needed to look at the wound after they cleaned him because she was informed that the nurse on 11/9/2024 had performed wound care and when the dressing was removed, skin came off with it. Staff provided incontinent care and a large wound to his sacrum was observed with the wound bed black in color with eschar, surrounding skin pink and white, borders irregular, and some skin missing with redness and small open areas. CNA B and CNA C both said the wound had been that way for a while. During an observation and interview on 11/10/2024 at 9:10 AM, the DON and CNA C were in the room of Resident #2. The DON was present to assess the area to his sacrum and provide wound care treatment. The DON said the wound was unstageable. The DON placed collagen in the wound bed and covered with dry dressing temporarily. She said they had some protocols that they could go by and would notify the physician. RN A entered the room and said the wound looked like it was unstageable with necrotic tissue but could not say if it looked that way on 11/9/2024 because the wound had a lot of barrier cream. She said on 11/9/2024 when she tried to remove the cream, Resident #2 was in pain and she could not see the wound bed and she placed an exoderm over the area per the orders. During a follow-up interview and observation on 11/10/2024 at 9:32 AM, RN A said on 11/9/2024 she provided wound care for Resident #2 and the wound was open without a dressing. She said the wound was close to his anus and they cleaned him up and the area had zinc cream on it. She said the wound was very moist and there was an order for exuderm to be applied to the scar tissue, so she placed a 4x4 exuderm per the orders. She said she was told to let the Treatment nurse know of any changes to any wounds in the facility or skin issues. She said the wound had been present since October 7, 2024. RN A still had the text message where she sent the Treatment Nurse a message to inform her that the zinc was not helping Resident #2. The State Surveyor observed the text message that was sent to the Treatment Nurse and the Treatment Nurse response was Ok, with a thumbs up emoji. She said there was not a dressing on Resident #2's sacrum on 11/9/2024 and it only had an order for exoderm. She said the skin did not come off because there was not dressing on it, and it only had zinc oxide present. She said they had standing orders for wound care at the nurse station and then would contact the physician with any new skin issues. During a phone interview on 11/10/2024 at 9:47 AM, the RP of Resident #2 said when he admitted to the facility it was to the secured unit. She said he had been at the facility for 2 years. She said he had been discharged from the secured unit for about 2 months. She said she tried to visit him at least three times out of the month. She said most of the time they keep her updated. She said she had been at the facility on the days of his showers. She said she was present one day this past week and observed staff change him. She said she did not get to see his bottom, she was used to him having his privacy, and when she thought about asking to see his bottom, it was too late. She said they told her he had a bed sore on his bottom when she visited this past week and asked why no one called her to inform her before then. During a follow-up interview and observation on 11/10/2024 at 10:05 AM, the Treatment Nurse said the last time she observed Resident #2's wound it had a lot of scar tissue from a previous wound which made it easier for skin break down. She said the wound started to crack open and it looked like excoriation and received an order to put exuderm on it. She said Resident #2 would hold his urine and when he urinated, he would saturate the brief. She said they tried to keep the exuderm on the wound and keep urine and feces out of it. She said she observed the area that day and it looked like it was starting to try to open, and she did contact the physician. She observed a picture of the wound of Resident #2 that was taken by the State Surveyor, and she said the wound looked like an unstageable wound with black tissue noted. She said they have had issues with the wound bleeding in some areas. She said an exuderm would not be appropriate for his wound at that time. During a phone interview on 11/10/2024 at 10:11 AM, the Medical Director said he was out of town, and he was informed that the State Surveyor had questions about the facility and them contacting him with any changes in the facility. He said he would have to call his NP and call back. During a phone interview on 11/10/2024 at 10:30 AM, the Medical Director said he spoke to his NP and said neither of them were aware of any standing orders for wounds in the facility for them to follow. He said they both received phone calls and were available for the facility and the facility did not mind calling them. He said Resident #1 had elevated white blood cell counts that were going up and down with the highest being about 18. He said it had been going on for about a month and they made him an appointment with an infectious disease physician so they could determine the source of the elevated white blood cells. He said they did not think that the wound for Resident #1 started the elevated white count as they looked at residents with leukocytosis more closely and they could not pinpoint the cause. He said he was not aware that Resident #1 was at the hospital but was glad to hear it because that was the purpose of him seeing the infectious disease physician. He said he was not aware of any skin issues in the facility until that day when the NP was notified about Resident #2. He said skin assessment were the responsibility of the nursing staff. He said he visited the facility twice a week and, in the past, had been asked to look at residents with wounds but not in a long time. He said he left the wound care treatments up to the Treatment Nurse at the facility, as she would evaluate and treat, if not effective then they would work on changing the treatments. He said if he had known about the skin issues, then they would have ordered appropriate treatments at that time. During an interview on 11/11/2024 at 9:43 Am, the DON said the Treatment Nurse and Weekend RN were responsible for wound care treatments. She said the Treatment Nurse was responsible for skin assessments and if the shower techs noticed anything they would tell her, and she did them weekly. She said she conducted a skin assessment about once a week and an overall monthly for the residents in the facility. She said she looked at the skin in the facility once a week because she helped with a lot of incontinent care to make sure the residents had barrier creams because there were a lot of new staff in the facility. She said she staged the wounds and classified them. She said the Treatment Nurse would let her know when a new skin issue was found, and she assessed and staged if appropriate. She said only a RN could stage the wounds, if the staff found something they could only describe the wounds. She said she did a contract with a wound care physician about a few weeks that would start soon. She said she provided care to Resident #2 on Friday 11/8/2024 and did not see any slough in his wound. She said the wound had excoriation but did not have any slough or necrotic tissue present. She said Resident #1's wounds started with minor excoriation, and had elevated WBCs before the wound started, and they checked lab work frequently. She said he had IV therapy, was on antibiotics, constantly doing change in conditions, going to appointments, saw the Medical Director, and his WBCs never went down. She said he was on antibiotics and went to the hospital a while ago and the excoriation to his sacrum continued to get worse. She said he had orders for supplements and therapy started seeing him and he received Ultramist (portable, painless, noncontact, noninvasive, low-frequency ultrasound to the wound. A fluid/saline mist is used to deliver the ultrasound, so there is no direct wound contact) wound therapy in the facility. She said they reported to the physician for any change in condition and if wounds changed. She said the Medical Director was aware of Resident #1's wound and said they changed orders for dressings and started the Ultramist. She said the Medical Director was not aware of Resident #2's wound. She said there was a risk for wound deterioration if the physician was not notified. She said when a new skin issue was identified, they should notify the nurse of any changes so the area would be assessed along with more frequent monitoring, notify the family, and care plan so everyone would be aware. During an interview on 11/11/2024 at 10:20 AM, the Administrator said she was aware that Resident #2 had some excoriation to his buttocks. She said the DON worked the hall where Resident #2 resided on Friday 11/8/2024 and said the area was not excoriated. She said Resident #1's RP had taken him to multiple physicians and took him to and Infectious Disease Specialist for an opinion. She said Resident #1 had elevated wbc's for weeks prior to his hospitalization 10/31/2024. She said skin assessments were to be done weekly by the Treatment Nurse and the DON was the only one that staged the wounds. She said she was not aware that the Medical Director was not updated of the change in Resident #2's wound. She said the facility was supposed to notify the physician of any change in conditions with the residents and there was a risk for wounds to worsen if they were not notified. Record review of a Skill Checklist-Treatment for the Treatment Nurse sated 5/8/2024 indicated she showed competency of treatments that was observed by the DON. Record review of Standing Orders for skin for the facility indicated orders for general skin protocol indicated any change in the resident's skin condition must be documented, and the physician and responsible party were to be notified dated 4/9/2024 and signed by the Medical Director. Record review of a facility policy titled Skin and Wound Monitoring and Management revised 1/2022 indicated, .It is the policy of this facility that: 1. A resident who entered the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; 7. Communication of changes: a. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party, the resident's physician, and others as necessary to facilitate healing . This was determined to be an Immediate Jeopardy (IJ) on 11/10/2024 at 11:15 AM. The facility's Administrator and the DON were notified. The Administrator was provided the IJ template on 11/10/2024 at 12:04 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 11/10/2024 at 4:50 PM. Plan of Removal 11-10-2024 F580 The facility needs to take immediate action to ensure proper physician notification is made to prevent worsening of pressure sores. 1.The Medical Director was notified of IJ on 11/10/2024 at 12:45pm. 2.Review of the 24-hour report was completed for the last 72 hours to ensure family and MDs were notified by DON, ADON on 11/10/24. 3.Education was initiated with Nurses on 11/10/2024 and will be completed on 11/10/2024 by the DON, ADON, and Clinical Resource. The training included Nurse Assessment, Change in Condition Process, documentation of the change in condition, notification to the physician, notification of family, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available. The DON, ADONs, and Clinical Resource used facility policy on change in condition facility procedures on head-to-toe assessment, and notification to family and MD. 4.A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses 11/10/2024 and will be completed for all nurses either in-person or via telephone on 11/11/2024at 6pm. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse. 5. This education and knowledge check will be completed with facility nurses on 11/10/2024 and 11/11/2024 by 6pm, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs, or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency /PRN staff (currently the facility does not utilize agency). 6.An ad hoc meeting regarding items in IJ template will be completed on 11/11/2024 Attendees include Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and will be agreed upon. 7.Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditio[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 2 of 6 Residents (Resident #1 and Resident #2) reviewed for pressure injuries. The facility failed to prevent Resident #1 from developing a wound to his sacrum that changed from excoriation to a stage 4 pressure ulcer on 10/24/2024. Resident #1 admitted to the hospital on [DATE] with sepsis (infection in the blood) and osteomyelitis (infection in the bone). The facility failed to prevent Resident #2 from developing a wound to his sacrum that changed from excoriation to an unstageable wound on 11/10/2024. The facility failed to follow their skin and wound policy by not notifying the Medical Director of the changes to Resident #1 and #2's wounds. The facility failed to accurately assess Resident #1 and #2's pressure sores. An Immediate Jeopardy was identified on 11/10/2024 at 11:15 AM. While the Immediate Jeopardy was removed on 11/11/2024 at 2:15 PM, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1.Record review of an admission Record dated 11/9/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of Alzheimer's disease, heart failure (heart's inability to pump blood effectively) and benign prostatic hyperplasia (enlarged prostate). Record review of an admission MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 6. He required supervision or touching assistance with toileting hygiene and personal hygiene. He was always continent of urine and bowel. He was not at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he has severe impairment in thinking with a BIMS score of 1. He was dependent on staff for all ADLs except for upper body dressing which he required substantial/maximal assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries. He did not have any unhealed pressure ulcers/injuries. Other ulcers, wound and skin problems indicated he had moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Treatments included applications of ointments/medications. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 updated 10/29/24 now a stage 3. Interventions included air mattress, clean sacrum with normal saline, pat dry and apply calcium alginate to wound bed, cover with dry dressing daily. Multivitamins with minerals, zinc sulfate and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 10/18/2024 indicated he had impairment to skin related to stage 2 to right ischial tuberosity. Interventions included air mattress, cleanse left ischial tuberosity (bone that makes up the bottom of the pelvis) with normal saline, pat dry and apply exuderm (thin protective dressing to provide a protective barrier for wounds) q 3 days. Multivitamins with minerals, zinc sulfate and vitamin c to be given daily for wound healing. Record review of a care plan for Resident #1 dated 2/28/2024 indicated he had pressure ulcer or potential for pressure ulcer development related to impaired mobility with interventions to notify nurse immediately of any new areas of skin breakdown. Record review of skin evaluations for Resident #1 dated 9/12/2024 to 10/17/2024 by the Treatment Nurse indicated he had excoriation to bilateral buttock and no other skin issues noted. Record review of a Skin/Wound Note for Resident #1 dated 10/18/2024 by the Treatment Nurse indicated, Excoriation to sacrum had deteriorated and presented as a stage 2 (top layer of skin is broken) measures 3.0 x 4.0 x 0.2 with serous (bloody) exudate (drainage) small amount no odor wound bed pink and stage 2 to left ischial tuberosity measures 2.7 x 3.0 with serous exudate small amount no odor wound bed pink peri wound pink excoriated (redness). C/o pain during treatment. Pain meds given. NP notified. New order: cleanse left ischial tuberosity ulcer with normal saline, pat dry, apply exuderm q3 days. Exuderm to left ischial. RP notified. Record review of a skin evaluation for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, .excoriation to sacral region (bottom of spine) and bilateral buttock, stage 3 (loss of tissue) to sacrum 3.8 x 4.4, stage 3 to left ischial tuberosity 3.0 x 3.0 x 0.2 . Record review of a Skin/Wound Note for Resident #1 dated 10/24/2024 by the Treatment Nurse indicated, sacrum has deteriorated now presents as a stage 3 measures 3.8 x 4.4 x 0.2 with serous exudate small amount no odor wound bed 50% non-granulated (tissues 50% yellow slough peri wound pink and stage 3 to left ischial tuberosity measures 3.0 x 3.0 with serous exudate small amount no odor wound bed 70% granulated tissues 30% yellow slough peri wound pink excoriated. C/o pain during treatment. No new orders at this time. NP notified. RP notified . Record review of a Nurse Progress Note for Resident #1 dated 10/31/2024 indicated, .patient out of the facility, went to appointment with Infectious Disease Specialist on this AM and transportation received notice per RP that patient was being admitted to the hospital . Record review of an History and Physical for Resident #1 dated 10/31/2024 from hospital indicated Resident #1 was sent to the hospital from Infectious Disease Specialist office for infection sacral decubitus ulcer. Assessment and plan of treatment revealed infection with some necrosis decubitus ulcer sacral . Record review of a Pathology Report dated 10/31/2024 for Resident #1 indicated a bone biopsy of the coccyx had acute osteomyelitis (infection in the bone). Record review of a Consultation Note for Resident #1 dated 11/1/2024 from hospital indicated he had been admitted to the hospital on account of worsening changes involving his sacrococcygeal wound (a pressure injury also known as a bedsore that occurs in the sacrum) with features suggestive of an infected stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) sacrococcygeal decubitus ulcer (bedsore). Record review of a Clinical Documentation Form for Resident #1 dated 11/8/2024 indicated sepsis (blood infection all over the body) was present on admission. During a phone interview on 11/8/2024 at 4:55 PM, RP for Resident #1 said he was at the hospital. She said he was admitted to the hospital on [DATE] from an appointment with an infectious disease physician. She said the facility had been checking labs for him and he had elevated WBC's and the facility Medical Director was giving orders. She said on 8/31/2024 he was admitted to the hospital with altered mental status, and it was documented the beginning of a wound. He discharged from the hospital 9/6/2024 back to the nursing home. She said he was on antibiotics, and they sent him to see a blood physician and was told by her she could not see find anything and was told he needed to see an infectious disease doctor. She said he saw the infectious disease doctor on 10/31/2024 and he immediately saw an area on Resident #1's bottom and sent him to the hospital and said that was the source of his infection. She said there was a huge hole that you could place your fist in, and she did not see it until Resident #1 was at the hospital. She said she was told by the nursing facility that they were using some type of saline spray in the wound. She said she visited her father daily and the last time she saw the wound before the last hospital stay it looked like raw meat. She said it was not open at that time, but it looked bad. She said he had one debridement (surgical removal of damaged tissue) of the wound since admission to the hospital and he had a colostomy (a surgical opening in the large intestine for stool which collects into a bag outside of the body) to keep feces from getting into the wound. She said they were planning on another debridement sometime next week. 2. Record review of an admission Record for Resident #2 dated 11/9/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, malignant neoplasm of prostate (cancer of the prostate) and atherosclerosis (buildup of plaque in the artery walls that can block blood flow). Record review of a Quarterly MDS Assessment for Resident #2 dated 9/30/2024 indicated he had severe impairment in thinking with a BIMS score of 1. He was dependent on staff with all ADL's except for eating which he required supervision or touching assistance. He was always incontinent of urine and bowel. He was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries. Other ulcers, wounds and skin problems indicated moisture associated skin damage (incontinence-associated dermatitis, perspiration, drainage). Skin and ulcer/injury treatments were nutrition or hydration intervention to manage skin problems and application of ointments/medications. Record review of a care plan for Resident #2 dated 7/18/2023 indicated he had pressure ulcer and potential for pressure ulcer development related to poor mobility and weakness. Interventions included to encourage fluid intake and assist to keep skin hydrated. Record review of a facility Skin Report for the month of October 2024 did not have Resident #2 listed as having a wound or other skin issues. Record review of active physician orders dated 11/9/2024 for Resident #2 indicated an order to cleanse scar tissue to sacrum with normal saline, pat dry and apply exoderm q3 days every day shift every 3 days that started on 10/18/2024. During an interview on 11/9/2024 at 3:56 PM, the Treatment Nurse said she had been the treatment nurse at the facility for 8 ½ years and was an LVN. She said she was responsible for skin assessments weekly and responsible for surgical and pressure wounds, venous stasis wounds and the charge nurses were responsible for the other ones. She said if a new wound were observed if the nurse aide found it during the day, they would notify her and if it were after she left for the day, the nurse aides would let the charge nurse know and put it on the 24-hour report. She said it depended on the type of wound and the severity if she would be notified the same day or not, if it were a skin tear, she may not be notified until the next day but if it were pressure, they would notify her immediately. She said if a new wound were present for pressure, she would contact the physician and notify them. She said excoriation looked like redness, scratches, or some type of minor injury without any skin breakage. She said pressure wounds varied according to the stage, stage 1 was non blanchable skin (when touched stays red), stage 2 top layer of skin was missing, stage 3 slough might be present, or it could be a stage 4. She said she staged the wounds. She said she had a lot of education on it and had been to different classes and seminars and the DON would come behind her and look at the wounds and then would notify the physician. She said she would assess the wound, stage it, and let the DON and physician know. She said they did not have a wound care physician that visited the facility and had not had one since she had been employed for 8 ½ years. She said she was responsible for all the pressure wound treatments for residents in the facility. She said Resident #1 buttocks started as a scratch from the hospital with excoriation, had small opens on his bottom that were sporadically, and they were using barrier cream after incontinent care episode. She said the wound was close to his rectum and he continued to have frequent bowel movements throughout the day. She said the interventions started as barrier cream and then an order for exuderm to keep feces out of it and then got wedges to turn q2 hrs and chair cushion when up. She said she noticed slough and it was a stage 3 and was about a size of a 50-cent piece. She said he had an appointment in Houston in October, and he was gone all day and noticed he started getting slough on his bottom. She said when the slough started, got an order for an air mattress to try and relieve pressure on his bottom and a wheelchair cushion, supplements for wound healing and wound care treatment order changed. She said the treatments were being done daily. She said the wound had gotten worse before he left the faciity on [DATE]. She said the wound was so close to his rectum and it was hard to keep feces out of it. She said they used waterproof nonadherent bandages, but when he had a bowel movement, it would get underneath the bandage and had a hard time keeping it out. She said they were contacting the NP and the Medical Director about the wound for Resident #1. She said the NP and the Medical Director would make rounds at about 6 am in the facility and never made rounds with her to see the wound on Resident #1 or any of the other residents. She said if they asked to see the wound it would have been with the charge nurses. She said she was not wound care certified. She said there was a RN weekend supervisor that performed wound care on the weekends. She said there were standing orders for certain types of wounds, if stage 2 would use exoderm, if stage 3 with minimal drainage would use collagen, moderate drainage calcium alginate, if it had depth could pack and use collagen powder. She said there was a book that was kept at the nurse desk. Record review of a Skill Checklist-Treatment for the Treatment Nurse sated 5/8/2024 indicated she showed competency of treatments that was observed by the DON. Record review of Standing Orders for skin for the facility indicated orders for general skin protocol indicated any change in the resident's skin condition must be documented, the physician and responsible party notified dated 4/9/2024 and signed by the Medical Director. During an interview on 11/9/2024 at 4:29 PM, RN A said she was one of the weekend supervisors and worked every other weekend for the past 2 ½ years. She said she was responsible for everything that went on in the facility except for staffing. She said she performed wound care on the weekends for the residents. She said had Resident #1 for daily wound care before he discharged to the hospital. She said the last time she saw Resident #1's wound on his sacrum it was macerated with a dressing noted the skin looked splotchy, some bleeding, some skin breakdown-top layer of skin missing. She said his left ischium seemed to be deeper about a quarter size in diameter-was open about 1-2 cm-no bleeding and had an exuderm and dressing on sacrum with collagen and dry dressing daily and exuderm every 3 days. She said the sacral wound was right by his rectum and was very hard to keep the area clean. She said she had been notified before and was told not to stage or classify the wounds because she was not, and the treatment nurse would be the one to measure and stage them. She said she could get an order for a dressing for the wound but could not stage it. During an interview on 11/9/2024 at 5:27 PM, CNA B said she had been employed at the facility for September 2023 and worked 6 am-6 pm and worked on all halls in the facility. She said on the weekends she helped with wound care by holding and positioning with the weekend RN supervisor. She said she found a wound on Resident #1 about a month ago and informed the weekend RN that he had a bad wound as it started out as two small red, circled areas in the butt crack on the weekend and told the weekend RN and a charge nurse about it. She said the weekend RN put a bandage on it and put a note for the Treatment Nurse about the wound. She said sometime after observing the new area on Resident #1, she had been off for a few days and came back and observed no bandage on his buttocks and the wound had started getting bigger. She said the area was bigger than the size of a 4 x 4 gauze. She said the last day she saw the wound was on 10/31/2024 before he left for a physician appointment, and he did not come back. She said the wound on 10/31/2024 was bad on both sides of his buttocks were open and could put at least three fingers inside and it smelled like dying flesh that was yellow and green in color. She said a charge nurse put a dressing on the wound before he left for that appointment on 10/31/2024. During an observation on 11/10/2024 at 8:55 AM, Resident #2 was in his room in bed with CNA B and CNA C present to provide incontinent care. CNA B and CNA C removed a dressing to his sacrum as the dressing had stool present that had gotten underneath the dressing to the wound. DON entered the room and said she needed to look at the wound after they cleaned him because she was informed that the nurse on 11/9/2024 had performed wound care and when the dressing was removed, skin came off with it. Staff provided incontinent care and a large wound to his sacrum was observed with the wound bed black in color with eschar, surrounding skin pink and white, borders irregular, some skin missing with redness and small open areas. CNA B and CNA C both said the wound had been that way for a while. During an observation and interview on 11/10/2024 at 9:10 AM, the DON and CNA C were in the room of Resident #2. DON was present to assess the area to his sacrum and provide wound care treatment. The DON said the wound was unstageable. The DON placed collagen in the wound bed and covered with dry dressing temporarily. She said they had some protocols that they could go by and would notify the physician. RN A entered the room and said the wound looked like it was unstageable with necrotic tissue but could not say if it looked that way on 11/9/2024 because the wound had a lot of barrier cream and when she tried to remove the cream, Resident #2 was in pain and she could not see the wound bed and she placed an exoderm over the area per the orders. During a follow-up interview and observation on 11/10/2024 at 9:32 AM, RN A said on 11/9/2024 she provided wound care for Resident #2 and the wound was open without a dressing. She said the wound was close to his anus and they cleaned him up and the area had zinc cream on it. She said the wound was very moist and there was an order for exuderm to be applied to the scar tissue, so she placed a 4x4 exuderm per the orders. She said she was told to let the Treatment nurse know of any changes to any wounds in the facility or skin issues. She said the wound had been present since October 7, 2024. RN A still had the text message where she sent the Treatment Nurse a message to inform her that the zinc was not helping Resident #2. Surveyor observed the text message that was sent to the Treatment Nurse and the Treatment Nurse response was Ok, with a thumbs up emoji. She said there was not a dressing on Resident #2's sacrum on 11/9/2024 and only had an order for exuderm and the skin did not come off because there was not dressing on it, and it had zinc oxide. She said they had standing orders for wound care at the nurse station and then would contact the physician with any new skin issues. During a phone interview on 11/10/2024 at 9:47 AM, the RP of Resident #2 said when he admitted to the facility it was to the secured unit. She said he had been at the facility for 2 years. She said he had been discharged from the secured unit for about 2 months. She said she tried to visit him at least three times out of the month. She said most of the time they keep her updated. She said she had been at the facility on the days of his showers. She said she was present one day this past week and observed staff change him. She said she did not get to see him bottom, and she was used to him having his privacy and when she thought about it asking to see his bottom, it was too late. She said they told her he had a bed sore on his bottom when she visited this past week and asked why no one called her to inform her before then. During a follow-up interview and observation on 11/10/2024 at 10:05 AM, the Treatment Nurse said the last time she observed Resident #2's wound it had a lot of scar tissue from a previous wound which made it easier for skin break down. She said the wound started to crack open and looked like excoriation and received an order to put exuderm on it. She said Resident #2 would hold his urine and when he urinated, he would saturate the brief. She said they tried to keep the exuderm on the wound and keep urine and feces out of it. She said she observed the area that day and it looked like it was starting to try to open, and she would contact the physician. She observed a picture of the wound of Resident #2 that was taken by the Surveyor, and she said the wound looked like an unstageable wound with black tissue noted. She said they have had issues with the wound bleeding in some areas. She said an exuderm would not be appropriate for his wound at that time. During a phone interview on 11/10/2024 at 10:11 AM, the Medical Director said he was out of town, and he was informed that the Surveyor had questions about the facility and them contacting him with any changes in the facility. He said he would have to call his NP and call back. During a phone interview on 11/10/2024 at 10:30 AM, the Medical Director said he spoke to his NP and said neither of them were aware of any standing orders for wounds in the facility for them to follow. He said they both received phone calls and were available for the facility and the facility did not mind calling them. He said Resident #1 had elevated white blood cell counts that were going up and down with the highest being about 18. He said it had been going on for about a month and they made him an appointment with an infectious disease physician so they could determine the source of the elevated white blood cells. He said they did not think that the wound for Resident #1 started the elevated white count as they looked at residents with leukocytosis more closely and they could not pinpoint the cause. He said he was not aware that Resident #1 was at the hospital but was glad to hear it because that was the purpose of him seeing the infectious disease physician. He said he was not aware of any skin issues in the facility until that day when the NP was notified about Resident #2. He said skin assessment were the responsibility of the nursing staff. He said he visited the facility twice a week and, in the past, had been asked to look at residents with wounds but not in a long time. He said he left the wound care treatments up to the Treatment Nurse at the facility, as she would evaluate and treat, if not effective then they would work on changing the treatments. He said if he had known about the skin issues, then they would have ordered appropriate treatments at that time. During an interview on 11/11/2024 at 9:43 Am, the DON said the Treatment Nurse and Weekend RN were responsible for wound care treatments. She said the Treatment Nurse was responsible for skin assessments and if the shower techs noticed anything they would tell her, and she did them weekly. She said she conducted a skin assessment about once a week and an overall monthly for the residents in the facility. She said she looked at skin in the facility once a week because she helped with a lot of incontinent care to make sure the residents had barrier creams because there were a lot of new staff in the facility. She said she staged the wounds and classified them. She said the Treatment Nurse would let her know when a new skin issue was found, and she assess and stage if appropriate. She said only a RN could stage the wounds if the staff found something they could only describe the wounds. She said she did a contract with a wound care physician about a few weeks that would start soon. She said she provided care to Resident #2 on Friday 11/8/2024 and did not see any slough in his wound. She said the wound had excoriation but did not have any slough or necrotic tissue present. She said Resident #1's wounds started with minor excoriation, and had elevated WBCs before the wound started, and they checked lab work frequently. She said he had IV therapy, was on antibiotics, constantly doing change in conditions, going to appointments, saw the Medical Director and his WBCs never went down. She said he was antibiotics and went to the hospital a while ago and the excoriation to his sacrum continued to get worse. She said he had orders for supplements and therapy started seeing him and he received Ultramist wound therapy in the facility. She said they reported to the physician for any change in condition and if wounds changed. She said the Medical Director was aware of Resident #1's wound and said they changed orders for dressings and started the Ultramist. She said the Medical Director was not aware of Resident #1's wound. She said there was a risk for wound deterioration if the physician was not notified. She said when a new skin issue was identified, they should notify the nurse of any changes so the area would be assessed along with more frequent monitoring, notify the family and care plan so everyone would be aware. During an interview on 11/11/2024 at 10:20 AM, the Administrator said she was aware that Resident #2 had some excoriation to his buttocks. She said the DON worked the hall where Resident #2 resided on Friday 11/8/2024 and said the area was not excoriated. She said Resident #1's RP had taken him to multiple physicians and took him to and Infectious Disease Specialist for an opinion. She said Resident #1 had elevated wbc's for weeks prior to his hospitalization 10/31/2024. She said skin assessments were to be done weekly by the Treatment Nurse and the DON was the only one that staged the wounds. She said she was not aware that the Medical Director was not updated of the change in Resident #2's wound. She said the facility was supposed to notify the physician of any change in conditions with the residents and there was a risk for wounds to worsen if they were not notified. Record review of a facility policy titled Skin and Wound Monitoring and Management revised 1/2022 indicated, .It is the policy of this facility that: 1. A resident who entered the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; 7. Communication of changes: a. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party, the resident's physician, and others as necessary to facilitate healing . This was determined to be an Immediate Jeopardy (IJ) on 11/10/2024 at 11:15 AM. The facility's Administrator and DON were notified. The Administrator was provided the IJ template on 11/10/2024 at 12:04 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 11/10/2024 at 4:50 PM. Plan of Removal F 686 11/10/2024 Per the information provided in the IJ Template given on 11/10/24, the facility needs to Take immediate action to ensure prompt identification and interventions for pressure sores are made to prevent serious harm and infection. 1. The Medical Director was notified by the Executive Director on 11/10/2024 at 12:45 pm. 2. The Attending Physician was notified by the Executive Director, of the IJ on 11/10/2024 at 12:45pm. 3. New Braden scales for the total census initiated 11/10/2024 and will be completed 11/10/2024 by Clinical Resources, Clinical Leaders MDS Nurse, ADON, and DON. 4. Audit completed by DON on 11/10/2024 of all residents who are at risk for PU/PI, care plans and care profiles were updated for all residents at high risk to include personalized/individualized interventions/prevention. This was also completed 11/10/2024. 5. Skin assessments were completed on all residents 11/10/2024. These were conducted by the DON, ADON, MDS Nurse, Wound Care Nurse, and Clinical Resource. 6. Education initiated 11/10/2024 by Clinical Resource with, DON, ADON, Nurses, CMAs, and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, turning and repositioning, notification of changes in wounds, interventions, and preventions, as well as communication between Nursing staff and health care professionals; will be completed by 11/11/2024 by 6pm. Any staff unable to attend will not be allowed to work unless they have received their training and knowledge check. 7. All licensed nurses will complete competency on skin assessments initiated on 11/10/24 and will be completed 11/11/2024 by 6pm by DON, ADON, and Clinical Resource. 8. All CNA's will complete competency on skin check initiated on 11/10/2024 and will be completed on 11/11/2024 by 6pm by DON, ADON, MDS Nurse, and Clinical Resource. 9. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 10. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 11/10/2024. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 11. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the skin check competency checklists. 12. All residents with pressure ulcers will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director, and Wound Nurse. The DON and Administrator will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 13.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90days to ensure ongoing compliance. 14.Resident #1 is no longer a resident in the facility. 15. Wound Care nurse was checked off on wound care, in-serviced on policies and procedures, change of condition, notification of physician, and responsible party on 11-10-2024 at 2pm. The State Surveyors monitored the Plan of Removal as follows: Record

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 3 residents (Resident #1 and Resident #4) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 11/7/2023 when he climbed out of a window in the secured unit and broke a fence in the courtyard. The facility failed to keep Resident #4 in a safe environment to prevent an elopement on 11/20/2023. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 11/7/2023 and ended 11/20/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury and accidents. Findings included: 1.Record review of an Elopement/Wandering Evaluation by ADON D dated 7/14/2023 for Resident #1 indicated he admitted to the facility on [DATE]. He had dementia, ambulated with an assisted device, was disoriented, and had a history of 2 or more episodes of elopement in the last 6 months. He was indicated as a high risk for elopement with a score of 16. Score ranges: low risk 0-9 and high risk 10-55. Record review of an admission Record dated 8/19/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, depression, and anxiety disorder. Record review of a care plan dated 9/19/2023 for Resident #1 indicated he had secure unit placement and was an elopement risk/wanderer related to dementia. History of dangerous walking, elopement attempts. Interventions included to document wandering behavior and attempted diversional interventions. Record review of an Elopement/Wandering Evaluation by ADON D dated 10/11/2023 for Resident #1 indicated he admitted to the facility on [DATE]. He had dementia and ambulated independently or with supervision. He had intermittent confusion, made statements about a desire to leave the facility and wandered aimless with the potential to go outside with active exit seeking behavior. He was indicated as a high risk for elopement with a score of 15. Score ranges: low risk 0-9 and high risk 10-55. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 9. He had potential indicators of psychosis with delusions (misconceptions or beliefs that are firmly held, contrary to reality). Record review of a nurse progress note for Resident #1 dated 11/7/2023 at 2:30 PM by ADON D indicated, Spoke with desk at Dr. office at this time, updated on incident which occurred on today regarding elopement attempts. Stated she would forward the message to Dr and his nurse with priority for response. Awaiting return call at this time. Record review of an Incident Report titled Skin Alteration for Resident #1 dated 11/7/2023 at 2:30 PM by ADON E indicated, Pt. noted not inside of room. Staff noted window unlocked and Pt. was not inside of unit. Staff went outside and noted Pt. behind storage building on outskirts of courtyard, during head-to-toe assessment/skin assessment. Pt noted with 0.5 cm x 0.5 cm S/T to right arm, scattered/multiple scratches to bilat upper and lower extremities. Resident description: Pt. states I just wanted to go outside so I unlocked my window and crawled out, I'm not hurt, it's just some little scratches. Record review of a witness statement dated 11/7/2023 by LVN C indicated, Resident #1 was in hallway upset, because he wanted to go home and requesting a phone. He stated that's ok, I'll find one. Resident then proceeded to his room and closed the door as he always does. I then preceded to contact his family member and update her on his request to go home. She stated, I'm gonna go ahead and get my husband and we'll be up there to let him know he'll be staying there permanently. I was in unit talking to staff about medications. Resident family and her husband arrived about 15-20 minutes later. She stopped to speak with me, then went into resident room. A few minutes later the daughter came out and said he's in the bathroom, I've been knocking and waiting but he won't come out. I immediately went in and knocked on the door, no response. I opened the door and resident was not inside. I went to the window and noticed the back gate was open. I then alerted admin and staff to search for resident. Record review of a Q 15-minute observation form for Resident #1 indicated q15 minute monitoring started at the facility on 11/7/2023 at 2:45 PM and ended on 11/8/2023 at 2:30 PM. Record review of an elopement/wandering evaluation post incident on 11/7/2023-11/10/2023 did not reveal any evaluations were conducted. 2. Record review of a facility face sheet dated 8/19/24 for Resident #4 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's and hypertension. Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that she had a BIMS score of 3, which indicated that she had severe cognitive impairment. She had no wandering behaviors during assessment period. She used a wheelchair for mobility and was dependent with most ADLs. Record review of a comprehensive care plan dated 11/20/23 for Resident #4 indicated that she was an elopement risk/wanderer related to history of attempts to leave facility unattended and she wandered aimlessly. Focus included secure unit placement on 11/20/24. Record review of a facility form titled Elopement/Wandering Evaluation dated 9/6/23 for Resident #4 indicated that she was mobile in wheelchair, had intermittent confusion, no history of elopement, and was a low risk for elopement. Record review of a facility incident report dated 11/20/23 for Resident #4 indicated that she propelled self out of facility. During an observation on 8/19/24 at 9:18 am Resident #4 was observed sitting up in wheelchair in common area of secured unit. She was confused and did not answer questions. During an observation on 8/19/2024 at 9:34 AM, in the secured unit by the dining room exit had a keypad, exit leads out into a wooden fenced in area in a courtyard. There was a wooden fence that was about 8 feet tall that had double doors that was secured by a metal latch and pad locked. During an observation and interview on 8/19/2024 at 9:38 AM, CNA B said she had been employed at the facility for 9 years and work 6a-6p and always worked in the secured unit. She said about 65% of the residents in the unit wander and some like to go up and down the halls and will go in other rooms rummaging through other resident's things. She said there were a couple of them that tried to exit seek with holding down the exit door and would get out in the courtyard that was fenced in. She said she remembered when Resident #1 was in the secured unit and there was an incident when he used silverware and popped the screen off his window and the screw or nail came out. She showed the Surveyor the room where he resided and the window in the room had 2 screws on frame of the window above the top of the window on the left and right side that were screwed into the frame. She said on that day a family member had stopped by to visit him. She said Resident #1 kicked the gate open in the courtyard and it had a pad lock. She said that day she was not on the clock but was at the facility visiting a friend who worked that day. She said they found Resident #1 not long after it was discovered that he was not in his room. She said if there was not a fence dividing the property, then there could have been a chance for it to have taken longer to find him. She said no one heard him go out of his window or break the fence. She said he was not outside for a long time. She said they brought him back in and he was winded but looked fine. She said they did provide 1:1 supervision with him after the incident and he was informed that he could not leave. She said shortly after the incident he discharged and did not return. She said following the incident they had in-services on elopement. She said if they noticed a resident was missing, they were to report to the nurse and check everywhere. She said she just tells the nurse, and they take over from there. Attempted a phone interview with LVN C on 8/19/2024 at 11:00 AM, left a message for a return phone call. During an interview on 8/19/2024 at 11:06 AM, ADON D, said Resident #1 resided on the secured unit when he was at the facility. She said she called the physician about Resident #1 having an elopement at the facility. She said on 11/7/2023, Resident #1 unscrewed the window in his room, as there was a screw that kept the window from opening all the way. She said he took a butter knife and opened the window and got out into the courtyard in the secured unit. She said he did go out of the gate, but never left the premises. She said the physician called her back on the 11/8/2023 and gave an order for Rexulti 2 mg daily and then recommended behavioral hospital and started working on that and he discharged to a behavioral hospital sometime after the incident. She said he was on the secured unit for wandering purposes, he was on q15 minutes checks. The other ADON was the one responsible for handling incident/accidents for the resident. She said an aide noticed him and would not tell the surveyor anything else. Said she needed to get someone else because she could not answer those questions. During an interview on 8/19/2024 at 11:26 AM, ADON E said she was responsible for the incident/accidents, changes in condition and 24-hour reports. She said Resident #1 was admitted to the secured unit when he arrived at the facility. She said on 11/7/2023, Resident #1 was in the secured unit when he broke out of his window in his room into the courtyard and got out of the fence. She said when he was found he had scratches on his arms and a skin tear. She said they found him back by some trees at the back of the facility behind the secured unit. She said he was immediately assessed; his family member was at the facility to visit but was not sure if the family member was present at the time of the elopement. She said he was found not far away from the facility and did not think the incident was a reportable event because he was still on the grounds. She said Resident #1 left the facility without staff knowing and was not sure if he had done that before. She said it was not left up to her to make the decision if the incident was reportable or not. She said the abuse coordinator who was the Administrator, and the DON would make that decision. During an observation and interview on 8/19/2024 at 11:38 AM, ADON E conducted a walk through the secured unit on how Resident #1 was able to exit the unit. She walked with the Surveyor from the room where Resident #1 resided in the secured unit into the courtyard and showed how he broke through the wooden fence and was found in the wooded area by the facility approximately 30 feet from the wooden fence. She said he was found leaning up against a tree still on the property, not in the woods. There were 4 brown portable buildings noted and 2 trash cans by the building where she said he was found. She said when they found him, they took him and sat him on the bench that was outside at the end of A hall because he was winded, and his daughter was present at that time. She said the facility did have cameras at the facility but had recently upgraded their system and was not sure if they still had video footage of the incident with Resident #1. During an interview and observation on 8/19/24 at 11:40 am ADON E said that Resident #4 was found near the dumpsters at end of C-hall. She said she can't remember who brought her back in, that it was on the night shift. Dumpsters observed near several portable buildings and wooded area with chain link fence. During an interview on 8/19/2024 at 11:49 AM, the Maintenance Supervisor said Resident #1 resided in the secured unit in room [ROOM NUMBER]. He said the windows in the secured unit had lag bolts on both sides of the windows. He said he found the bolt and a butter knife in Resident #1's drawer in the room following the incident. He said Resident #1 was able to tell him that he used it to get out of the window on 11/7/2023. He said Resident #1 broke the back double gate in the courtyard of the secure unit and it previously had a smaller hook and clasp, and it broke. He said the door on the fence with a larger clasp and a bigger bolt with a pad lock. He said he also secured the door on the fence with stronger lag bolts and wood to secure it. He said he conducted an elopement drill with staff on day and night shifts following the incident and made sure all the lag bolts on the windows were secured and replaced and put in a different place on Resident #1's window. He said he made sure all the windows had devices in place in the secure unit. During an interview on 8/19/2024 at 12:11 PM, the DON said Resident #1's family member was at the facility at the time of the incident on 11/7/2023. She said the family member of Resident #1 told the aides that he was in the bathroom and would not come out. She said that was when they discovered he was not in the room and said she was not gone for no more than 5 minutes. She said the staff in the secured unit had just seen Resident #1 in his room. She said Resident #1 broke out of the window in his room and kicked the door down in the courtyard. She said following the incident, the Maintenance Supervisor placed a bigger latch on the courtyard door. She said since he was not gone anytime, she did not report it. She said she investigated the incident, talked to staff, and said the staff told her they had just seen him prior to the incident. She said she in-serviced the staff on elopement. During an interview on 8/19/24 at 12:15 pm DON said the staff heard the alarm go off when Resident #4 went out the end B-hall door. She said staff were all in rooms and when they heard the alarm go off, they looked out of the rooms into the hallways. She said they were doing a foley catheter on someone on F-hall and they didn't see anyone. She said they did not do a room check. She said resident was outside a long time and that it was reported to state agency as an elopement. During an interview on 8/19/24 at 12:25 pm Maintenance Sup said he was not here when Resident #4 eloped and did not remember exactly where she was found. He said he did elopement drills afterwards and checked the egress doors. During an interview on 8/19/24 at 1:42 pm DON said that the garbage man found Resident #4 while he was here to pick up the trash from the dumpsters. She said she watched the video showing Resident #4 eloping from the egress door on the end of B-hall. She said she could not remember exactly how long she had been outside but said possibly 15 to 20 minutes maybe. Said that staff did not do a head count after they heard the alarm going off, said they did look outside but it was dark, and they did not see anything. During a telephone interview on 8/19/24 at 2:18 pm Director of city disposal services was questioned on which driver would have picked up trash that night and he took surveyors name and telephone number. He said he would call back with further information if he found out anything. During a telephone interview on 8/19/24 at 2:18 pm Director of city disposal services returned phone call and said that he had spoken to his driver that picked up the trash at facility. He said the driver did not recall any incident of finding a resident outside and bringing her back. During a follow up interview on 8/19/2024 at 2:42 PM, the DON was questioned about how they determine when an incident should be reported to the state agency. She said it depended on the situation. She said she did a lot of the reporting to the state agency when she was on call, but they were mostly done by the Administrator. She said they followed their policies and incidents were situational. She said she could not give any specifics regarding incidents being situational. She said they did reach out to their Resource Leader who helped the facility with making decisions about reporting incidents. She said she did not consider a resident missing if they did not leave the premises and Resident #1 did not leave the premises. She said she in-serviced the staff and started a soft file on the incident but did not report it. During an interview on 8/19/2024 at 2:52 PM, the Administrator said she was the abuse coordinator for the facility. She said she was notified on the day Resident #1 eloped from the facility on 11/7/2023. She said he had gotten out of the gate of the secured unit, exited the window and went through the gate. She said he was found next to a tree outside of the facility. She said the incident was not reported because he did not leave the premises. She said on admission to the facility, Resident #1 was confused but at the time of the incident on 11/7/2023 his thinking had improved. She said regarding reporting if someone was missing or not, the time frame would have to be about 10 minutes or so of not being aware of them missing. She said she did not think the incident needed to be reported. She said she did not consider him a missing resident. She said she and the DON on occasions reach out to their Resource Leader and they would let them know if the incident was reportable or not. During an interview on 8/19/2024 at 3:14 PM, the Resource Leader said the facility did not contact her on a regular basis about any issues because she visited the facility about once a week. She said she spoke to the DON and another Resource Leader about the incident on 11/7/2023 with Resident #1 and they looked at the PL 19-17 for guidance. She said Resident #1 did not leave the premises and according to their elopement policy, if a resident does not leave the premises, then they are considered missing, so the incident was not reported to the state agency. During a telephone interview on 8/19/24 at 4:07 pm CNA AB said she was in a room with a resident when she said she heard the alarms going off. She said she notified the nurse and went outside to look for resident but did not find her. She said that they checked the rooms and by then, someone was ringing the doorbell with Resident #4. During a telephone interview on 8/19/24 at 4:20 pm CNA AC said she was in another room on F hall helping the nurse do a catheter on a resident. She said she never heard the alarms going off when Resident #4 opened the egress door. She said after she came out of the room, they heard the alarm going off, but they thought it was the fire alarm. She said they checked rooms, but did not notice that Resident #4 was missing, and they assumed she was in the bathroom. She said someone came to empty the trash and found her, then brought her back to the front. She said she was new at the time and did not know what the fire alarm sounded like. She said shortly after the incident they had an in-service on alarms to distinguish the difference. During a telephone interview on 8/20/24 at 8:18 am LVN A said that she, another nurse and 2 CNAs were in a resident room doing a catheter for a urine sample. She said she thought the other 2 aides in the facility were making rounds. She said she did not hear the door alarm going off at all while she was in the room, but when she came out of the room, the doorbell was ringing. She said after resident was brought back in, they assessed her, did vitals, and the other nurse did notifications of on-call nurse. The on-call nurse then notified the DON. She said she did not remember doing any in-services after the incident. She said after Resident #4 was back in facility and all notifications were made, they then did a head count to ensure there were no other missing residents. Record review of a facility policy titled Secured unit admission Criteria dated 9/2023 indicated, .admission to the Secured Unit is based on diagnostic, functional and behavioral criteria that determine that the resident can benefit from this special environment. Once a resident is accepted for admission to the unit, assessment of the resident's status and appropriateness for the unit is ongoing (at least quarterly and PRN for changes in condition) . Record review of a facility policy titled Elopement/Unsafe Wandering revised 12/2023 indicated, .If is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. Elopement occurs when a resident leaves the facility premises without the facility's knowledge, authorization (i.e., an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so. 6. Complete an Elopement/Wandering Evaluation of the resident post elopement incident with continued follow up documentation for a minimum of 72 hours following the incident . The facility took the following action to correct the non-compliance on 11/20/2023: Record review of emergency preparedness drill: missing person/elopement was conducted on 11/7/2023 at 10:15 AM by the Treatment Nurse. Record review of emergency preparedness drill: missing person/elopement was conducted on 11/7/2023 at 8:00 PM by the LVN AD. Record review of a Q 15-minute monitoring for Resident #1 was started on 11/7/2023 at 2:45 PM and ended on 11/8/2023 at 2:30 PM. Record review of an In-service training report dated 11/20/23 indicated that all staff were in-serviced on fire drills on 11/20/23. Record review of facility form titled Emergency Preparedness DRILL: Missing Person/Elopement dated 11/20/23 indicated that staff on all shifts received an elopement drill on 11/20/23. Record review of an in-service training report dated 11/20/23 indicated that all staff were in-serviced on Elopement drills, trauma, sensitivity, Alzheimer's Dementia, and elopement/unsafe wandering guidelines on 11/20/23. Record review of a physician's order dated 11/20/23 for Resident #4 read .May admit to secured unit . Record review of a facility form titled Weekly Preventative Maintenance Task Sheet - Door Security Systems dated 11/20/23 indicated that all egress doors had been checked and were functioning and that affected personnel in area had been trained on 11/20/23. Interviews on 8/21/2024 from 9:27 AM to 12:00 PM included: During an interview on 8/21/2024 at 9:27 am, the DM said she had a training drill on elopement early this morning in the facility and had in-services on elopement/missing residents this past week. She was able to verbalize the silver dots on the doors indicated that a resident was a high risk for elopement, could also look in the elopement binder and the Kardex. She said dietary did not have access to the Kardex. She said she took a test on wandering on their online training program and had one that was written when they did in-service over true/false questions. She said if you received a notification that a resident was missing, then you did a head count, checked closets, bathrooms, go outside and around building and if resident cannot be found, call the DON. She said you must check to see if they are out on pass, if not, call the emergency contact, physician, and law enforcement. During an interview on 8/21/2024 at 9:30 am, the [NAME] verbalized trainings on elopement/missing residents was held this past week. She said if a resident came up missing, if a light goes off, they have probably gone out of the door. She said they are to immediately stop what you they were doing, try to locate the resident and conduct a head count. She said she was trained on where to find the elopement binder, to look in the book to see if the resident was out on pass, and to call and see if they are out on pass. She said they would also conduct a head count. She said the silver stars on doors and the elopement book would let them know which residents were high risk for elopement. She said she took a test on the computer and did a paper test over elopement. During an interview on 8/21/2024 at 9:36 am, the DA said he received training on elopement/missing residents this past week. He said he was trained on the silver dots are for residents that are high risk. He said if a resident was missing then they would look for the lights on the hall, go outside to try to find the resident, and if unable to locate, then would notify the nurse. He said he took a test online and a true/false test on paper. During an interview on 8/21/2024 at 9:38 am, the Dishwasher said he had trainings this past week on elopement/missing residents. He said he had training on the computer regarding if someone came up missing, on the door alarms, and steps to take on when they are or not found. He said if a resident was missing, find out which hall the alarm was going off on and go out there and look for the resident, notify the nurse, and conduct a head count. He said he would look behind the buildings, by dumpsters, and in wooded areas to try and find residents. He said residents that were high risk in the facility had a silver dot on their doors, listed in the binder by nurses' desk, and was in the Kardex. He said he took a test on what to do when the alarm goes off and a test on paper. During an interview on 8/21/2024 at 9:45 AM, the BOM said she received training this past week on elopements on their online training program, had active drills for elopements, and was in-serviced as a group over elopements. She said if a resident was missing, they would call a code silver, start search, notify the nurse, the Administrator and DON. She said she was part of the calvary that was called in to help search and they would also call the police but would immediately start searching. She said she was taught in elopement training that if an alarm goes off, a light above the hall that the alarm was from, go outside and physically search for them while other employees look inside the facility. She said they would then conduct a head count, call the police, notify the DON, Administrator, and other department heads. She said residents that were high risk for elopement had silver dots outside their door, there was a book at nurses' station with their information in it and they could look at the Kardex in the computer charting system. She said she took a test online and a paper test with the in-service. During an interview on 9:48 am, Admissions said she was trained on how to identify elopement risks, and there were silver dots on the name plates of the residents that were high risk and could find the information in the Kardex in the charting system. She said there was a binder that also had the information. She said if an alarm went off, employees would split up and start searching, and do a head count. She said they had elopement drills, took a test on paper and online. During an interview on 8/21/2024 at 9:50 am, the ABOM said this past week she had trainings over elopement and wandering risks. She said they had an elopement drill and completed videos online on elopement, and took a test on elopement, and had in-service trainings. She said a resident that was high risk for elopement would have a silver dot outside of their room on their doors, they would also be in the elopement risk binder, and in the Kardex. She said if a resident was missing, would notify the Administrator, Don, MD on call, law enforcement the family. She said they would immediately search for the resident outside of the facility, do head count, and search facility wide. She said they would check the binder to see if family had taken them out on pass, if not, would keep searching and get everyone involved. She said she took a written test and online training with a test on elopement. During an interview on 8/21/2024 at 9:54 AM, the Receptionist said this past week she had trainings on elopement/missing residents. She said they had drills for when the lights flash to see if a resident had gotten out and to check all areas inside and out. She said she had training and testing on the computer and an in-service on elopement. She said the silver stars or dots on door nameplate, a binder with info, and the Kardex (she does not have access) would help to identify what residents were at risk for elopement. She said she took tests online and one on paper. During an interview on 9:56 am, the Transportation Driver said she had trainings over elopement this past week. She said there were alarms on each door, and it would identify which hall and go out that hall door and look. She said if you do not see anyone, notify the nurse and she would call a code silver. She said the nurse would then assign everyone somewhere to search and conduct a head count, identify who was missing and if not located, notify the DON, Administrator, and the police. She said residents who were high risk for elopements could be found in the Kardex, a binder, and there were silver dots on their doors. She said she had tests on paper and one online. During an interview on 8/21/2024 at 10:00 am, PTA said she had elopement training this week. She said the training included on knowing what to do, what the alarm sounded like, fastest way to identify a missing patient, identify which hall alarm was coming from, go outside and look, if you don't see anyone, notify nurse, code silver, check all rooms, closets, bathrooms, do head count. Look to see if they are on pass. She said there was an elopement binder at nurses' station that had residents who were high risk for elopement, could also find the information in the Kardex in the charting system and their rooms would have a silver dot by their names. She said she did a test on paper and online over elopement. During an interview on 8/21/2024 at 10:03 am, the OTA/ADOR said he was trained on elopement this week and how to identify a resident who was at risk along with the steps to take. He said the elopement binder, Kardex and a silver dot on the name plates indicate who are high risk for elopement. He said if a resident was missing, would identify door light, report to the charge nurse, check the immediate area outside, call code silver, and do a head count. He was tested on elopement online and paper. During an interview on 8/21/2024 at 10:05 am, PT said he was trained on identifying elopement risks for residents and procedures. He said if a resident was a high risk for elopement could find that information in the Kardex, in the care plan, the elopement binder at nurses' station, or a silver dot on the resident's door. He said if a resident was missing resident an alarm would go off, would go down to the end of the hallway and report to the charge nurse. He said he would go outside and search for the resident, conduct an internal search, and conduct a head count of the residents. He said then they would notify the DON, Administrator, RP, and the police. He said he was tested on procedures on paper and online. During an interview on 8/21/2024 at 10:07 am, OT said he had been trained and had in-services on elopements and identifying if someone had left the facility. He said they were told to look for the lights, sounds, and see where they were coming from. He said they would look for them, do a head count, and notify the DON and the Administrator. He said if a resident was high risk for elopement they would have a silver sticker on their doors, could find the information in the Kardex and in the elopement binder. He said he was tested on paper and online. During an interview on 8/21/2024 at 10:10 am, COTA said she had elopement trainings and some on the computer. She said they were taught on the procedure to take which included if an alarm sounded, look at the end of each hall to identify the hall where the resident was, look outside to see if you can see them, and if not notify [TRUNCATED]