**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents received care and services consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to:A. Ensure Resident #1 had appropriate interventions in place to prevent unstageable pressure ulcers under her C- Collar neck brace.B. Perform thorough skin assessments under Resident #1's C-collar to ensure pressure ulcers were not developing.C. Ensure Resident #1's C-collar was applied properly and maintained, as it was noted to be taped in place to prevent removal, with fecal matter smeared on tape.These failures resulted in an Immediate Jeopardy (IJ) situation on 09/17/2025. The IJ template was provided to the facility on [DATE] at 1:01PM. While the IJ was removed on 09/18/2025, the facility remained out of compliance at a scope of isolated and a severity level potential for more harm than minimal harm that is not Immediate Jeopardy, due to staff needing more time to monitor the plan of removal for effectiveness.These failures could place residents at risk of physical harm.Record review of Resident #1 face sheet, dated 09/16/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, dissection of vertebral artery (small tear in artery wall), nondisplaced posterior arch fracture of first cervical vertebra(hairline break in back part of top neck), and non-displaced fracture of seventh cervical vertebra(small break in seventh bone).Record Review of Resident #1's Significant Change MDS assessment, dated 09/11/2025, reflected she was assessed with a BIMS score of 00, indicating severe cognitive impairment. Further review reflected she was assessed as not having any pressure ulcers.Record Review of Resident #1's initial skin assessment, dated 09/04/2025, reflected she was assessed as having no pressure ulcers. Record Review of Resident #1's comprehensive care plan reflected a focus area, dated 09/12/2025, Resident #1 has cervical fractures related to falling from her wheelchair-neck brace in place per MD orders. Review of interventions included neck brace as orders and skin assessment per facility protocol and prn. The care plan did not include interventions for brace removal.Record Review of Resident #1's physician orders reflected an order dated 09/05/2025, C-Collar on at all times except for showers. Further review reflected an order for Philadelphia collar, dated 09/05/2025, for showers (soft collar). Further review of Resident #1's physician orders reflected no order for removal of the collar to perform skin checks.Record Review of Resident #1's hospital record, dated 09/15/2025, reflected, Patient diagnosis pressure ulcer unstageable.Skin.bruising under c-collar, inspection findings include pressure ulcer, wound behind left ear and on chin under c-collar. Inspection findings include swelling to the anterior neck. Notes . c-collar taped to patient with fecal matter smeared on tape.During an interview on 09/16/2025 at 2:54 pm, the ER RN stated the ER did a head-to-to-toe assessment, and the ER was concerned about: ER removed the Aspen Collar which was missing all padding from the plastic collar, no padding at all noted and the collar was wrapped with 2-inch silk tape all the way around, rolled around the brace to adhere it to the neck. ER RN stated the tape was not on the skin, but the neck brace was wrapped so tightly around the neck that they had to use bandage scissors to remove the 10 -12 wrapped circles of tape around the brace and around her neck. ER RN stated, I understand she was probably pulling it off, but the tape was excessive and if it was an emergency they would not be able to get it off of the resident's neck. The ER RN stated in the ER they cut it off with bandage scissors and it took about 5 minutes to get off. The silk tape was soiled with food and fecal matter. The ER RN stated when they finally got it loose, there was bloody tissue where a skin adhesion to the collar had occurred. It was difficult to get the collar off the skin. The skin had a very strong smell the ER RN described as rotting flesh, putrid, or a bacteria smell. The smell was so strong the ER cultured the wounds on the left ear area of the neck, and chin for bacteria. The ER RN described the wounds as ulcers from the c-collar. In an interview on 09/16/2025, at 3:39 PM, the RP stated on 9/11/2025, she visited the facility to pick up Resident #1's cell phone for repair. The RP stated the facility had her sign a form acknowledging Resident #1 may fall and sustain injury due to her behaviors. The RP stated that during that visit, her loved one was wearing a brace that was covered with cotton gauze which had a foul odor and appeared dirty. She further stated that each time she visited, she requested that the facility clean Resident #1's room. She also reported observing fecal matter on the resident's bedsheets and fingers. Review of Resident #1's weekly skin assessment dated [DATE] performed by LVN C reflected no identified pressure ulcers.Review of Resident #1's weekly skin assessment dated [DATE] performed by the Treatment Nurse reflected no identified pressure ulcers.In an interview conducted on 09/16/2025 at 4:35 PM, the Treatment Nurse stated she had been in her position for a few months but was with the company for 6 years. The Treatment Nurse stated when she assessed Resident #1 on 09/13/2025 she stated she noticed some redness but that she did not remove the c-collar or loosen it to do a full assessment. She stated she did not notice any tape on the c-collar. The Treatment nurse stated on yesterday she sent Resident #1 to the ER, and she did not notice any tape on resident.In an interview conducted on 09/16/2025 at 5:17 PM, LVN D stated Resident #1 had tape on her C-Collar since she returned from the 9/10/2025 ER visit. LVN D stated he was off work two days and when he returned Resident #1 had tape on the collar. LVN D stated there were no instructions given on the tape.In an interview conducted on 09/16/2025 at 5:24 PM, LVN C stated Resident # 1 returned from the ER with tape at the bottom of her collar. The LVN stated this information was not documented but stated vanilla tape was at the bottom of the collar. LVN C volunteered this information without being prompted by the surveyor. LVN C stated she knew the tape was a concern. LVN C further explained that the nurses removed the C-collar at bath times and applied a different type of collar that could get wet. LVN C stated the C-collar was only removed when Resident #1 did not refuse shower. LVN C stated she was PRN and her last time at work was last Thursday, 9/11/2025. LVN C stated the Treatment Nurse checked the resident on that same day.In an interview conducted on 09/16/2025 at 6:00 PM, CNA A stated she worked at the facility since March of 2024. CNA A stated she worked with Resident #1. CNA A stated she did not shower Resident #1 the previous day. She stated the night shift normally provides the showers for Resident #1. She further explained that Resident #1 showers had recently been changed to daily. CNA A stated the last gave Resident #1 a shower on 9/5/2025. She also stated that LVN C removed the gray C-Collar and placed a tan collar on Resident #1 that could get wet.Review of Resident #1's ADL flow sheet for bathing reflected Resident #1 was documented as having a bath on 09/05/2025 and 09/13/2025.In an interview conducted on 09/17/2025 at 10:53 am, CNA B stated she worked with Resident #1 one day. She stated she provided Resident #1 with a bed bath on 9/13/25 but did not remove the collar. CNA B stated she didn't touch that area during bath. CNA B stated only the nurses touch the collars and wounds; the aids do not.In an interview conducted on 09/17/2025 at 9:44 am, Resident #1's physician stated it was his expectation that staff check the resident's skin for pressure areas when a splint was in use. He explained the brace/ collar must be fitted correctly by medical staff. Resident #1's physician stated a collar should not necessarily be taped unless there was a malfunction with the splint. The physician stated there should be a follow up with orthopedic surgeon, based on orthopedic recommendation. Resident #1's physician stated the splint should not be altered unless it was cleared by the medical doctor.In an interview conducted on 09/17/2025 at 12:30 PM, the RCN stated Resident #1 should have had orders in place to remove the splints and conduct skin assessments every shift. The RCN further stated a thorough skin assessment should have been completed upon the resident's readmission from the hospital.Review of the facility's policy immobilization devices, splint/slings/collars/straps (not rated) reflected, Immobilization devices are splints, slings, cervical collars and clavicle straps that are applied to restrict movement, support and preserve the integrity of an injured arm, shoulder or neck. 3. Secure with Velcro, strips of cloth, pin, or tape the loose end. Secure the material with firmness but without compromising circulation. 4. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 8. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet.Review of the facility's policy pressure injury: prevention, assessment and treatment (not rated) 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 9. Assess early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet.This was determined to be an Immediate Jeopardy (IJ) on 09/17/2025, the Administration was notified. The Administrator was provided with the IJ template on 09/17/25 at 1:01 PM and a plan of removal was requested. The following POR was accepted on 09/18/2025 at 8:30 AM. Plan of removalProblem: F686 Failure to prevent pressure injury On 09/16/2025 an abbreviated survey was initiated at the facility. On 09/16/2025 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The facility failed to ensure Resident #1 had interventions in place to prevent unstageable pressure ulcers from forming under her C-Collar neck brace. The facility failed to perform through skin checks under her C-Collar to ensure pressure ulcers were not forming. The facility failed to ensure the C-Collar was applied properly and maintained when it was noted to be taped to prevent removal with fecal matter smeared on tape.There are 3 residents with braces and splints ordered that could potentially be affected by the deficient practice. 1. Resident #1 remains in the hospital as of 09/15/2025. No other residents in the facility have cervical collars. 2. Action: o 100% resident head to toe skin assessments initiated 09/17/2025 by DON, ADON, and treatment nurse. No further residents were noted with any skin integrity issues. o Head-toe assessment skin assessments were completed for the two residents with orders for a leg brace and bilateral hand splints. No further skin integrity issues were noted. No tape was noted. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: These assessments were completed by DON, ADON, and treatment nurse with oversight from Regional Compliance Nurse. 3. Action: o The two residents identified with a brace and a splint were verified to have physician orders to remove for skin assessment and showers. o The two residents identified with a brace and a splint were verified to have the orders to remove for skin assessments and showers were also care planned. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: The orders were care planned by Regional Compliance Nurse, DON, and treatment nurse. 4. Inservice Action (Leadership): The Administrator and DON were in serviced 1:1 and for the following policies:o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by regional compliance nurse for Administrator and DON understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: This Inservice was completed by Regional Compliance Nurse.5. Inservice Action (All Staff): All staff were inserviced on the following topics. Any staff member not present or inserviced as of 9/17/2025 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will inserviced prior to assuming their next assignment.o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: All staff were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by Administrator of all staff understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: These in services were completed by Administrator and DON.6. Monitoring: Monitoring steps will be documented on the individual monitoring tools.o The DON/designee will monitor all new residents with braces to ensure orders are in place for removal of brace per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. o The DON / designee will view each pressure ulcer weekly X's 6 weeks using available monitoring tool.o The DON / designee will audit all skin assessments weekly to ensure all assessments match the resident's current condition for 6 weeks using current monitoring tool.o DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks.o DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks o The QA committee will review findings at the monthly QA meeting and makes changes as needed. o Monitoring will be initiated 9/17/25 and will continue indefinitely. 7. ADHOC QAPI: This meeting was completed by the interdisciplinary team to include the Medical Director and wound care doctor on 09/17/2025.8. Involvement of the Medical Director: The medical director as notified of the immediate jeopardy on 09/17/2025 by the Administrator.Monitored the POR on 9/18/2025 as followed:In an interview on 9/18/2025 at 9:25 AM, the RA stated all in services were completed and provided surveyor with the plan of removal binder.In an interview on 9/18/2025 at 11:07 AM, the RCN stated she in serviced the facility leadership 1on 1 which includes, the ADM, Interim DON, ADON, and the Treatment nurse on proper precautions that need to be in place for residents with collars, braces, and splints. RNC stated the topics were pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect, and new process on weekly skin assessments. RNC stated she completed a 1 on 1 with Treatment Nurse on skin assessments and stated she also trained the ADM on nursing items as she can follow-up in morning meetings.RNC stated she also in- serviced CNAs, medication aids, the Activity Director, therapy staff housekeeping, dietary, and administration staff. She stated all staff were in serviced, some in person, some by phone and some were notified through their electronic message system, COVR. RNC stated everyone that worked on yesterday reviewed and signed off on their trainings, and the staff who were trained via phone and their electronic system will have to sign in-service sheet prior to working their shift. RNC stated monitoring will be ongoing by Interim DON and herself.In an interview on 9/18/2025 at 12:25 PM, the physical therapist assistant stated she was in serviced on 9/17/2025 by the RA and the ADM on abuse and neglect and resident rights. The physical therapist assistant stated she also trained on refusal of care, the process to notify when there is refusal of care, pressure ulcers, showers, braces/splints, and notification of changes. The physical therapist assistant stated they were given a cheat sheet to keep with their name badge for reference.In an interview on 9/18/2025 at 12:47 PM, the ADM stated the RNC in serviced her on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, showers, abuse and neglect. ADM stated they will review skin reports in morning meetings. ADM showed surveyor the cheat sheet for in services they all have in their name badge.In an interview on 9/18/2025 at 1:46 PM, the Interim DON stated she was in serviced by the RNC. The Interim DON stated she was trained on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect. She stated the trainings included procedures to take for notification in skin changes, refusals, showers, and maintaining integrity of the skin. Interim DON stated training included removal of braces every shift per physician orders. In an interview on 9/18/2025 at 1:55PM, the ADON stated she was in serviced by the RNC. ADON stated she was trained on abuse an neglect, pressure ulcer and treatment, she provided examples of turning residents every two hours, elevating elbows, and making sure body parts are offloading. ADON described the process for braces/splints, initial skin assessments, weekly skin assessments, and refusals indicating she received all in servicing.In an interview on 9/18/2025 at 2:04 PM, the TN stated she was in serviced by the RNC on weekly skin assessments, pressure ulcer prevention and treatment, braces/splints, initial skin assessments, and abuse and neglect. TN stated she will be completing initial skin assessments with in the first 4 hours of arriving to the facility and at readmission. TN stated if she is not available the assessments will be completed by the charge nurse. TN provided examples of braces/splint checks and pressure ulcer prevention treatment.Interviews conducted on 9/18/2025 with nurses on shift between 2:11 PM -2:35PM [LVN E, MDS Nurse, LVN C] indicated they participated in the mandatory in service training about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. The nurses summarized the topics of discussion in their own words of procedures to follow. Nurses stated they would notify the treatment nurse, DON, and physician immediately of resident change in condition.Interviews conducted on 9/18/2025 with CNAs on shift between 2:43 PM-3:04 PM [CNA G, CNA H] indicated they participated in an in-service training about reporting refusal of care, abuse and neglect, resident rights, pressure ulcer prevention, braces/splints, showers, and notification of change in condition. The CNAs summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews conducted on 9/18/2025 with night nurses and night CNAs scheduled for night shift between 3:19 PM-4:35 PM [RN K, LVN J, LVN L, LVN M, CNA B, CNA F] indicated they participated in the mandatory in-services. The LVN nurses indicated they received training via phone with RNC about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. RN K stated she received her training through the facility's electronic notification system, she summarized the topic of discussions and stated she will sign off before working her next shift. The CNAs stated they received their in-service training prior to starting their shift on 9/17/2025. The night CNAs both summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews attempted via outbound calls to LVN D, RN N, and RN P, the calls were unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to exit on 9/18/2025.Record Review on 9/18/2025 of the In-Service Training Sheets reflected all facility staff had been in-serviced on all training topics listed on the plan of removal. About 5 percent of signatures were still needed as those employees had not worked a shift, those employees will reconfirm understanding of the training and sign off prior to working their shift. Record Review on 9/18/2025 of skin assessments completed, reflected all 56 residents in the facility had been completed.Record Review of care plans on 9/18/2025 for Resident #2 and Resident #3 reflected they were updated to include removal of braces/splints for skin assessments and showers.The Administrator was informed the Immediate Jeopardy was removed on 09/18/25 at 5:50 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and scope of isolated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A, on 07/30/25, did not transfer Resident #1 from his bed to a shower chair without using two people and a mechanical lift. Resident #1 fell and suffered pain to his right ankle and behind his right knee. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 07/30/25 and ended on 07/30/25. The facility had corrected the noncompliance before the survey began.This deficient practice placed residents at risk of pain, injury, and hospitalization. Findings included:Review of Resident #1's face sheet dated 08/08/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral palsy (a group of neurological disorders that primarily affect movement and muscle coordination), other reduced mobility (a situation where an individual's ability to move is impaired, but not due to a specific condition), and lack of coordination (refers to a condition where a person experiences difficulty with smooth, precise movements).Review of Resident #1's care plan revised on 05/21/2025 reflected Resident #1 had an ADL self-care deficit related to impaired cognition and decreased mobility with intervention dated 07/30/25 that stated Resident #1 required a mechanical lift and assist of 2 staff for transfers. Review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 15 indicating no cognitive impairment. Review of nursing notes dated 07/30/2025 by LVN B reflected Resident #1 had a fall in his room when he was being assisted by CNA A and slid out of chair. LVN B was notified by CNA A that Resident #1 was lowered to the floor in room. CNA A stated that Resident #1 was being transferred to a shower wheelchair and wheels on wheelchair would not lock completely and CNA A then lowered Resident #1 to the ground for safety to get nurses' help. CNA A and LVN B got Resident #1 onto [mechanical lift] pad and lifted Resident #1 via [mechanical lift] onto the shower bed. Resident #1 appeared and/or states to be in pain. Resident #1 described the pain as Sharp, Location of pain: right ankle Pain relieving intervention used at this time. PRN pain medication given and STAT x-ray in place. Resident Statement: The wheels on the chair wouldn't locked and CNA A helped me to the floor. MD/NP and RP notified. Review of witness statement by CNA A dated 07/30/25 reflected CNA A was going to give [Resident #1] a shower and planned to put him in the shower chair. When I was transferring him to the chair the brakes didn't fasten enough and the chair went back I assisted him down to the floor and made sure he was ok I went and got my nurse to assist and assessed him and we got him back in the shower bed with the [mechanical lift] and give him the shower and we put him back in the wheelchair for the day. Review of Resident #1's 07/30/25 radiology results reflected no fracture of Resident #1's right ankle. Interview on 08/08/25 at 9:39 am with Resident #1 reflected he fell a while ago when he was being transferred to a chair. He said he was sore for several days after he fell. He said he asked CNA A why there was not another person in there when she was transferring him from the bed to the chair because he said it took two people to transfer him. He said CNA A told him it did not take two people to transfer him. Interview on 08/08/25 at 1:40 pm with CNA A reflected she was going to transfer Resident #1 from his bed to a shower chair, but the chair went back, and she assisted Resident #1 to the floor. She stated Resident #1 did not hit his head. CNA A said Resident #1 was care planned for a mechanical lift, which required two people when transferring a resident, and she was in Resident #1's room alone transferring him not using the mechanical lift. CNA A said she was transferring him alone because she was just going to move him to the shower chair and she could transfer him to the shower chair not using a mechanical lift, which required two people. She said she had not previously transferred him alone, she always used the mechanical lift but because she was going to transfer him from the bed to shower chair, she felt like she could transfer him without using two people and a mechanical lift. CNA A said Resident #1 did not ask her why there were not two people transferring him or why she did not use a mechanical lift. She stated she was familiar with the Kardex (a documentation system that provides a concise summary of patient information, aiding nurses in organizing and referencing patient care details). She said the Kardex gave information about the residents' transfer status and included how to transfer Resident #1 when he was going to have a shower. She stated she was trained at the facility on how to use a mechanical lift and was told a mechanical lift always required two people. CNA A said she thought Resident #1 used a mechanical lift because he was obese, and he did not have a lot of control of his legs. She said she made the decision to transfer him alone because she was confident she was going to be able to do it and never expected the chair to go backwards. She said she was aware that he could have been hurt and she thought it was unsafe to transfer Resident #1 on her own. She said knowing the transfer status of the resident was the responsibility of everybody who worked with residents, and it was her responsibility to follow information in the Kardex and she had full access to the Kardex. CNA A stated she was aware prior to this transfer that Resident #1 needed a mechanical lift transfer that required two people. She said after Resident #1 went to the floor she asked Resident #1 if he was okay then found the nurse and together, CNA A and LVN B, put the mechanical lift sling under Resident #1 and picked him up by the mechanical lift. CNA A said she had not transferred any other facility residents who used mechanical lifts by herself. Interview on 08/08/25 at 1:40 pm with LVN B reflected that on 07/30/25 CNA A was the aide on charge nurse LVN B's assigned hall where Resident #1's room was located. LVN B said CNA A called her to Resident #1's room and Resident #1 was on the floor and there was a shower chair in the room. LVN B said she did not see a mechanical lift in Resident #1's room and no other person was assisting CNA A with transferring Resident #1. LVN B said Resident #1 told her he did not hit his head and initially denied he was in pain, but about 30 minutes later Resident #1 complained of right ankle pain and Resident #1 said he did not want to go to the hospital. STAT x-rays were ordered and reflected no fracturs. A day after the incident Resident #1 complained of the back of his right knee hurting and he was successfully treated with Tylenol and bio freeze. LVN B said he might have had some soreness from the fall on 07/30/25. LVN B said Resident #1 was care planned for a two-person transfer using a mechanical lift. She said there was enough staff at the time of the incident for Resident #1 to have received a two-person mechanical lift transfer. LVN B said she was not aware of CNA A not conducting a two-person mechanical lift transfer when a resident was care planned for a two-person mechanical lift transfer. LVN B said it was the responsibility of CNAs and the charge nurses to ensure residents were transferred appropriately according to their care plan. LVN B said there was no reason for CNA A to be in Resident #1's room doing a transfer alone without a mechanical lift. The possible negative effects of not having two people when using a mechanical lift transfer was the resident could get hurt. LVN B said she did not believe Resident #1 sustained a severe physical injury; it was more mental because staff were constantly redirecting Resident #1 to let him know that he was okay. LVN B did not witness transfers of other residents in the facility who were care planned for mechanical lift transfers that always required two people who were transferred using a mechanical lift using one person. Interview on 08/08/25 at 5:16 pm with CNA C reflected Resident #1 was to always be transferred by 2 people using a mechanical lift. CNA C said all residents who required a transfer using a mechanical lift were a two-person transfer. She said it did not matter if they were going to transfer them to a wheelchair or a shower chair, a mechanical lift required two people for the transfer. She said it was very unsafe to not have two people when transferring a resident using a mechanical lift. She said the resident could be dropped on the floor. She said everyone was responsible for looking at the Kardex before transferring a resident to confirm the residents' transfer safety needs. Interview on 08/08/25 at 5:47 pm with LVN D reflected she was a charge nurse and if a resident used a mechanical lift transfer, they required two people for a transfer no exception. She said if staff were working with her, they better get two people to do a mechanical lift transfer. She said CNAs had access to the Kardex. She said it was everybody's responsibility to make sure the Kardex was followed for safe transfers.Interview on 08/08/25 at 5:47 pm with the Administer reflected it was the responsibility of everyone, CNAs and nurses, who provided care to residents, to know the required transfer needs of all residents. She said CNAs could find resident transfer requirements on the Kardex. The Administer stated that when the resident status stated mechanical lift was required, two people were required for the transfer using a mechanical lift with no exceptions to that rule for the safety of the residents. The negative outcome of not following the resident's care planned required transfer status was there could be either major or minor injuries to the resident. The Administer stated that CNA A had returned to work but as of 08/12/25, she had not worked in the capacity of a CNA after the incident. Interview on 08/08/25 at 6:45 pm with the CN reflected it was the responsibility of the person who transferred the resident to know the safe transfer needs of the resident. She stated CNAs could locate resident transfer information on the Kardex and they could ask the charge nurse. She said it took two people for a safe mechanical lift transfer and there were no exceptions to that requirement. She said if a resident was care planned and required a mechanical lift transfer it was for the safety of the resident. She said if a resident was care planned and required a mechanical lift transfer it was because they were not able to stand. She said all CNAs were trained by the facility to use a mechanical lift when they were hired by the facility. Interview on 08/12/25 at 7:00 pm with the Administrator revealed she reviewed facility policies on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex and trained the MDS Coordinator and former DON on these policies and procedures prior to the MDS Coordinator and former DON administering the in-services, skills training, and mechanical lift demonstration to the facility staff. Interview on 08/12/25 at 4:25 pm with the MDS Coordinator reflected she administered 50 - 75 percent of the in-services given to the staff on 07/30/25. The remainder of the staff were in-serviced by the former DON. The MDS Coordinator said she and the former DON immediately began in-services to the staff after the morning meeting on 07/30/25. The MDS Coordinator said she received her instructions for all in-servicing from the former DON and the Administrator. She said staff was in-serviced at a 100 percent completion rate on 07/30/25.Observation on 08/12/25 at 3:40 pm of CNA A and RN E who conducted a transfer of Resident #2 from her wheelchair to her bed reflected a safe transfer.Interview on 08/12/25 at 3:04 pm with Resident #5 reflected the staff treated her respectfully. She said two people always assisted when she was transferred by a mechanical lift. Interview on 08/12/25 at 3:08 pm with Resident #3 reflected the staff treated her respectfully, she felt safe at the facility, and the staff used two people when they used a mechanical lift to transfer her. Interview on 08/12/25 at 3:17 pm with Resident #4 reflected she was transferred by a mechanical lift and felt safe when staff used a mechanical lift and staff always used two people when they transferred her using the mechanical lift. Interview on 08/12/25 at 2:54 pm with Resident #6 revealed the staff treated her respectfully and she felt safe at the facility. She said staff used a mechanical lift to transfer her, and they always had two people when they used the mechanical lift. She did not have any concerns about her care or treatment at the facility. During interviews on 08/12/25 from 4:25 pm - 6:23 pm, two RNs, two LVNs, and six CNAs from different shifts all stated they were in-serviced on 07/30/25 on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex. All staff interviewed stated that if a person was care planned for a mechanical lift transfer, always use a mechanical lift to transfer the resident and always have two people to transfer the resident to ensure resident safety. All staff interviewed stated they knew where to locate the resident transfer information in the Kardex. Review of the facility's self-report to HHSC, dated 07/30/25 reflected the Administrator reported the incident with CNA A not using a mechanical lift to transfer Resident#1 as care planned the same day it occurred. Record review of CNA A's Employee Disciplinary Report dated 07/30/25 reflected CNA A was placed on investigatory suspension pending an investigation into allegations of not following a resident's care plan. CNA A would remain on investigatory suspension until the investigation was completed. Record review of in-service dated 07/30/25 given by the MDS Coordinator to the nursing and CNA staff on Mechanical Lift Transfer Skills Check and demonstration on using a mechanical lift was administered to 100 percent of facility nurses and CNAs included training for CNA A.Record review of in-services dated 07/30/25 on Abuse and Neglect administered to all facility staff at 100 percent staff completion rate included training for CNA A.Record review of in-service dated 07/30/25 on Trauma Informed Assessment administered to all facility staff at 100 percent completion rate. Record review of in-service dated 07/30/25 on how to use the Kardex located in the eMAR was administered to all nurses and CNAs at 100 percent completion including CNA A. Review of facility undated Hydraulic Lift Policy reflected the hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Goals:a. The resident will achieve safe transfer to bed or chair via a mechanical lift device.b. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift.The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable, safe transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #21) of six residents reviewed for pressure ulcers. The facility failed to ensure Resident #21 who was at risk for skin breakdown was turned every two hours and provided incontinent care. on 05/07/2024, Resident #21 was left in the same position in her Geri-chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl.) for 6 and a half hours from 8:00 AM till 2:30 PM. Once Resident #21 was placed in bed she was observed to have two DTIs (A pressure-related injury to subcutaneous tissues under intact skin.) to her coccyx that were previously unidentified by the facility. An immediate Jeopardy (IJ) situation was identified on 05/07/2024 at 5:10 PM. While the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained out of compliance at a scope of isolated with no further actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Findings Include: Review of Resident #21's face sheet dated 05/07/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and chronic lymphocytic leukemia (is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell). Review of Resident #21's quarterly MDS dated [DATE] reflected Resident #21 was assessed to have a BIMS assessment was not conducted indicating Resident #21 had severe cognitive impairment. Resident #21 was assessed to be dependent on staff for all areas of ADL care and was assessed to be incontinent of bowel and bladder. Review of Resident #21's comprehensive care plan reflected: -problem dated 09/26/2022 Resident #21 is incontinent of bowel and bladder. Interventions included .Check resident every two hours and assist with toileting as needed. Provide peri care after each incontinent episode and report any skin change to nurse immediately. -problem dated 11/22/2023 and revised 04/19/2024 Resident #21 has actual impairment to skin integrity related to fragile skin, prone to easily bruising with pressure due to chronic lymphocytic leukemia. Interventions included .Keep skin clean and dry .reposition resident to prevent pressure for body parts . further review of Resident #21's care plan reflected no plan of care for pressure ulcers. Review of Resident #21's consolidated physician orders dated 05/07/2024 no orders for pressure ulcer wound care. Further review reflected an order dated 09/27/2022 pad all boney prominences with pillows to prevent breakdown. Review of Resident #21's weekly skin assessment dated [DATE] and locked on 05/06/2024 reflected no MASD or pressure ulcers were identified. Observation and interview on 05/07/2024 at 8:00 AM, revealed Resident #21 in her Geri chair in her room. Resident #21 was not interviewable. Observation on 05/07/2024 at 9:43 AM, revealed Resident #21 in her Geri chair in the same position in her room. Observation on 05/07/2024 at 12:00 PM, revealed CNA E passing out meal trays on Resident #21's hall. CNA E arrived at Resident #21's room at 12:25 PM and started feeding Resident #21. CNA E did not reposition Resident #21. Observation on 05/07/2024 at 12:45 PM, revealed Resident #21 up in her Geri chair in the same position. Observation on 05/07/2024 at 1:45 PM, revealed Resident #21 up in her Geri chair in the same position. In an interview on 05/07/2024 at 1:54 PM, CNA E stated she had not done incontinent care or repositioned Resident #21 since she got her up at around 8:00 AM. She stated she was fixing to go get help since she was on the hall by herself, and she needed help to put her to bed. Observation on 05/07/2024 at 2:30 PM, revealed CNA E and CNA F in Resident #1's room to put her in bed via the Hoyer lift. Observation of Resident #21's brief revealed it was saturated with urine and had a strong odor. CNA E turned Resident #21 to her right side to reveal a DTI approximately 0.1cm x 0.1cm to her right ischial tuberosity surrounded by a blanchable area of redness approximately 3 cm long and a 0.2 cm x 0.2 cm DTI to her lower coccyx area. In an interview on 05/07/2024 at 3:00 PM, the ADON state Resident #21 did not currently have skin breakdown so any areas on her would be new. After observing the areas to Resident #21's coccyx area she stated Resident #21 did have breakdown areas on her boney prominences. In an interview on 05/07/2024 at 3:15 PM, the DON stated she looked at Resident #21 yesterday and her skin was clear. When asked if the area could have resulted from her being up in her chair for an extended period of time she stated, I did not know she was up all day. In an interview on 05/07/2024 at 3:20 PM, Resident #21's Hospice Nurse stated Resident #21 was at risk for breakdown and her skin was very delicate. She stated Resident #21's coccyx area was clear on her last visit a few days ago. Observation and interview on 05/08/2024 at 10:38 AM, revealed Resident #21 in room being prepped for wound care with the Wound care physician. Observation of Resident #21's coccyx area DTIs revealed both had declined and were darker in color from 05/07/2024. Resident #21's wound care physician stated both areas on Resident #21's coccyx were DTIs. He stated the areas could definitely be caused by not being turned and being on the same bony prominences for an extended period of time. Review of Resident #21's Physician wound evaluation and management summary dated 05/08/2024 reflected Resident #21 was assessed to have an unstageable DTI to the distal sacrum measuring 0.1cm x 0.1cm and undetermined depth. Further review reflected an unstageable DTI to the sacrum measuring 0.3cm x 0.3cm and undetermined depth. In an interview on 05/08/2024 at 2:13 PM, the DON stated she expected the CNAs to check on the residents every 2 hours and do position changes. She stated CNA E could have asked anyone to help her and she did not. The DON stated CNA E did not give her an explanation of why she did not change Resident #21. The DON stated she expected the nurses as well to make rounds every two hours to ensure the CNAs are doing their jobs and to make sure the residents are taken care of to prevent skin breakdown. Review of the facility policy pressure injury prevention, assessment and treatment dated 08/12/2016 reflected 1.Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems . 4. Causes of Pressure Injuries: Unrelieved pressure over a bony prominence resulting in ischemia at the area of pressure. 1.Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test. Review of the facility' policy Perineal care dated 04/27/2022 reflected An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. Macerated skin has a white appearance and a very soft, sometimes soggy texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel), leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . The Administrator was notified on 05/07/2024 at 5:10 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/09/2024 at 11:40 AM: Date: 5/7/2024 On 5/6/2024 an annual survey was initiated at the facility. 5/7/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate jeopardy to resident health and safety. Plan of Removal for F686 Approximately 48 residents who are incontinent and/or require assistance with turning and repositioning could be affected by this deficient practice. Problem: Failure to prevent pressure injury Root cause analysis was conducted. CNA E failed to change the resident's brief timely. CNA E failed to reposition the resident at minimum of every two hours while in the Geri chair. This caused pressure injuries. The Administrator, DON, and ADON will review the schedule daily to include weekends. This review will include that 2 staff members will be present at all times on station #1 to assist with ADLs. The call-in process is that they call the DON's cell phone when calling in. DON is responsible for initiating finding additional coverage. The DON will utilize the PRN call list, shift bonuses, staff from nearby sister facilities, or agency staffing if needed. Interventions: Weekly ulcer assessments for Residents #21 were completed to include measurements by DON, ADON, and Tx Nurse on 5/7/24. Two new pressure wounds were identified, measured, and treated according to physician orders. The MD was notified on 5/7/24 of Resident #21 new pressure wounds by the Tx Nurse. Orders were received for treatment and implemented on 5/7/24. Wound care treatments for Residents #21 were completed as ordered by the Tx Nurse on 5/7/24. 100% skin rounds were initiated 5/7/24 by DON, ADON, Treatment Nurse. No additional pressure wounds were identified. Administrator, DON, ADON, and Tx Nurse were in-serviced 1:1 by the Regional Compliance Nurse on 5/7/24 on the following topics. Completed 5/7/24. Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. CNA E was in-serviced 1:1 by the DON on 5/7/24 for the following topics. Completed on 5/7/24. Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. In-services: The following in-services were initiated by Regional Compliance Nurse, DON on 5/7/24 for all clinical staff. Any clinical staff not present or in-serviced on 5/7/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. The Administrator, DON, and ADON/designee will be responsible for ensuring that residents are checked for incontinence, brief changed, turned, and repositioned while in bed or Geri chair. Monitoring will occur during rounds daily for 10-15 randomly selected residents 7 days per week across all shifts including weekends. Monitoring will be documented on a form will continue for a minimum of 6 weeks. The Medical Director was notified of the immediate jeopardy situation on 5/7/24 by the administrator. An ADHOC QAPI meeting was held with the Administrator, DON, ADON, Tx Nurse and Medical Director to discuss the immediate jeopardy and plan of removal. Completed 5/7/24. The Survey Team monitored the POR on 05/08/2024 through 05/09/2024 as followed: Review of the facility's weekly wound assessment for Resident #21 reflected it was complete and conducted by the wound care physician on 05/08/2024. Review of Resident #21's nursing progress notes and weekly wound assessment dated [DATE] reflected Resident #21's physician was notified, and orders received for treatment and consult with wound care physician. Observation on 05/08/2024 at 10:38 AM, revealed wound care treatment conducted by the ADON and wound care physician. Review of the facility's skin round documentation initiated on 05/07/2024 reflected skin assessments conducted on all residents without new pressure ulcers being identified. Review of the one-on-one in-services for the Administrator, DON, ADON and Treatment Nurse dated 05/08/2024 reflected it was conducted by the RNC and covered the following areas: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing included requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. In an interview on 05/08/2024 at 9:29 AM, the DON stated she was in-serviced by the RNC regarding pressure ulcer prevention, ADL care and monitoring staff to ensure care is provided. In an interview on 05/08/2024 at 9:45 AM the Administrator stated the RNC performed the one on one inservices for her and the DON and ADON. Review the one-on-one in-service for CNA E dated 05/08/2024 reflected it was conducted and covered the following topics: Pressure Injury Prevention Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair. Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours could result in skin breakdown which is neglect. Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The hall is adequately staffed with 1 nurse, 1 med aide, and 2 CNAs. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately. Attempts to interview CNA E on 05/09/2024 were unsuccessful. Review of the facility conducted in-services for Pressure Injury Policy- to include incontinent care and repositioning at a minimum of every two hours while in bed or chair was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. Review of the facility conducted in-services for Abuse and Neglect- failure to provide incontinent care or reposition a resident every two hours while in bed or chair could result in skin breakdown which is neglect was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. Review of the facility conducted in-services for Incontinent care- all residents should be checked and changed for incontinence at a minimum of every 2hrs while in bed or chair. The in-servicing includes requesting assistance for ADLs when needed. If staff can't locate assistance, notify the DON immediately was signed by 9 out of 10 CNAs and MAs and all 29 nurses dated 05/08/2024 and 05/09/2024. In an interview on 05/09/2024 at 9:18 AM, CNA H stated she had been trained on rounds. She stated that the training covered doing rounds every two hours, changing the resident, and getting them off their bottoms. She stated residents on the secure unit were changed every hour to every hour and a half. She stated that when a resident had a change in skin condition that it should be reported to the nurse. She stated she was trained on pressure injury prevention. She stated the training covered making sure the resident was not on their bottom for an extended period and to keep them dry. She felt like the facility had enough staff and that the staff could do all their tasks and showers. In an interview on 05/09/2024 at 9:23 AM, the ADON stated she had been trained on doing rounds. She stated that the training covered turning the resident and changing the resident. She stated residents were checked every two hours. She stated that when changing a resident staff were to reposition the resident to ensure the resident was not on the same side they had been on. The ADON stated she had been trained on change in skin condition. She stated that she would take care of the resident. She said she would assess the skin, so she could get measurements. She said she would then call the wound doctor and the family about the change in skin. She stated she would get an order in place. She stated that she had been trained on pressure injury prevention. She stated the training covered making sure that the resident is turned or repositioned every two hours. She stated when the resident was in a chair staff are supposed to repositioned in the chair. She stated that she felt the facility had enough staff. She stated everyone worked together and the staff were able to get everything done. She said she felt she had enough time to do all tasks and rounds. In an interview on 05/09/2024 at 9:37 AM, CNA G stated he was trained on rounds. He stated the training covered making sure the rounds were done every two hours and repositioned when finished changed. He stated that if the resident had a change in skin condition, he would report it to the nurse. He stated he was trained on pressure injury prevention. He stated the pressure injury prevention training covered turning the resident every two hours, making sure the resident was of the injury and put a pillow under the resident and keeping them dry. He stated he did not think the facility had enough staff. He stated he was able to complete all tasks because the shift is 12 hours. He stated he will do a shower for 30 minutes and then check the residents. He stated that the nurses and CMAs were good about helping. In an interview on 05/09/2024 at 9:12 AM CNA I stated she has been in-serviced this morning on turning every 2 hours, abuse, and neglect, not feeding 2 patients at one time, and reporting skin issues. I asked if you see a change in skin condition what do you do? She stated she tells her charge nurse immediately. When asked her if she felt there is enough staff working on the floor. She said yes. There is always 2 people on the locked unit. She stated if someone calls in sick, they bring someone else in. In an interview on 05/09/2024 at 9:22 AM LVN C stated she had been in-serviced this morning on abuse and neglect, pressure injury, skin breakdown, turning residents every 2 hours, not to feed 2 patients at one time and reporting skin issues. I asked if you see a change in skin condition what do you do? She told me she does an assessment, reports to the DON, lets the doctor know, and then puts treatment into place. I asked her how often she checks on residents, and she told me every 2 hours and if resident is having diarrhea more often. I asked her if she felt there is enough staff. She said for the most part yes. There is a shortage everywhere. I asked her what happens when there is not enough staff on the floor. She said there are enough resources and people come help. In an interview on 05/09/2024 at 9:32 AM, CNA J stated she had in serviced on rounds, checking residents every 2 hours, abuse, and neglect, and who to report skin breakdown to. I asked her how often she checks on her residents she said every 2 hours. I asked her if she felt there was enough staff on the floor. She said yes. I asked her what happens when there is not enough staff. She said she does her job and does what she needs to do. In an interview on 05/09/2024 at 9:38 AM, CMA D stated she has been in serviced this morning on not feeding 2 people at once, completing rounds every 2 hours, abuse, and neglect. I asked her if she sees a change in skin condition what she does. She reported she goes to the charge nurse. I asked her who she reports skin changes to she said the charge nurse. I asked her how often rounds are she said every 2 hours. In an interview on 05/09/2024 at 9:42 AM, LVN B stated she has been in-serviced this morning on abuse and neglect, skin breakdown, incontinent care, cleaning glucometers. I asked her how often they check on residents. She said every 2 hours. I asked her if she felt there was enough staff she said yes. That they always call people in if someone does not come in. In an interview on 05/09/24 at 12:55 PM, LVN K worked 6P to 6 A on 5/8 to 5/9 She stated they were in serviced on a lot last night and she was half asleep and will try to remember 1. Incontinent care 2. Using barrier cream 3. Foley catheter and using PPE when giving care to Foley Catheter 4. Abuse and Neglect 5. Reporting any new skin concerns 6. Pressure Ulcers She stated there was more, but she could not remember. In an interview on 05/09/2024 at 12:49 PM, CNA O stated she was in serviced on abuse neglect the rounds and PPE for open wound and foley. Reposition the resident every two hours with the rounds. Was in serviced on pressure injury precautions put a pillow under the resident. The resident has heel protectors on to prevent pressure. Stated she thinks there is enough. No task not able to complete has not been short in over a month. Yes, stated she can do all her rounds and shower she is the only aid for two halls. In an interview on 05/09/2024 at 12:58 PM, CNA P stated he had been in serviced on rounds, checking residents every 2 hours, abuse, and neglect. He said he checks on residents every 2 hours and felt there was enough staff on the floor. He said they will call and see if more people come in she stated there is not enough staff. On 05/09/2024 at 3:12 PM, the Administrator was notified the IJ was removed on 05/09/2024 at 3:12 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 14 residents (Residents #1 and 2) reviewed for quality of care. The facility failed to ensure TLVN and LVN C assessed and reported a new new skin injury to Resident #1's first two toes of the right foot and a new skin injury to Resident #'s first and fifth toes of the right foot. An Immediate Jeopardy (IJ) situation was identified on 03/06/24. While the IJ was removed on 03/08/24 at 03:00 PM., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of new or worsening pressure ulcers. Findings included: 1. Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses of quadriplegia (paralysis of all four limbs), type two diabetes mellitus with diabetic polyneuropathy (nerve damage causing weakness, numbness, and/or tingling), and history of transient ischemic attack and cerebral infarction (stroke). Review of the Discharge MDS for Resident #1, dated 02/18/24, reflected she could not participate in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she did not have any unhealed pressure ulcers. Review of the care plan for Resident #1, dated 02/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. It also reflected the following: The resident has a pressure ulcer or potential for pressure ulcer development: The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Review of the initial skin assessment for Resident #1, dated 02/08/24, and completed by the LVN C, reflected she had no skin issues noted. Review of the weekly skin assessment for Resident #1, dated 02/14/24, and completed by LVN C, reflected she had no skin issues noted. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 02/08/24, and completed by the TLVN, reflected she had a score of 7, which indicated a severe risk for pressure ulcers. Review of physician's orders for Resident #1, on 03/05/24, reflected there were no orders related to prevention of pressure ulcers. Review of the skin observation tool in the CNA documentation portal for Resident #1, dated 02/16/24, reflected a new skin tear on the buttocks and discoloration on the left lower foot, documented by CNA A. Review and observation of hospital records for Resident #1, dated 02/18/24, reflected a photograph, taken on 02/18/24 at 09:11 PM, of her right anterior foot showing a red discoloration of the first and second toes. The first toe also had a partial thickness opening in the center of the reddened area that had a yellow tint. An attempt was made on 03/06/24 at 08:30 AM at the hospital to identify and interview the nurse who took the photograph of wounds on Resident #1's foot on 02/18/24, was unsuccessful. An attempt was made to interview the hospital physician who saw Resident #1 in the ER on [DATE], but the hospital administrator would not provide direct contact information for him. During an interview on 03/06/24 at 09:58 AM, LVN C stated her process for conducting a skin assessment was during an initial skin, she looked at the resident's entire body, starting at their neck, to go down their legs to their feet and looked at their heels and then turned them over to look at their front, under the breasts, and in the perineal area. LVN C stated she looked between their toes and fingers, as well. LVN C stated when she conducted the initial skin assessment for a new resident, she did not know who cared for the resident or what state their skin might have been in, so she checked very carefully. LVN C stated the toes and feet were important during skin checks due to them being areas vulnerable to injury and skin breakdown. LVN C stated she conducted the initial skin assessment for Resident #1 on 02/08/24 and the weekly skin assessment on 02/14/24. She stated she did not see any new skin issues during either procedure. LVN C stated she had gotten Resident #1 dressed on the morning of 02/18/24 when she was sent to the hospital, and LVN C had not seen any marks or skin issues on Resident #1's legs or feet. LVN C stated she did not know what anyone was talking about when they asked her about wounds on Resident #1's feet. LVN C stated if she thought she would have seen any marks on Resident #1 especially if they were on the front, because she helped her dress. LVN C stated Resident #1 required total assistance with all of her activities of daily living, so they had a large amount of observation of and contact with her body. During an interview on 03/06/24 at 11:40 AM, CNA A stated she and her coworker, CNA B, showered Resident #1 on 02/16/24 and noticed a scratch under her right buttock, a blister on her big toe, and redness on both her big toe and her second toe. CNA A stated she and CNA B reported the skin changes to LVN C that day. CNA A stated she cared for Resident #1 while she was in the facility, and Resident #1 sat mostly in her chair and only got in bed at night. CNA A stated Resident #1 seemed uncomfortable in her chair, but the resident's FM had insisted she be placed in her chair during the day. CNA A stated she and her colleagues floated Resident #1's heels while she was in bed, but in the chair, they could not float her heels. CNA A stated was taught to place wheelchair leg rests at a 45 degree angle when the resident did not use them, but CNA A noticed Resident #1's feet, which were very contracted so the toes almost faced downward, would graze the foot rests sometimes on the tops of her toes. CNA A stated she and CNA B removed the footrests while Resident #1 was at rest in her chair and not being moved so her feet would not hit the footrests. CNA A stated she thought it was possible the wounds on Resident #1's right foot had occurred that way. CNA A stated after Resident #1's shower on 02/16/24, she and CNA B took Resident #1 to the dining room for her meal, and they stopped and showed the new wounds on her right foot to LVN C. CNA A stated she also documented the wounds in the CNA documentation portal. She stated the notations in the Skin Observation tool for 02/16/24 referred to the new wounds she saw on Resident #1's right foot. During an interview on 03/06/24 at 11:50 AM, CNA B stated on 02/16/24, which was a Friday, she and her coworker CNA A showered Resident #1 and saw marks on her. CNA B stated that day she saw a water blister on her big toe and a red mark on the next toe where the bone was. CNA B stated the injuries might have been from the footrest on the wheelchair, but she was not sure how they occurred, because the FM would not let Resident #1 stay in bed during the day. CNA B stated the day they discovered the wounds on Resident #1's toe, they were bringing her to lunch, and LVN C was sitting at the second nurse's station. CNA B stated they showed the toe wounds to LVN C. CNA B stated she did not remember LVN C being distracted or talking on the phone or to anyone else at the nurse's station. CNA B stated she thought the TLVN was sitting at the nurse's station with LVN C. CNA B stated CNA A did most of the documentation for Resident #1, but CNA B was pretty sure the new skin problems were documented in the skin observation tool by CNA A. CNA B stated they showed LVN C the toe wounds and told her about the scratch under Resident #1's buttock. Review of the, undated, face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia, cerebral vascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus, and hemiplegia affecting right dominant side (paralysis on one side of the body). Review of the quarterly MDS for Resident #2, dated 02/24/24, reflected her cognition was too poor to take part in the brief interview for mental status. The section for Functional Status reflected in the activities of rolling left to right and transfer from chair to bed that she was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. The section related to Skin Conditions reflected she was at risk of pressure ulcers but did not have any unresolved pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #2, dated 10/23/23, and completed by LVN F, reflected she had a score of 10, which indicated a high risk for pressure ulcers. Review of the care plan for Resident #2, dated 01/17/24, reflected the following: Notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Weekly skin assessments. Review of physician's orders for Resident #2 on 03/06/24 reflected no order for treatment of any wounds on her foot. Review of the skin observation tool for Resident #2 reflected a discoloration on the right lower leg or foot was documented on 02/14/24, 02/15/24, 02/19/24, 02/20/24, 02/24/24, 02/25/24 and 02/28/24 by CNA E. An additional documentation of a right leg or foot discoloration was documented on 02/27/24 by CNA D. Review of the weekly skin assessment for Resident #2, dated 02/26/24, and completed by the TLVN, reflected the following notes 2x1cm open area to left shin below knee, no drainage noted, skin-prep applied; 4x2cm open area to left leg, no drainage noted, skin-prep applied and LUQ Peg tube. The answers to the following questions Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete The Ulcer Assessment and Are there any new areas that have not been communicated to the physician/NP or family? was marked as No. As of 03/06/24, this was the most recent skin assessment. Review of wound physician progress notes, dated 03/06/24, reflected Resident #2 received wound care and assessment for a non-pressure wound of the left leg- full thickness. It also reflected the following: Chief Complaint Patient has wounds on her left leg; left shin. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition. There was no mention of any wound on the toes of her right foot. Record review of the most recent podiatry progress note for Resident #2, dated 01/10/24, reflected no skin issues on either foot. The podiatrist marked the resident had diabetes and peripheral vascular disease. During observation on 03/06/24 at 12:10 PM, CNA D removed Resident #2's socks and shoes to observe Resident #2's feet. The fifth (pinky) toe of Resident #2's foot had black tissue covering the entire toe, and her first (big) toe was black surrounding the proximal nail fold (part of the nail bed closet to the rest of the foot and ankle) and a portion of the skin around the distal nail plate (part of the nail bed farthest away from the rest of the foot and ankle). During an interview on 03/06/24 at 12:10 PM, CNA D stated the wounds on Resident #2's feet were very black, and they were there for several months. CNA D stated she had not seen Resident #2 receive any treatment for the injuries on her right toes. CNA D stated she had not been the person to initially report the injuries to a charge nurse, but she had documented the injuries on the Skin Observation tool. CNA D stated she did not know who discovered the injuries, but she thought they were well known, because the CNAs were documenting them in the Skin Observation for quite some time. During observation and an interview on 03/06/24 at 12:30 PM, the DON observed the injuries on Resident #2's right toes. The DON touched the injuries on Resident #2's fifth toe and watched the resident's reaction. Resident #2 did not wince or exhibit any other sign of pain. The DON stated the black area on the pinky toe was hard like a scab. She stated the injuries should not necessarily have been documented in a weekly skin assessment because they were not open areas but instead were scabbed. During an interview on 03/06/24 at 12:56 PM, the MD stated he expected a resident with Resident #1's clinical condition would develop pressure ulcers given the protein status, poor immunity and immobility. He stated the important thing was for new wounds to be identified and treated so they did not worsen. The MD stated he was not aware of any wounds that had developed on Resident #1 during her stay in the facility. The MD stated he expected to be notified of new skin conditions. He stated he could not say how a wound like the one Resident #1 had could worsen over a two-day period without being addressed, but any medical diagnosis needed intervention as early as possible. The MD stated he did look at residents' feet normally when he did an exam or an assessment. The MD stated Resident #1 was only in the facility for ten days, and he had not done an in-person exam with her. The MD stated he was not aware of any black wounds on Resident #2's feet. The MD stated he did not have his computer and could not say exactly when the last time he performed a physical exam with Resident #2, but she did not have any wounds on her feet at that time. The MD stated most of her skin assessments were being done by the WCD. The MD stated once wound care was involved with a resident, it was a professional courtesy to defer to the WCD for decision-making. An attempt was made on 03/06/24 at 01:12 PM to interview the POD by telephone. A voicemail was left on the clinic's main phone line. An attempt was made on 03/06/24 at 01:14 PM to interview CNA E about Resident #2's skin observations. A voicemail was left. During an interview on 03/06/24 at 01:44 PM, the WCD stated he saw Resident #2 earlier that day. He stated they did not conduct a full skin assessment. The WCD stated Resident #2 had a wound on her shin that he was treating. The WCD stated he did not think he saw her feet recently and was sure he did not see her feet that day. The WCD stated he saw Resident #2 on and off for pressure ulcers and skin tears. The WCD stated no one from the facility reported any new skin issue to him on Resident #2. The WCD looked at a photograph of Resident #2's toe wounds taken by the State Surveyor, and he stated he could not diagnose from a photograph, but the wound on her fifth toe looked like it was probably a pressure or arterial wound. The WCD stated the treatment for that type of wound would like be Betadine or something similar. He stated the rest of her foot looked healthy, and he was not very aggressive with debriding so he would probably only monitor and treat with Betadine. During an interview on 03/06/24 at 02:16 PM, the TLVN stated her protocol when she saw a wound like the ones on Resident #2's toes was to refer to the physician, the wound care surgeon and notify the family. She stated she had not noticed an alert that would notify her a CNA had documented a skin observation. The TLVN stated she had not seen the wounds on Resident #2's toes prior to the State Surveyor pointing them out to her, but she had now gone to look at the wounds, and she thought they might be purpura (a condition of red or purple discolored spots on the skin that do not blanch on applying pressure). The TLVN stated she did not see the wounds a few weeks ago. The TLVN stated she would not document something like that on the weekly skin assessment, because it was a scab. The TLVN stated the wound was a closed wound and had never been opened and had not bled and was not from trauma, so it did not quality as a wound to be documented on the weekly skin assessments. The TLVN stated the wound might have been a pressure or arterial ulcer, and she would have documented a pressure or arterial ulcer on the skin assessment. The TLVN stated she was not qualified to diagnose a wound and only the physician could diagnose. The TLVN stated she should have reported the wound to the nurse management team and the physician. She could not or would not say why she did not do so and stated she was very nervous. The TLVN stated potential negative outcomes of not addressing a skin issue immediately were infection and ultimately, amputation. During an interview on 03/06/24 at 03:20 PM, the DON stated she monitored for new wound and skin conditions by discussing any new issues with the IDT and communicating frequently. The DON stated CNAs communicated new skin observations in the point of care documentation system, an alert showed up on the EMR dashboard, and the IDT pulled the records describing the new skin issue every shift. The DON stated the people responsible for noticing the alerts on the EMR were her, the ADON, the TLVN, and the charge nurses. She stated the CNAs were instructed to document in the EMR instead of relying on a verbal notification of a new skin issue. The DON stated she was mistaken when she stated the wound on Resident #2's fifth toe had not needed to be documented on the weekly skin assessments. The DON stated she called the MD when she learned of the wound on Resident #2's toe, and he ordered a venous doppler (a special ultrasound technique that evaluates blood as it flowed through a blood vessel) to ensure the toes were still receiving blood flow. The DON stated the wound could have been a blood blister that progressed. The DON stated she did not know why nobody noticed the alerts that should have triggered when CNAs entered skin observations for Residents #1 and #2. She stated she was still investigating why the failure occurred. The DON stated if the wounds were on Resident #2's foot for months as CNA D reported they were, then the TLVN should have seen them during previous skin assessments. The DON stated the fact the TLVN did not notice the wounds was concerning. The DON stated a potential outcome of the failures was the wounds would tend to get worse, because the body might not self-heal without medical intervention. During an interview on 03/06/24 at 04:30 PM, the ADM stated she monitored for compliance with the skin program in the facility by discussing issues in care plan meetings and their morning meetings. The ADM stated she was notified of the unidentified wounds on Resident #2's foot. The ADM stated she had also been made aware Resident #1 had something on her foot that she thought was a blister and CNAs had documented the area but LVN C had not followed up on the wound before Resident #1 was sent to the hospital. The ADM stated Resident #1 had not returned to the facility. The ADM stated the process for identifying new skin issues was the CNAs put the skin observation into the EMR, and it alerted for anyone to see on the EMR dashboard. The ADM stated the TLVN had access to the same information as the rest of the team, and the ADM did not know why the TLVN did not follow up on reports of either Resident #1's or Resident #2's wounds. The ADM stated a potential negative outcome of the failure was a worsening of wounds, but particularly for someone with Resident #2's clinical condition, a wound on her foot had the potential to become a major issue where it would be detrimental, possibly causing sepsis. Review of facility policy, dated 08/12/16, and titled Pressure Injury: Prevention, Assessment and Treatment reflected the following: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation and prevent, breakdown, injury, and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission, and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sores is indicated and notify the treatment nurse/design of any potential problems. 3. Assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of sore and obtain any follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification. This was determined to be an Immediate Jeopardy (IJ) on 03/06/24 at 5:00 PM. The ADM was notified . The ADM was provided with the IJ template on 03/06/24 at 05:05 PM. The following Plan of Removal submitted by the facility was accepted on 03/07/24 at 05:30 PM: [The facility] Plan of Removal: 3/6/24 On 3/5/2024 an abbreviated survey was initiated at [the facility]. 3/6/2024 the surveyor provided an Immediate Threat (I) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. F686 The facility failed to prevent pressure ulcers and ensure residents did not develop pressure ulcers. All residents had the potential to be affected by the deficient practice. Head to toe assessments were completed on all residents in the facility to ensure no other residents were identified. Interventions: Resident #1 no longer resides in the facility as of 3/6/24. The MD was notified by the DON for resident #2 on 3/6/24. Treatment orders are in place. All residents in the facility received a head-to-toe skin assessment by the DON/ADON/Tx Nurse. Assessments will be completed 3/6/24. No new skin issues were identified. A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on the policy for Pressure Prevention and the Completion of Skin Assessments. Completed 3/6/24. The Regional Compliance Nurse is a part of the corporate structure. The DON /designee will review the EMR dashboard daily and throughout shifts for clinical alerts pertaining to skin issues that are documented to ensure that all skin issues have been addressed by a nurse. This will start 3/6/24 and continue indefinitely. The DON or ADON will conduct skin rounds weekly with the treatment nurse to ensure skin issues are identified, MD/family notified, and a treatment is ordered. This will start 3/6/24 and continue indefinitely. The Medical Director was notified of the immediate jeopardy situation on 3/6/24. An ADHOC QAPI meeting was conducted on 3/6/24 to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal. Identification: All residents residing in the facility received a head-to-toe assessment by the DON/ADON and treatment nurse. No new skin issues were identified on 3/6/2024. In-services: All direct care staff were in-serviced on the following topics below on 3/6/24 by the DON/ADON. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on. o Pressure Prevention Policy o Completing Skin Assessments o Notification of change in condition to the charge nurse and DON including new skin issues. Monitoring of the Plan of Removal included the following: Review of physician's orders for Resident #2 on 03/06/24 reflected an order had been entered for Bilateral Arterial legs Ultrasound Verbal Active 03/08/2024 ultrasound of both legs. Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk every 12 hours as needed for R 5th Toe Wound Phone Active 03/06/2024, 03/06/2024 Cleanse Right 5th toe Wound W/WC or NS, Pat Dry, Apply Betadine 3xwk one time a day every Mon, Wed, Fri for right 5th toe wound. Review of the March 2024 TAR for Resident #2 reflected Betadine was administered to her right toes by the TLVN on 03/06/24 and 03/08/24. Review of skin assessments for Residents #3-#7 and #9-#21 conducted on 03/06/24 and 03/07/24 reflected no new skin issues identified. Review of the weekly skin assessment tool for Resident #8 completed on 03/08/24 reflected the following: Red flat rash to back; skin intact; TX PRN. 28/24 Review of physician orders for Resident #8 reflected the following with a start date of 05/28/24: Nystatin Powder 100000 UNIT/GM. Apply to affected area topically as needed for rash twice daily. Review of the March 2024 TAR for Resident #8 reflected Nystatin powder was administered to her back on 03/08/24 at 01:35 PM. Review of in-services conducted one-to-one with the TLVN, ADON, and DON reflected they had each signed the following in-service on 03/06/24: Pressure prevention, injury, completion of skin assessment, and treatment weekly and with changes in skin integrity. Review of an in-service conducted by the DON on 03/06/24 reflected the following content: Notification of change in condition to the charge nurse and DON, including new skin issues. See attachment of policy and procedures. 39 staff members had signed the signature page of the in-service. An additional 29 staff were listed as being notified by phone on 03/06/24. During an interview on 03/08/24 at 08:40 AM, the ADM stated education of staff was ongoing. She stated the staff in the facility today were in-serviced by phone and were to be tested on their knowledge today. She stated copies of in-service education and the staff who completed it were ready. She stated she was re-educated by the RCN to monitor the nursing for compliance with the plan and program. During an interview on 03/08/24 at 09:05 AM, LVN F stated she completed in-service education in ANE and Assessment. She stated topics included skin assessment, changes in skin, reporting, documentation and informing the ADON and DON. She stated skin assessments were documented in the computer and an incident report was to be completed and forwarded to risk management. She stated as a charge nurse she was also to initiate treatment and inform the physician and family of changes. During an interview on 03/08/24 at 09:10 AM, MA G stated she completed in-service education and testing for ANE and Assessments. She stated she was informed she was to report any skin tears, bleeding or observed skin changes to the charge nurse and the DON. She stated as a med aide she would occasionally see a skin tear. During an interview on 03/08/24 at 09:19 AM, the RCN stated she instructed 100 percent of staff (nurses and CNAs) on ANE and Assessment at this time. She stated changes in residents were to be reported to the Administrator and DON. She stated nurses must assess residents when a change was reported and initiate treatment. Nurses must report changes to physicians and family. She stated education did not reflect any knowledge gaps among staff, and she was unsure how the IJ occurred. She stated the facility was nearing 100 percent of staff completing the posttest knowledge check. During an interview on 03/08/24 at 09:50 AM, RN H stated she received in-service education on ANE and skin assessments. She stated she was taught about the reporting system and reporting changes to the DON and charge nurse. She stated as a nurse she would also report changes to the physician and family. She stated skin assessments were to be completed weekly, as needed and on admission. She stated she completed a test after the in-service. During an interview on 03/08/24 at 09:55 AM, the ADON stated she was in-serviced and tested on ANE and skin assessments. She stated any changes had to be assessed, reported to the doctor and the DON and family. She stated skin assessments were to be completed weekly and incident reports were to be filled out for changes in skin condition (such as bruises, scrapes and skin tears). She stated the nurse documented the change and entered orders for treatment from the physician. During an interview on 03/08/24 at 10:09 AM, CNA I stated he received in-service education on ANE and assessments. He stated aides were informed any changes in skin condition must be reported to the nurse, the ADON and DON. He stated if no one responded to his report he was to report to the administrator. He stated most observations were documented in the computer but the facility also utilized shower sheets to assessed resident skin health. During observation and an interview on 03/08/24 at 10:10 AM, Resident #19 stated he had no discomfort to his below the knee amputation site. He stated he received wound care three times a week. He stated he was taking pain medications. He was observed ambulating in his wheelchair in his room. During an interview on 03/08/24 at 10:15 AM, CNA E stated she received in-service education on ANE and skin assessments. She stated she completed a post education test, she added they always wanted to test them. She stated she would report any skin changes to the nurse, DON or Administrator. She stated the situation was as simple as see something report something. She stated any changes had to be reported as soon as they were discovered. Observation on 03/06/24 at 11:20 AM revealed LVN F assisted to show Resident #2's right fifth toe which revealed no drainage, skin was intact and a 1.5 cm long dark black area was present on the outside of her little toe. Resident #2 did not indicate any discomfort to the area. The tip of the toenail had been removed and a purple swollen area was seen to the inside of margin of the toenail. During an interview on 03/06/24 at 11:20 AM, LVN F stated Resident #2 was receiving betadine lotion to the site daily per instructions from the wound care physician. During an interview on 03/08/24 at 11:27 AM, CNA J stated she received in-service education on ANE and assessments. She stated the facility emphasized skin assessments and reporting changes to the charge nurse. She stated the DON and administrator were also to be informed. She stated she had not observed any concerns among residents she worked with at the facility. During an interview on 03/08/24 at 11:30 AM, the TLVN stated she completed the in-service education and posttest knowledge check. She stated the ANE and skin assessment requirements were known, that she needed to check the EMR for skin alerts daily, and the DON would be rounding on wounds with her for the time being. She stated she was requested to assess the toe of Resident #2 on a Wednesday. She stated she was not aware

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement written policies and procedures that ensured reporting of crimes in federally funded long-term care facilities in accordance with section 1150B of the Act, any incident that involved an emergency situation that posed a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected. The facility failed to: 1. The facility failed to report to State Survey Agency (HHSC), immediately, but not later than 24 hours, when, on [DATE], two employees witnessed another employee with a gun in the facility. 2. The facility failed to follow their own procedures when a verbal altercation between employees occurred, and, on [DATE], one of the employees involved in the verbal altercation brought a handgun into the facility, and the incident was not immediately reported to the administrator or the DON. 3. The facility failed to call the police and to follow its own facility protocol for an armed individual listed in the emergency preparedness manual. 4. The facility failed to implement their written policies and procedures to ensure the reporting of crimes to State Agency and law enforcement within the appropriate timeframes. 5. The facility failed to in-service all staff on reporting to the Administrator emergency situations including reporting handguns brought into the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:53 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place the residents at risk for unreported allegations of a threat to resident health and safety and potential for injury or death. The findings were: In an interview on [DATE] at 5:24 PM with CNA C revealed she saw LVN A take a gun from underneath the driver's side of her truck and put it into her lunch box and carry the lunch box into the facility and put the lunch box below the top counter on a shelf at nurses' station one. The lunch box with the gun remained there until LVN A ended her shift on [DATE] at 6:00 am. When surveyor asked why she did not call the police, LVN A said she did not seem like she was for sure going to use the gun. CNA C revealed she called her DON two times and left her a message, but the DON did not return her calls. CNA C revealed she was never told they could not bring guns into the building. She said there were no signs on the outside of the doors telling them they could not enter the facility with a gun. CNA C said it was her 2nd or 3rd day working at the facility and she did not know the rules about when it was legal to carry a gun and when it was not legal to carry a gun. She said she knew that people carried guns all the time. She said when she began working the facility front doors were under repair and there no signs posted outside the facility about the prohibition of carrying guns into the facility. In an interview on [DATE] at 5:54 PM with CNA D revealed LVN A was having a dispute with CNA E and a lot of racial comments were made. CNA D saw LVN A's partially unzipped lunch bag and saw the butt of a gun in the lunch bag. CNA D revealed that the lunch bag was at nurses' station one on top of the desk below the counter next to the printer. CNA D revealed she heard LVN A make a statement that CNA E was going to get what was coming to her. CNA D revealed it was reported to the ADON on Friday, [DATE]. CNA D revealed she was not at all concerned about the residents' safety and thought the situation was under control. LVN A never mentioned anything about hurting the residents. In an interview on [DATE] at 5:54 PM with CNA D when asked why she did not call the police when she knew that LVN A had a gun she said she did not see it as a threat at the time. CNA D said that LVN A always talked about having her gun with her and LVN A never made a threat of using it against the residents. When the surveyor asked CNA D if she saw the signs posted on the outside entrance to the facility reading handguns prohibited she said the signage was not posted outside, it was posted inside on the side of the wall in the lobby. She said she told the ADON next day, on [DATE], about LVN A having the gun inside the facility. In an interview on [DATE] at 3:07 PM LVN B revealed LVN A was always a little difficult to get along with. LVN B did not see a gun. He revealed that LVN A was very racial. He revealed he was not worried about the resident safety that evening. In an interview on [DATE] at 11:15 am with the ADON she stated the staff came and reported to her about the LVN A and a handgun during the Christmas party on [DATE]. She stated she reported it to the DON and the DON told her to in-service the staff about reporting incidents. The ADON stated she did not report it to the Administrator because it was 10 o'clock at night. In an interview on [DATE] at 12:58 PM with LVN A revealed she was the charge nurse on station one on [DATE] and her shift began at 6:00 PM. She said that it was, bull crap that she brought in a gun into the facility and there were no racial slurs and none of this happened. LVN A revealed she knew it was a criminal offense to bring a gun into the nursing facility. In an interview on [DATE] at 4:00 PM with the DON revealed no staff member contacted her on [DATE] and told her about LVN A having a gun in the facility. The DON revealed that on [DATE] the ADON told her that CNA D told her that LVN A brought a gun into the facility. The DON did not tell the ADM about the report of the gun in the facility until Monday, [DATE]. The DON said that if a staff member saw another staff member with a gun, that staff member should have called the police and the ADM should have been notified immediately. When the surveyor asked the DON why she did not tell the ADM about the gun in the facility until Monday she said, there was no particular reason why she did not call her. When the surveyor asked the DON about the reports of racial slurs the DON said that she did not feel it was racial. A review of TULIP facility self-report revealed the facility investigation summary that on [DATE] at 6:30 PM a facility charge nurse was witnessed bringing a handgun into the facility and the facility first learned of the incident on [DATE]. Investigation summary reported on [DATE] LVN A brought a handgun into the facility. Two staff members reported seeing the handgun. CNA C reported she witnessed LVN A go to LVN A's vehicle, remove the handgun from under the seat of her trunk, place it in LVN A's lunch box and bring it into the building. Later, CNA D reported standing at the nurses' station and observed the gun in the green and black lunch bag when LVN A went into it to get something. LVN A denied owning a gun. A review of TULIP revealed the HHSC TULIP reporter was contacted on [DATE], AT 4:55 PM, the date and Time of the incident: was [DATE] 6:30:00 PM. The date facility first learned of Incident was [DATE] 10:00:00 AM. The Actions and Notifications taken by the facility were statements were taken alleged perpetrator was terminated, in-services were provided, notifications were made to facility administration, police dispatcher and HHSC. Review of written statement of CNA C, undated, revealed on [DATE] LVN A said that us white people need to stick together because there are a lot of nigger clicks out here. A resident call light went off and CNA C said she would answer the call light even though the resident was the responsibility of CNA E. CNA C revealed that LVN A told her, no let that nigger get off her ass & do something . LVN A walked to the resident's room beside CNA E and told CNA E she would take care of the resident and CNA E could clock out and go home. CNA E told LVN A she was not going to clock out and told LVN A to, stop talking crazy. LVN A and CNA E kept arguing. CNA C said she stepped in to calm down the situation. When CNA E walked away LVN A said, I wish you touched me because then it would be self-defense. CNA C asked LVN A why she did not call and the DON or ADM about CNA E not answering the call light and LVN A said the ADM had (illness) and was weak and that is why, these niggers are out of control. CNA C followed LVN A out the front door and LVN A went to her truck and took a gun from underneath the seat and put the gun in a lunchbox. CNA C revealed, I told her it was not that serious or worth her freedom and she said yes it was she would kill those niggers and LVN B. CNA C revealed LVN A was walking around CNA E's car taking pictures. CNA C asked LVN A why she did not like LVN B and LVN A said it was because, the nasty MF deals with niggers. CNA C revealed LVN A walked to LVN B's station and LVN A told him you are going to get what is coming to you. CNA C revealed in her statement, at this point myself and the other workers feel for our safety as well as the safety of the residents when LVN A is here. Review of statement, undated, of CNA D revealed on [DATE] she observed a gun in LVN's lunch bag. CNA D revealed this was, after several incidents when her & a fella CNA had words. LVN A was, nit picking with all of the staff in a degrading racist manner. Everybody black was a nigger and I tried very hard to keep the peace. LVN A is a very confrontational nurse lies, starts mess with the patients and other staff . The lady is very delusional, suicidal, homicidal, bipolar, and she needs help. We fear for our safety and the residents when she is here. Review of statement, undated, of CNA E revealed on [DATE] LVN A told her to go home and said negative comments about African American people. CNA E revealed that LVN A, started to walk up on me like she was going to do something so I told her to stop walking up on me or it would be an issue. CNA E revealed she told LVN A to leave her alone and stop harassing her. And LVN A told her this is my hall and CNA E will do what she tells her to do. CNA E revealed, I told her to her face I don't care who hall it is don't come tell me how to do my job. LVN A told her to go home and LVN A would do her hall and CNA E told her she would not go home. LVN A yelled from station one desk to station two desk for LVN B to send her home. CNA E revealed LVN A told her LVN B would not send her home because, yall F*ucking. CNA E revealed that she told LVN A she needed to stop harassing them and let them do their jobs that is when LVN A was making comments involving nigger this and nigger that. CNA E revealed LVN A walked outside and stayed out for about thirty minutes and came in with a lunch kit. Review of statement dated [DATE] of CNA F revealed she, overheard LVN A making racist remarks this is not the first time if anything doesn't go her way, she gets upset and goes in a uproar. We (staff) have already came to the DON about it. It's a very hostile environment when LVN A is here. Review of statement, undated, LVN B revealed LVN A told him, I should stick up for my own kind and LVN A pointed a finger at him and stated one day I would be sorry. Review of statement, undated, of ADON revealed that on [DATE] she was asked to be on standby when LVN A arrived for her shift and instructed to not allow LVN A in the build, lock the door, and call non- emergency to issue LVN A criminal trespass for the handgun a that was reported to have been in the building on [DATE]. Review of LVN A's employee time sheet revealed she worked at the facility on [DATE]. Review of statement of ADON, undated, revealed LVN A's employment was terminated on [DATE]. Review of inservices conducted on [DATE] reflected not all staff were in-serviced on reporting to the Administrator emergency situations including reporting handguns brought into the facility. Review of facility employee abuse prevention proficiency test revealed that it was the responsibility of the facility to train employees, report, and investigate incidents and prevent abuse. Review of facility reporting crimes test, undated, revealed, as an employee of the facility you are considered a covered individual. Each covered individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. Any other crime against a resident described in the Texas Penal code time frame requirements to report: No serious bodily injury - not later than 24 hours after forming the suspicion. If you have any questions regarding reporting of crimes contact your administrator immediately. Review of facility reporting crimes test revealed each individual has an obligation to report the suspicion of a crime against a resident directly to local law enforcement and the State Survey Agency. Review of facility Abuse/Neglect policy, undated revealed, all reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated per facility protocol. Investigations will be reviewed by the facility administrator and/or abuse preventionist within 24 hours of compliant. Appropriate notification to state and home office will be the responsibility of the administrator per policy. When a suspected abused, collected, exploitative, mistreated or potential victim of misappropriation of property comes to the attention of an employee, that employee will make an immediate verbal report to the abuse preventionist or designee. If the discovery occurs outside of normal business hours, the abuse preventionist and or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated [DATE]. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome. Other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination. Review of facility Corporate Code of Conduct, from facility personnel handbook dated [DATE], revealed the types of behavior this facility feels are inappropriate include having unauthorized firearms on this facilities premises or while on this facilities business. Review of facility personnel handbook dated [DATE] revealed Weapons in the Workplace - it is not permissible for any person to carry firearms on the property in this facility. It is prohibited for anyone to possess or carry firearms. Review of Employee Disciplinary Report Action Request for LVN A, charge nurse hire date [DATE] termination dated [DATE] date of infraction [DATE], Specific reason for the disciplinary action revealed on the [DATE]O23 a CNA witnessed [sic] LVN A take a gun from under the seat of her truck and bring it into the building in a green and black lunch bag after having several confrontations with one of the CNA's, another CNA observed the gun in her lunch bag as well. She made threatening remarks about shooting staff members due to her dislike for them. She also directly threatened the charge nurse at LVN B (because he doesn't stick with his kind). In addition to this she made racial remarks about an African American resident (deceased ) and staff. LVN A failed to adhere to the corporate code of conduct and weapons in the workplace by possession of weapons on company property. On [DATE] after making several harassing and racial remarks LVN A was seen getting a gun out of her personal vehicle and brining into the in a lunch box. The weapon was seen by at least two individuals while it was in the facility. LVN A is a threat to other staff members and is aware of the corporate code of conduct and weapons policy via her signature on the employee acknowledgment form. Review of LVN A's [DATE] signed acknowledgement and signature that LVN A, read, understand, and agree to abide by the facilities rules of behavior for general users. Review of in-service training attendance roster dated [DATE] revealed LVN A received a reprimand for conduct unbecoming of an employee of the company. Review of facility armed intruder/active shooter emergency policy, undated, reflected the presence of any person on the premises with the presumed intention of harming others. Victims are family members or associates with a weapon. Oftentimes the incident is domestic in nature and targeted victims are family members or associates of the intruder. Purpose to outline steps for the facility to take, if there is a reported threat to a resident, associate, or visitor of the building, from an individual outside the facility period to also provide direction with this staff to follow, should an armed intruder enter the facility and slash or become violent with staff, residents or visitors period to ensure law enforcement is familiar with the layout of the facility by inviting law enforcement into the facility and providing a facility floor plan to enforcement. Procedure Do not confront or attempt to reason with the individual. Stay calm period call 911 and give the facility name, and your name. Give as many details of this situation as you can to the dispatcher, such as how many perpetrators, location of the armed intruder and their description, type of weapons being used, any hostages, casualties, etcetera. Announce over the pager system code white open parent security slash aggression close parent and the location of the situation. If safe passage is available, leave the area immediately, by way of the nearest exit. Move as far away from the facility as possible protecting their residents' safety. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 6:53 PM. The DON was notified. The DON was provided with the IJ template on [DATE] at 6:53 PM. The following POR was accepted on [DATE] at 5:07 PM Date: [DATE] F609 The facility failed to develop and implement written policies and procedures that: Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. Interventions: As of [DATE] the Charge Nurse suspended and terminated from the facility by the Administrator. As of [DATE] the allegation was reported to the police and HHS by the Administrator. As of [DATE] the DON was in-serviced 1:1 by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. As of [DATE] the Administrator was in-serviced 1:1 by the Area Director of Operations on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. As of [DATE] the CNA who witnessed the handgun was in-serviced 1:1 by the Regional Compliance Nurse to call 911 and the administrator immediately. Medical Director was notified of the immediate jeopardy on [DATE] by the DON. An ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan. In-services: All Staff: All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. Abuse and Neglect Policy. Timely reporting of abuse and neglect to the abuse coordinator. Monitoring: Monitoring was initiated on [DATE]. Reviewed the payroll/input personnel action form that reflected LVN A's employment at the facility was involuntary terminated for bringing a gun into the facility. Reviewed of Self-reporting ad hoc QAPI - Emergency Situation Document that reflected both law enforcement and the State of Texas were informed of the incident. Interview with the DON revealed she had been in-serviced by the Regional Compliance Nurse on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. She stated she was also in-serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. Interview with the Administrator revealed she was on vacation but reached by phone on [DATE] and confirmed she was in-serviced on reporting emergency situations including handguns brought into the facility according to the provider letter within 2 hours of suspicion. Interview with the CNA who witnessed the handgun confirmed that she received an in-service that if someone brings a gun into the facility, she needs to call 911 then report to the administrator immediately. Interview with the DON revealed she contacted the Medical Director and notified him of the immediate jeopardy. Reviewed ADHOC QAPI meeting was conducted on [DATE] to discuss the immediate jeopardy and subsequent plan. In-services: All Staff: All staff were in-serviced on the following in-services below on [DATE] by the Regional Compliance Nurse and DON. All staff not present will be in-serviced prior to start of their shift. All new hires will be in-serviced during orientation prior to start of their assignment. All agency staff will be in-service prior to the start of their shift. To notify 911 immediately in the event that a firearm is suspected in the facility and not with law enforcement. Then notify the Administrator and DON. Abuse and Neglect Policy. Timely reporting of abuse and neglect to the abuse coordinator. Interviews on [DATE] from 10:37AM to 12:22PM with 3 Nurses, 6 CNAs and 1 MA revealed the following: *10:37 AM ADON J stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. *11:30 AM CNA H stated she was in serviced on the facility's abuse and reporting policy. She stated she was also in serviced on who and how soon you would report altercations or observations of a handgun to. She stated the abuse coordinator the administrator. *11:40 AM LVN I stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder. *11: 45 CNA J stated she was in serviced and she would report anyone with a firearm immediately and call the police. *11:50 AM CAN K stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *11:55 AM CNA L stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *12:00 PM CNA M stated she was in serviced yesterday on abuse reporting and who to report it to. She stated she would report to Administrator right away and if she saw someone with a gun, she would call 911. *12:05 PM CNA M stated he was in serviced on who to call if someone had firearm and what to do if someone brought one to the facility. He stated he would let the administrator know and call the police. *12:10 PM CNA N stated she was in serviced on the facility policy regarding reporting abuse and you would tell the administrator right away. If I saw someone with a gun, yes, I would report it and call 911. *12:18 PM Medication Aide O stated she was in serviced and would immediately report anyone with gun to the administrator and the police. *12: 22 PM LVN P stated she was in serviced regarding the facility's abuse and neglect policies and stated any incident that puts the residents in danger should be reported immediately to the administrator. She further stated she was in serviced on firearm awareness and armed intruder. Review of in-service records reflected the facility in serviced staff on abuse and neglect, Firearm awareness and armed intruder/active shooter. Review of the facility's abuse and neglect policy reflected the policy included the key components of screening, training, prevention, identification, investigation, protection and reporting alleged incidents of abuse, neglect, and exploitation/misappropriation. The Administrator/ DON/Designee will interview 15-20 staff members weekly on what they would do if a handgun was observed in the facility that doesn't belong to law enforcement. Monitoring will continue for 6 weeks. Administrator/DON will monitor PCC documentation daily during the morning meeting for any evidence of an emergency situations to ensure timely reporting. Monitoring will begin [DATE] and will continue for 6 weeks. Review of staff list and in service trainings reflected 80% of staff in serviced. The DON was informed the Immediate Jeopardy was removed on [DATE] at 6:18 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of three residents reviewed for advanced directives, in that: The facility failed to ensure Resident #1's DNR was signed by the MD until [DATE] when it was ready to be signed on [DATE]. Resident #1's DNR was not uploaded into the EHR, resulting in LVN A having an incomplete OOH-DNR form with which to make her determination of whether to begin CPR. This failure also resulted in Resident #1's Care Plan reflecting a now incorrect code status at the time Resident #1 became unresponsive. These failures resulted in LVN A performing CPR for 5 minutes, and in 911 being called, who continued CPR for an additional 30 minutes, intubated Resident #1 and transported Resident #1 to the hospital. An IJ was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 06:00PM. While the POR was accepted on [DATE] at 1:40 PM and the immediacy was removed on [DATE] at 4:20 PM, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not having their wishes known, respected, and implemented in emergency. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Chronic Combined Systolic and Diastolic Heart Failure (heart failure affect the left ventricle), Abnormalities of breathing, Chronic Obstructive Pulmonary Disease (Difficulty to breath) , Hypertension, Depressive episodes, Acute and Chronic Respiratory Failure, Paroxysmal Atrial Fibrillation ( irregular shallow heart beat), Type 2 Diabetes Mellitus, Obstructive Sleep Apnea ( breathing obstruction while sleeping) , Anemia, Mood Disorder and Cellulitis of face. Review of Resident #1's MDS assessment dated [DATE], reflected a BIMS of 4, indicating a severe cognitive impairment. Section I (active diagnoses) reflected Resident #1's primary medical condition was debility from Cardiorespiratory Conditions. Review of Resident #1's initial care plan, dated [DATE] reflected, Resident #1 requested a full code status, and the relevant interventions were: Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. Review of Resident #1's DNR revealed, it had been signed by the responsible party and notarized on [DATE] and the MD signed on it on [DATE]. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 11:50PM, reflected the following: Nurse called into resident's room at 6:20 PM. CNA found resident unresponsive, and very pale. Resident was lying in bed and had no response to calling of his name or to touch. CPR started at about 6:23PM. Requested that 911 be called, since resident did not have a signed DNR. Resident was on Hospice [company], also instructed that they be contacted. EMS arrived at 6:30PM and continued CPR. Upon other help arriving EMS placed resident on floor and continued working with patient. Was informed that they had a faint pulse, they prepared to transport resident to hospital at 7:02PM. Nurse thereafter contacted [family member] of resident to inform her that resident was taken to hospital by EMS, at which time she became very upset and hung up the phone. DON contacted and informed of the situation. [MD] contacted and was informed that resident was transferred to hospital, however informed nurse that resident was supposed to have DNR on file. DNR was in file however it was not signed by doctor, and resident full code was indicated on system. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 03:36AM, reflected: deceased . Review of Resident #1's Death Report from the hospital dated, [DATE] reflected the resident expired on [DATE] at 7:23PM. Review of Resident #1's hospital record dated [DATE] reflected: Patient in cardiac arrest on arrival to emergency department. Patient in respiratory arrest on arrival to emergency department. Length of downtown time, (min) one hour. Patient intubated prior to arrival with endotracheal tube [a tube that is placed between the vocal cords through the trachea to provide oxygen and inhaled gases to the lungs.]: size (mm) 7.0, at lip(cm)21. Patient not on spinal immobilization on arrival. Blood pressure:0, pules0, respiratory rate :0, cardiac rhythm in field pulseless electrical activity . Record review of the doctor's note at the hospital on [DATE] at 05:28AM reflected: Patient is a [AGE] year-old male brought in by EMS after being found in cardiac arrest at the nursing home. ACLS was performed by EMS and then continued on arrival to the ER. Patient was found after the conclusion of ACLS to be in systolic and resuscitative measures were halted . Of note on patient's physical exam there was an unusual articulation between the neck and the head when the patient had his neck turned to the side given the impression of a possible broken neck. There was a palpable discontinuity at the back of the base of the skull where it meets the cervical spine suggesting a possible cervical spine fracture. These findings were communicated to the patient's primary care physician who recommended an autopsy and also to have JP evaluate the case. During an interview on [DATE] at 10:30AM ADM stated, the DNR was notarized and received from FM on [DATE] however was not signed by MD until [DATE]. She stated it was a mistake from the facility that DNR was not get signed by MD immediately after received from the family. She stated MD visits the facility every month and the facility was waiting for his next visit to get it signed. She added, this incident was an opportunity to learn from the mistakes. ADM stated LVN A conducted the CPR based on the DNR on the E H R, which was not signed by MD. ADM stated MD signed the DNR on [DATE] before the incident occurred however the code status was not changed in the system as soon as it got signed. ADM stated, the mistake from the facility side was, the DNR did not get signed by MD in a timely manner. During an interview on [DATE] at 11:00AM, Resident #1's FM stated she was the responsible party for Resident#1, and she was horrified with what had happened to Resident #1. She stated, she wanted to know what had really happened and why his DNR was not respected. The FM stated after discussing various aspects of the DNR with Resident #1, it was signed by her and notarized on [DATE]. She stated she wanted to know why it was not get signed by MD immediately after the facility received it. The FM stated this negligence from the facility lead to denying Resident #1's right to have a peaceful and dignified death wished by him and the family. She stated, she heard from the facility that the medical report from the hospital stated Resident #1 had a broken neck and wanted to know how, when and where this was occurred. During a telephone interview on [DATE] at 4:00PM MD stated he visited the residents at the facility once a month. MD reported on [DATE] he met with Resident #1 and his FM at the facility and there was no concern about Resident #1 at that time, other than his normal presentation of labored breathing. MD stated on [DATE] there was no abnormality with the neck noticed and the resident did not report of any discomfort with his neck. MD stated he interacted with Resident #1's FM too and no concerns of any kind raised by them. MD said, he heard about the report of the broken neck of the resident at the hospital on [DATE] and was looking forward for the autopsy result. MD stated he signed on Resident #1's DNR dated [DATE] on 12/04 / 23 in that afternoon and did not remember the exact time. The MD stated he was not aware of the existence of a DNR as the facility did not inform him about it, which was why the DNR was not signed immediately after it was signed and notarized on [DATE]. He stated it was a concern that the DNR was not executed on time and Resident #1's wish was not respected. During an interview and observation on [DATE] at 6:00PM, LVN A stated she was the one who initiated CPR. She stated on [DATE] at about 6:15pm one of the staff members stated, Resident #1 was unresponsive. She said, she immediately went into E H R and confirmed his code status. She said she decided to initiate CPR since the copy of the DNR in the E H R was not duly signed by the MD and thus it was not valid. She said she did the CPR for about 5 minutes while Resident #1 was in bed and mean time ER arrived and took over. She said, they continued CPR for about 5 minutes while resident was in bed and then took him to the floor and continued the process for about 30 minutes. Later they took him to the hospital and later came to know that the resident was pronounced dead at the hospital. LVN A provided a copy of the DNR in which there was no signature of the MD. This was contrary to the copy of the DNR in the E H R uploaded on [DATE], in which there was a MD's signature. When investigator asked why there were two copies of DNR, one with and the other without MD's signature, LVN A stated the copy without MDs signature was in the E H R at the time of the incident and the one with MD's signature was uploaded to the system after the incident occurred. She sated she was an LVN for more than 30 years and she knew it was a complicated situation and that was why she decided to preserve the copy of the DNR that was effective at the time of the incident. When the investigator asked about Resident #1's broken neck, LVN A stated when she was conducting CPR there were no abnormalities noticed. Record Review of E H R on [DATE] revealed, the copy of the DNR uploaded to the system on [DATE] was duly signed by the MD and the responsible party. Record Review of the facility's undated policy Resident Rights reflected the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regard less of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States Self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice 2. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. The ADM was notified on [DATE] at 06:00PM that an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on [DATE] at 01:39PM, and included: F578 - The facility failed to protect Resident #1's right to request, refuse, and/or discontinue treatment. All residents could be affected by this deficient practice at the facility. Interventions: 1. 100% audit was completed for resident advance directives by the DON and ADON as of [DATE]. All DNRs are completed and signed by the resident or person acting on behalf of the resident, along with witnesses or notary and physician. All advance directive orders are care planned. No additional issues were discovered during the audit. Completed [DATE]. Once notified by medical records and/or administrative staff, nursing personnel will change the status in PCC and update care plan 2. The Administrator and DON were in-service 1:1 on the completion and implementation of advance directives, Abuse and Neglect, and the CPR policy by the Area Director of Operations. Completed [DATE]. All nurses are certified in CPR and the team have verified that each shift has a nurse certified in CPR. 3. The Medical Director was notified of the immediate jeopardy on [DATE] by the Administrator. 4. An ADHOC QAPI meeting was conducted as of [DATE] to discuss the immediate jeopardy and plan of removal. In-services: 1. All staff were in-serviced on Abuse and Neglect by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. 2. All Charge Nurses were in-serviced on policy for CPR and procedures for performing CPR by the Administrator and DON on [DATE]. All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. 3. All Charge Nurses and M/R were in serviced on the process to obtain and implement a DNR by the Administrator and [NAME] on [DATE] All staff not present will not work their next assignment until in-serviced. All newly hired staff/agency staff will be in-serviced at orientation before assuming an assignment. Staff will demonstration understanding/comprehension of process by teach back. A change to obtaining the physician's signature if not completed as soon as requested was put in place (Medical Records or designee will fax DNR to the physician. If not received back medical records or designee will deliver DNR to physician. Once signed medical records or designee will upload DNR to PCC. DON or designee will change status in PCC and notify staff of status change during nursing stand up. Care plan will be updated by nursing management). Monitoring: 1. At least 5 times per week, advance directive orders will be reviewed by Administrator/DON and/ADON and ensure that all orders are completed and entered correctly. Monitoring will start [DATE] and continue x 6 weeks. The Survey Team monitored the Plan of Removal on [DATE] Interview on [DATE] at 12:37PM with DON and Administrator revealed the one-on-one training was done with Compliance Nurse regarding resident rights and advance directives. The DON stated they reviewed all residents records for code status stating she reviewed DNRs and ensured the out of hospital was in the resident record and that the records reflected the DNR status she stated she also reviewed full code residents to ensure they had not initiated a DNR she stated Resident #1 was a hospice resident and hospice usually does the DNRs and stated the facility needed to ensure the records reflected the residents status. She stated the record reflected the resident was a full code and the nurse did what she was supposed to since she had no way of knowing his code status had changed. Interview on [DATE]PM started at 12:50PM with 8 nursing staff in the facility revealed they were in serviced on resident rights, CPR, and DNRs and were able to explain the procedure for identifying a residents code status, locating the documents. Record review of In-services revealed an Inservice for CPR/ and Code policy conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy Cardiopulmonary resuscitation and inservice for steps to execute a DNR conducted on [DATE] and ongoing for staff coming to work which reviewed the facility ' s policy for out of hospital DNRs. The ADM was notified on [DATE] at 4:30 PM that the Immediate Jeopardy was lowered, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep two (Resident #1, Resident #2) of sixteen residents free from accident hazards and supervision. The facility failed to: 1. Ensure Resident #1, who had exit-seeking behaviors and resided in the secure unit, did not elope from the facility on 12-16-22. 2. Ensure Resident #2, who had exit-seeking behaviors and resided in the non-secure unit, did not elope from the facility on 09-14-22. On 1-2-23 at 5:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 1-5-23 at 7:00 PM, the facility remained out of compliance at a scope of J isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, harm, or hospitalization. Findings Included: Record review of Resident #1's undated admission record reflected, Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1's diagnoses included dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis ), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs ), and major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), recurrent, severe with psychotic symptoms (hallucinations, delusion, confused/disturbed thoughts). Record review of Resident #1's MDS assessment, dated 12-21-2022, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Resident #1 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #1 did not require any assistive mobility devices. Record review of Resident #1's care plan, initiated on 10-22-21, reflected Resident #1 is at risk for wandering. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system. Resident #1 had cognitive function/dementia or impaired thought processes Dementia. Record review of Resident #1's Securecare Environment Screening Tool dated 7-18-22, reflected Resident #1 had a diagnosis of Alzheimer's disease, continued to exhibit exit seeking behavior and resident is continuously wandering and looking for an exit. Record review of Resident #1's progress note, dated 7-23-22, reflected Resident #1 had pushed his way through the doors of the locked unit and took off running down the street. Law enforcement assistance had been required because Resident #1 was running down the road and Licensed Vocational Nurse D had to block traffic. 911 was called, resident [#1] was restrained after swinging at officers. Resident #1 had been transferred to local hospital. Resident #1 returned to the facility with a diagnosis of altered mental status with no new orders. Record review of Resident #1's progress note, dated 7-24-22, reflected Resident #1 was increasingly agitated and commenting I'm going to the house. Resident #1 had set off the back door alarm 3 times. Staff attempted to redirect him and he charged at them with a closed fist. Record review of Resident #1's progress note, dated 8-6-22, reflected Resident #1 had been observed due to increased agitation. Resident #1 had been walking from one door to the next, and walking away from the front door down to the hall. Record review of Resident #1 progress note, dated 10-29-22, reflected Resident #1 tried to push the courtyard door open and stated I want to go home. Resident #1 was shaking the front doors to the secure unit and became combative with staff, and law enforcement was called. The law enforcement officer spoke to Resident #1 and Resident #1 was redirected to his room without complaints. Record review of Resident #1 progress note, dated 12-16-22 reflected, Resident #1 had run and hit the exit doors in the secure unit which caused it to open. Resident #1 ran down the sidewalk and was followed by Certified Nurse Aide F. Resident #1 was in view of Certified Nurse Aide F at all times. Record review of Texas Department of Aging and Disability Services Form 3613-A provided by the Administrator reflected the Investigation Findings to be confirmed. Staff were moving residents from the dining room to the day room following an activity. [Certified Nurse Aide F] was coming out of the dining room, she spotted resident [Resident #1] running down the hall toward the door. When he [Resident #1] reached the door he pushed hard on it until it released. [Certified Nurse Aide F] was running after him calling for help as she went. [Certified Nurse Aide E] was asked to help. He [Certified Nurse Aide E] told [Licensed Vocational Nurse B], what was going on and joined the pursuit. Resident [#1] was in eye sight at all times. Staff caught up with the resident [#1] (as he was running down the sidewalk), calmed him down and coaxed him into a care to return him to the facility. Resident [#1] had been taken out on a pass the day before. The form was signed by the Administrator and dated on 12-20-2022. On 1-2-23 at 10:05 AM, an observation revealed, the nurse's station outside of the secure unit. Two locked clear doors led to the secure unit. Licensed Vocational Nurse A pressed the doorbell located on the left side of the wall and unlocked the doors to the secure unit. On 1-2-23 at 10:07 AM, Resident #1 was observed in the secure unit at the end of the hall, trying to push the emergency doors open. Certified Nurse Aide C and Licensed Vocational Nurse A stood in front of the doors and redirected him away from the doors. Resident #1 was angry and agitated, and continued trying to push the doors open. Resident #1 continued to talk loudly and aggressively to staff as he walked away from the exit doors. On 1-3-23 at 9:15 AM, an observation revealed the distance between the private driveway in front of the home where Resident #1 was found and the facility was .26 miles. Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour. During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. During an interview on 1-3-23 at 9:04 AM, Licensed Vocational Nurse B stated she had been trained in elopement procedures and she had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Licensed Vocational Nurse B stated Resident #1 had a history of being upset after the family visited and attempted to leave the facility after those visits. Licensed Vocational Nurse B stated a family member visited Resident #1 the day before and he had been upset since then. Licensed Vocational Nurse B stated she had been told by Certified Nurse F that Resident #1 was running back and forth down the hallway of the secure unit when he hit the exit doors and they opened. Licensed Vocational Nurse B stated she and Certified Nurse Aide E ran out of the facility and saw Resident #1 running down the sideway next to a busy street. Licensed Vocational Nurse B stated Resident #1 ran fast and finally stopped near a fast food restaurant, a couple of blocks away. Licensed Vocational Nurse B stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Licensed Vocational Nurse B stated a head-to-toe assessment was done on Resident #1 and no injuries were noted, vitals were taken and all were normal. She stated he was also hydrated, and was assigned a one to one person for the next 72 hours. Licensed Vocational Nurse B stated on 12-30-22, Resident #1 was moved from his room located at the end of the hall to the first room at the beginning of the hall because the facility need his room for a new admission. During an interview on 1-3-23 at 10:56 AM, Certified Nurse Aide E stated he had been trained in elopement procedures and had worked in the facility on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide E stated the Maintenance Supervisor notified the nurse who in turn notified him that Resident #1 had eloped. Certified Nurse Aide E stated he ran down the sidewalk located next to a busy street and saw Resident #1 on the opposite side of the street running away from the facility. Certified Nurse Aide E stated he saw cars slowing down as Resident #1 continued to run down the street. Certified Nurse Aide E stated Resident #1 was found approximately 2 blocks away in a private driveway in front of a home. Certified Nurse Aide E stated the street located in front of the facility was very busy and there was traffic on the day Resident #1 eloped. Certified Nurse Aide E stated Licensed Vocational Nurse I drove her car to the location and picked up Resident #1 and transported him back to the facility. Certified Nurse Aide E stated Resident #1 has a history of trying to exit the facility and has witnessed him push and pull the front doors of the secure unit attempting to leave when he is mad or agitated. During an interview on 1-3-23 at 3:38 PM, Certified Nurse Aide F stated she had been trained in elopement procedures and she had worked on the secure unit on 12-16-22 when Resident #1 eloped through the exit doors located in the secure unit. Certified Nurse Aide F stated she was in the dining room in the secure unit when she heard the alarm door beeping and saw Resident #1 standing at the exit doors. Certified Nurse Aide F stated she knew she had 15 seconds before the door released and opened. Certified Nurse Aide F stated the door opened and Resident #1 ran out the door and it shut behind him. Certified Nurse Aide F stated when she opened the door, Resident #1 was running in a private driveway located next to the facility. Certified Nurse Aide F stated she could see Resident #1 as he ran away from the facility. Certified Nurse Aide F stated Resident #1 stopped at the grocery store near the facility. During an interview on 1-3-23 at 10:36 AM, the Licensed Vocational Nurse I stated she had been trained in elopement procedures. Licensed Vocational Nurse I stated she was in orientation on 12-16-22 when Resident #1 eloped from the secure unit. Licensed Vocational Nurse I stated she got into her personal vehicle and traveled down the road and saw Resident #1 and other staff members across the street in the private driveway of a home. Licensed Vocational Nurse I stated she coaxed Resident #1 into her vehicle and transported him back to the facility. Licensed Vocational Nurse I stated the street had a normal flow of traffic. Licensed Vocational Nurse I stated she was stationed at the nurse's station outside of the secure unit and will do rounds every hour or as needed. During an interview on 1-2-23 at 10:10 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated Resident #1 was agitated and attempted to push the doors open on 1-2-23. Certified Nurse Aide D stated she had redirected Resident #1 away from the door. Certified Nurse Aide D stated Resident #1 had exit seeking behaviors and had eloped from the facility in the past. Certified Nurse Aide D stated when Resident #1 is agitated, extra eyes were kept on him to prevent him from eloping. Certified Nurse Aide D stated Resident #1 had touched the exit door bar and waited for the staff to respond. Certified Nurse Aide D stated Resident #1 had acted up after past family visits. Resident #1 had been visited by family on 1-1-23 and that is what caused him to become angry and agitated. Certified Nurse Aide D stated Resident #1's room was located at the end of the hall, near the exit doors. Certified Nurse Aide D stated Resident #1 had been in the secure unit for a couple of months and he had eloped a couple of times before. Certified Nurse Aide D stated when she worked in the secure unit, she always kept an eye on Resident #1 to ensure that she knew where he was at all times. Certified Nurse Aide D stated Resident #1 liked to sit in the dining room, listen to music, and drink coffee. Certified Nurse Aide D stated rounds are done at least every 2 hours, but more frequently in the secure unit. Certified Nurse Aide D stated 2 CNA's and 1 nurse covered the secure unit. During an interview on 1-2-23 at 10:29 AM, Certified Nurse Aide M stated she had been trained on elopement procedures. Certified Nurse Aide M stated she worked in the secure unit with Resident #1 and when he was upset, he would attempt to leave the secure unit through the exit doors. Certified Nurse Aide M stated Resident #1 had been redirected away from the exit doors. Certified Nurse Aide M stated Resident #1 had been verbally aggressive when he was angry or agitated. Certified Nurse Aide M stated rounds are done at least every 2 hours but more frequently in the secure unit. Certified Nurse Aide M stated 2 CNA's and 1 nurse covered the secure unit. Certified Nurse Aide M stated 16 residents resided on the secure unit. During an interview on 1-2-23 at 10:36 AM, Licensed Vocational Nurse A stated she had been trained in elopement procedures. Licensed Vocational Nurse A stated she had been working the secure unit on 1-2-23 and Resident #1 attempted to push the exit doors open. Licensed Vocational Nurse A stated Resident #1 stated, I figured it out as he attempted to push the exit door open. Licensed Vocational Nurse A stated she and Certified Nurse Aide B stood in front of the exit door to prevent Resident #1 from eloping. Licensed Vocational Nurse B stated Resident #1 was agitated and high strung because he had a family visit the day before [1-1-23] and he kept stating he wanted to go home. Licensed Vocational Nurse A stated the exit door push bar had to be held for 15 seconds before the door was unlocked and released. Licensed Vocational Nurse A stated the exit door alarm will beep loudly during the 15 seconds. Licensed Vocational Nurse A stated the beeping could be heard at the nurse's station located outside the secure unit. Licensed Vocational Nurse A stated after 15 seconds the door will open and the alarm will sound at which time all available staff is to respond to the opened door. Licensed Vocational Nurse A stated she sits at the nurse's desk located outside the clear doors of the secure unit. Licensed Vocational Nurse A stated a doorbell is located on the left side of the wall next to the clear doors leading to the secure unit and the doorbell had to be pushed to release the lock and open the doors to the secure unit. Licensed Vocational Nurse A stated a code to the keypad is needed to exit the secure unit. During an interview on 1-2-23 at 10:50 AM, Certified Nurse Aide D stated she had been trained on elopement procedures. Certified Nurse Aide D stated she had worked the secure unit and cared for Resident #1. Certified Nurse Aide D stated Resident #1 had a history of being agitated after family visits and would attempt to exit through the back exit doors. Certified Nurse Aide D stated when she worked the secure unit, Resident #1 was with her or within eyesight because of his past history of elopement. Certified Nurse Aide D stated Resident #1 did respond to redirection when he is upset and wanting to go home. Certified Nurse Aide D stated Resident #1 pressed the push bar and when she heard the beeping she immediately responded to the exit door and redirected him to activity room. Certified Nurse Aide D stated Resident #1 is very strong and can be physically/verbally aggressive when upset. Certified Nurse Aide D stated she had been told Resident #1 ran very fast when he eloped from the facility. Certified Nurse Aide D stated rounds in the secure unit are completed at least every 2 hours, but she did them every 30 minutes because some residents like to walk up and down the hallway. Certified Nurse Aide D stated the doorbell outside the secure unit must be pressed and it will open the door. Certified Nurse Aide D stated when the push bar on the exit door is held it will beep for 15 seconds then the door is opened and the alarm will sound. Certified Nurse Aide D stated the alarm can be heard outside the doors of the secure unit and all available staff are to respond. She stated the code, to the keypad, is needed to exit through the clear doors located at the front of the secure unit. During an interview on 1-2-23 at 10:59 AM, the Maintenance Supervisor stated he checked all exit doors every other day. The Maintenance Supervisor stated he checked all keypads daily to make sure they were working. The Maintenance Supervisor stated he did not keep a daily log of the checks, but if a repair is needed, it will be logged in the system and then show up on a report when it is completed. The Maintenance Supervisor stated the push bar to the exit doors, in the secure unit, is very sensitive and will beep if it is touched and the constant beeping will sound when the push bar is held and the alarm will go off when the door is opened. The Maintenance Supervisor stated the push bar had to be held for 15 seconds, before it would open and set off the alarm. The Maintenance Supervisor stated the alarm in the memory care unit is loud and can be heard through the clear doors of the unit. The Maintenance Supervisor stated a code is needed to exit through the door that leads to the courtyard in the secure unit. The Maintenance Supervisor stated staff and visitors must press a doorbell located on the right side of the wall and someone from inside the facility will come to the front door and open it. The Maintenance Supervisor stated a red push button located on the right side of the wall near the front doors had to be pressed before the doors will open automatically. The Maintenance Supervisor stated a code is not needed to exit the facility through the front doors. On 1-2-23 at 11:05 AM an observation revealed the exit door to beep when touched and then a long beeping sound when the push bar was held for 15 seconds before being opened. The exit doors led to the side of the building and a sidewalk that leads to the facility parking lot. On the other side of the sidewalk is a grassy area which leads to an open part of the fence that leads to a private property. The sidewalk ends at the parking lot. A sidewalk is located between the facility parking lot and a street. The street was observed to be busy with traffic. On 1-2-23 at 11:08 AM an observation revealed a red button located on top of a blue handicap mount was located on the wall near the front entrance doors. During an interview on 1-3-23 at 10:00 AM, Certified Nurse Aide D stated she had been trained on elopement procedures and worked in the secure unit with Resident #1. Certified Nurse Aide D stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset or agitated after family visits. Certified Nurse Aide D stated she had not worked in the secure unit on 12-16-22, when Resident #1 eloped. Certified Nurse Aide D stated the facility had been short staffed during the month of December 2022, and she worked the secure unit alone a few times because of staffing issues. Certified Nurse Aide D stated at least 2 Certified Nurse Aides needed to work the secure unit to meet the residents needs and ensure they get proper care. During an interview on 1-3-23 at 10:20 AM, Certified Nurse Aide G stated he had been trained in elopement procedures and worked in the secure unit at the facility. Certified Nurse Aide G stated Resident #1 had a history of elopement and had eloped from the secure unit back in July 2022. Certified Nurse Aide G stated Certified Nurse Aide D was the only person working on the secure unit on that day. Certified Nurse Aide G stated the facility was short staffed and there had been times where only one person worked the secure unit. Certified Nurse Aide G stated Resident #1 is fast and no one here can catch him once he gets to running. Certified Nurse Aide G stated all staff are aware Resident #1 will be upset after family visits and will try to leave the facility. Certified Nurse Aide G stated Resident #1 can be redirected sometimes but when he was upset he would not listen. During an interview on 1-3-23 at 12:45 PM, the Director of Nursing stated she and all staff had been trained on elopement procedures. The Director of Nursing stated she had worked on 12-16-22 when Resident #1 eloped from the facility. The Director of Nursing stated Resident #1 eloped through the exit doors of the secure unit. The Director of Nursing stated Certified Nurse Aide F ran after Resident #1 and kept him within eyesight. The Director of Nursing stated she and other staff members ran down the sidewalk next to a busy street and finally reached Resident #1 on the opposite side of the street in a private driveway. The Director of Nursing stated there was a steady flow of traffic on the street located next to the facility. The Director of Nursing stated Resident #1 was transported back to the facility by Licensed Vocational Nurse I. Resident #1 was assessed from head to toe with no injuries noted, vitals were taken, he had been given fluids for hydration, and then had dinner. Resident #1 was placed on a one to one watch for the next 72 hours. The Director of Nursing stated Resident #1's room was located at the end of the hallway near the exit doors in the secure unit, but he was moved on 12-30-22 because the facility needed that room for a new admission. The Director of Nursing stated Resident #1 would have been able to stay in his room located at the end of the hall near the exit doors if the facility had not needed it for a new admission. The Director of Nursing stated rounds were done every 2 hours and more frequently in the secure unit and there are 2 Certified Nurse Aides and 1 Medication Aide assigned to the secure unit on a daily basis. The Director of Nursing stated 1 Licensed Vocational Nurse is stationed outside the secure unit and will conduct rounds and coverage as needed. The Director of Nursing stated the Licensed Vocational Nurse is responsible for performing rounds throughout the facility and there will be times when she is not at the nurse's station to keep an eye on the secure unit. The Director of Nursing stated that the doorbell must be pressed before the entry doors to the secure unit are opened and an exit code on the keypad is needed to exit. The Director of Nursing stated the press bar, located at the end of the hallway on the secure unit, must be held for 15 seconds before it is released and it will beep until opened at which time the alarm sounds and all available staff are to respond to the door. The Director of Nursing stated there is always a risk that a resident will elope from the secure unit. During an interview on 1-3-23 at 8:55 AM, the Administrator stated she and all staff were trained in elopement procedures. The Administrator stated Resident #1 eloped through the exit doors located in the secure unit on 12-16-22. The Administrator stated Resident #1 had a history of exit seeking behaviors and would attempt to leave the facility when upset after family visits. The Administrator stated a family member had visited Resident #1 the day before and he had been upset since the visit. The Administrator stated Resident #1 was placed on one to one monitoring for 72 hours after the elopement. The Administrator stated Resident #1's room was located at the end of the hall next to the exit doors but was moved to the first room at the beginning of the hallway close to the nurses station because his room was needed for a new admission. Record review of Resident #2's undated admission record reflected, Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistent feeling of sadness and loss of interest and can interfere with your daily), primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and asthma (disease that affects your lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing). Record review of Resident #2's MDS assessment, dated 12-21-2022, revealed Resident #2's BIMS score was blank which indicated it could not be completed. The MDS further reflected Resident #2 had a behavior of wandering that occurred daily during the look-back period of the assessment. Resident #2 required any assistive mobility devices. The MDS reflected daily decision making as being severely impaired. Record review of Resident #2's care plan, initiated on 9-8-22, reflected Resident #2 is at risk for wandering, and at shift change if staff see resident outside, staff will invite resident to come inside. Resident #2 hadcognitive function/dementia or impaired thought processes Dementia, communication problem, and impaired visual function. Record review of Resident #2's progress note, dated 5-15-22, reflected, Resident #2 remained tearful and continues to ask to go home and went back to her room to get her belongings. Resident #2 wandering the halls and was found on hall 3 tearful and upset with a bag in her hand that contained her belongings. Urine sample was taken and 15-minute checks will be done until reports are back from the lab. Record review of Resident #2's elopement risk assessment, dated 6-13-22, reflected she was not on a secured unit and ambulated independently or with a device. Assessment also indicated Resident #2 stated and/or threatened to leave the facility, frequent request to go home, confused expression related to tasks to complete, and verbalizes anger and frustration in reference to placement. Resident #2 did not recognize stop lights and signs and does not know precautions when crossing the street. Record review of Resident #2's Event Nurse Note 12 hour-Elope or Attempt, dated 6-13-22, reflected Resident #2 was sitting outside with another staff around 6:30 PM when night shift nurse came on. Around 7:00 PM staff noticed that Resident #2 was not in the building and went outside to get her she was not sitting where she had been. Resident #2 was found in the parking lot next door. Resident #2 had been missing for 30 minutes; no injures resulted from elopement. Resident #2 was brought back inside to her room and given something to drink. Cognition/Behavior at the time of event were marked cognitive impairment, wanders and requires cueing. Record review of Resident #2's progress note, dated 9-14-22, reflected Resident #2 was brought back from the porch area at approximately 3:30 PM. She went to the bathroom and then back to the nurses station. At 4:00 PM, Resident #2 was informed not to go back outside at which time she continued to go outside. Licensed Vocational Nurse B was informed that Resident #2 was down the street from the facility. Licensed Vocational Nurse B got into her car and went to look for Resident #2. Certified Nurse Aide E and Human Resources were walking around and looking for Resident #2. Licensed Vocational Nurse B stated she received a call from Human Resources that Resident #2 was found near the community hospital. Licensed Vocational Nurse B stated Resident #2 refused to get into her vehicle and was escorted back to the facility by Certified Nurse Aide E and Human Resources. Resident #1 was assessed upon return, no injuries, hydrated and he was moved to the secure area. On 12-28-22 at 1:24 PM, an observation revealed the community hospital area where Resident #2 was found was approximately .17 mile from the facility. There was a steady flow of traffic on the road that led from the facility to the hospital. Record review of the posted speed limit on the busy street in front of the facility to be 30 miles per hour. During an interview on 1-2-23 at 11:48 AM, the Dishwasher stated she had been trained in elopement procedures. The Dishwasher stated on 9-14-22, she had finished her shift and clocked out at 4:00 PM and ran some errands. The Dishwasher she had traveled down the busy street located in front of the facility and saw Resident #2 walking on the opposite side of the street near a private residence and called the facility and notified them of what she had seen. The Dishwasher stated Resident #2 was approximately half a block away from the facility on the opposite side of the street. The Dishwasher stated Resident #2 had to have crossed the busy street to end up in front the house where she saw her. The Dishwasher stated the street located in front of the facility was busy at all times of the day. The Dishwasher stated she was in an uber car when she saw Resident #2 down the street from the facility. The Dishwasher stated she had not asked the uber driver to stop when she saw Resident #2. During an interview on 1-2-23 at 12:33 PM, Certified Nurse Aide E stated he was trained in elopement procedures. Certified Nurse Aide E stated he was working in the facility on 9-14-22 when Resident #2 eloped from the facility. Certified Nurse Aide E stated he was told by another staff member that Resident #2 had left the facility and was next door at a grocery store. Certified Nurse Aide E stated he and Human Resources left the facility and began looking for Resident #2 and did not see her in the parking lot of the grocery store near the facility. Certified Nurse Aide E stated he looked across the busy street, located next to the facility, and saw Resident #2 across the street near the community hospital. Certified Nurse Aide E stated he and Human Resources ran across the street and up a side road and stopped Resident #2 near a county owned building. Certified Nurse Aide E stated Resident #2 was walking on the sidewalk next to the community hospital. Certified Nurse Aide E stated Resident #2 required the assistance of her walker to elope from the facility. Certified Nurse Aide E that at some unknown point Resident #2 had to have crossed the busy street located in front of the facility to end up in front of the community hospital. Certified Nurse Aide E stated the street in front of the facility was a busy street and there is traffic on it at all times of the day. Certified Nurse Aide E stated Resident #2 stated she left the facility because she was going to visit family. Certified Nurse Aide E and Human Resources had to cross the busy street and walked Resident #2 back to the facility which took about 10 minutes. Certified Nurse Aide E stated Resident #2 was assessed by the nursing staff. Certified Nurse Aide E stated Resident #2 lived in the non-secure part of the facility on the day she eloped. Certified Nurse Aide E stated Resident #2 had to have left the facility through the front door of the facility. [TRUNCATED]