**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent the development of pressure ulcers for 1 of 7 (Resident #7) residents reviewed for pressure ulcers. - The facility failed to prevent Resident #7 from acquiring DTIs to both of her heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels. Resident #7 required hospitalization for the treatment of the injuries to her heels.An Immediate Jeopardy (IJ) was identified on 8/21/2025. The IJ template was provided to the facility on 8/21/2025 at 12:55pm. While the IJ was removed on 8/22/2025 at 4:00pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk for pain, infection, and hospitalization.Findings include:Record review of Resident #7's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes (body does not make insulin or resists it), retention of urine, osteoarthritis (joint disease where cartilage breaks down), neuropathy (nerve pain), and difficulty walking.Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMs score of 15 out of 15 which indicated normal cognition. She had an impairment on both sides of her upper and lower extremities. The resident was partial/moderate (helper does less than half the effort) assistance with ADLs. She had an indwelling catheter and was incontinent of bowel. The MDS revealed the resident had no pressure injuries on admission.Record review of Resident #7's admission and Baseline Care plan dated 6/30/25 revealed the resident had redness to her right and left heel on admission, with no DTIs or open wounds to her heels. Resident #7 admitted with a wound to the sacrum but there was no evidence of it worsening.Record review of Resident #7's care plan dated 6/30/25 revealed a Focus: Resident #7 admitted with DTI of the L heel (Initiated 6/30/25, Revised 7/30/25). The goal was to remain free from further breakdown through the next review. Interventions included floating the heels, heel boots, weekly skin inspection, and treatments as ordered. Focus: Resident #7 admitted with DTI of the R heel (Initiated: 6/30/25, Revised: 7/30/25). The goal was to remain free from further breakdown through the next review. Interventions included weekly skin inspections, float the heels, heel boots, and treatments as ordered.Record review of Resident #7's previous hospital's Initial admission Physical assessment dated [DATE] at 10:19pm, revealed redness to the sacrum (tailbone), but no wounds and no mention of redness or any concerns to the heels.Record review of Resident #7's previous hospital's Wound Care Consult dated 6/24/25 at 12:42pm, revealed she had .sacral blanchable [turns white] redness over intact skin.Bilateral lower extremities with edema [swelling].no open wounds. Bilateral feet had palpable [able to feel] pulses. No other alterations to skin integrity noted.Record review of Resident #7's previous hospital's Shift Physical assessment dated [DATE] at 9:00am, revealed her exception to a normal skin assessment was having swollen bilateral legs. There was no mention of any other skin issues.Record review of Resident #7's Progress Note dated 7/1/25 at 1:14pm by LVN W, revealed the resident had pressure ulcers on her sacrum and Wound Care was consulted. Nothing was noted about the heels having wounds.Record review of Resident #7's Physician Orders revealed the following orders from MD M:- Consult Wound Care. Ordered on 7/1/25.- Wound Care: Cleanse R Heel with NS, Pat dry, Apply skin prep to wound and LOA, QD. Ordered on 7/9/25 at 6:00am.- Wound Care: Cleanse L Heel with NS, Pat dry, Apply skin prep to wound and LOA, QD. Ordered on 7/10/25 at 6:00am.- Use Heel Lift to float heels at all times while in bed, every shift. Ordered 7/10/25 at 2:00pm.- May send to [hospital] for eval and tx, one time. Ordered on 8/3/25 at 8:30pm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/7/25 at 12:34pm by LVN C, revealed L heel with no description and no mention of the R heel. Under the weekly heel check questions LVN C answered the L heel was not boggy (mushy), not discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/8/25 at 4:39pm from MD O, revealed the resident had a R heel deep tissue injury that was 3cm x 4cm x 0cm. She also had a L heel deep tissue injury that was 3cm x 3.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/14/25 at 12:38pm by LVN C, revealed R heel DTI and no mention of the L heel. Under the weekly heel check questions LVN C answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/15/25 at 9:11pm from MD O, revealed the R heel DTI was 3.2cm x 3.5cm x 0cm. The L heel DTI was 4cm x 4.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/21/25 at 12:38pm by LVN C, revealed R heel DTI and no mention of the L heel. Under the weekly heel check questions LVN C answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 7/24/25 at 6:45pm from MD O, revealed the R heel DTI was 3cm x 3.5cm x 0cm. The L heel DTI was 4cm x 4.5cm x 0cm.Record review of Resident #7's Weekly Head to Toe Skin Check dated 7/29/25 at 7:11am by LVN D, revealed R heel pressure and no mention of the L heel. Under the weekly heel check questions LVN D answered the L heel was not boggy, it was discolored, did not have an open area, and did not have a blister.Record review of Resident #7's Wound Care Note dated 8/1/25 at 8:59pm from MD O, revealed the R heel DTI was 3cm x 3.4cm x 0cm. The L heel DTI was 3.5cm x 4.5cm x 0cm.Record review of Resident #7's hospital Wound Care Consult, dated 8/4/25 at 10:49am from MD Q, revealed the resident had a DTI of the R heel and an unstageable L heel ulcer.In an observation and interview on 8/7/25 at 10:55am with Resident #7, she was admitted to the hospital and lying on her left side in bed. She had pressure relieving boots (foam boots for pressure) on both of her feet. She said she did not like the nursing facility she came from because they did not change her frequently but was unable to answer any other questions due to having severe pain in her bottom from her pressure ulcer.In a telephone interview on 8/7/25 at 3:25pm, Resident #7's family member said the resident's mom admitted to the nursing facility with a very small sacrum wound, but nothing on her heels. She said the resident was always calling her and telling her she had to go potty in her diaper because she could not wait anymore for someone to come help her.In a telephone interview on 8/8/25 at 3:28pm, Resident #7's other family member, said the resident would always complain about hitting the call bell and no one would come to help her so she would have to go in her diaper because she could not hold it anymore. She also said every time she went to the facility the resident was on her back in bed. She never saw Resident #7 on her side. The family member said she spoke to the Director of Rehab about the issues many times and nothing got done. She spoke to the Director of Rehab because that was the only phone number she had for Leadership Personnel.Record review of Resident #7's hospital Wound Care Consult dated 8/9/25 at 6:30pm from MD Q, revealed the resident had a DTI of the R heel and an unstageable L heel ulcer.During an attempted telephone interview on 8/12/25 at 9:13am, a message was left for LVN C.During an attempted telephone interview on 8/12/25 at 10:18am, a message was left for LVN W.In an interview on 8/12/25 at 10:50am, LVN G said the weekly head to toe assessment should still be completed by the floor nurse, even if the wound assessment was performed. She said the admitting nurse measured the wounds, consulted the Wound MD, and treated the wounds by getting orders from the doctor.In an interview on 8/12/25 at 11:41am, the ADM said a skin assessment was performed at every admission and documented under the Admission/Baseline Care Plan. She said the weekly head to toe assessments were performed on a schedule by the 3 different shifts. The ADM said the head to toe skin assessment should still be completed along with the Wound Assessment. She said the admitting nurse would identify any wounds and stage them, but not measure them, and then notify the MD to get orders. She said the Wound Care MD would measure the wounds and document the measurements.In an interview on 8/21/25 at 12:53 pm, the ADM said the facility was treating Resident #7's heels and there was no way to avoid the PUs. She said sometimes residents got facility acquired PUs and there was nothing the facility could do.In a telephone interview on 8/21/25 at 2:53pm, NP B said she performed her own skin assessment at admission, but she did not remember if the resident had heel DTIs or not, even though nothing was mentioned in her H&P. She said interventions that would prevent heel wounds would be offloading, pressure relieving boots, heel protectors, and nutritional support. She said she did not know if Resident #7's heels got better or worse because she defers all wounds to the Wound Care MD.In a telephone interview on 8/21/25 at 2:57 pm, MD O said if the staff were using heel cushions, offloading, and repositioning for Resident #7, the heels would have gotten better and not opened into ulcers. She said if the DTIs to her heels opened into an ulcer, it would have been because the pressure was not relieved to her heels. She also said if a resident came to the facility with no wounds, and precautions were put in place to prevent PUs, there would be no reason why a resident would get a pressure ulcer.Record review of the facility's policy and procedure on Pressure Injury Prevention and Management, undated, read in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.Licensed nurses will conduct a full body skin assessment on all residents upon admission/re­admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record.Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and Maintain or improve nutrition and hydration status, where feasible. The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.This was determined to be an Immediate Jeopardy (IJ) on 8/21/25 at 12:55pm. The ADM and the DON were notified on 8/21/25 at 12:55pm. The ADM was provided with the IJ template on 8/21/25 at 12:55pm.The following Plan of Removal submitted by the facility was accepted on 8/22/25 at 1:02pm.The plan of removal reflected the following:Name of Facility: [Name of facility]Date: 8/22/2025F686 - Treatment/Services to Prevent Pressure Ulcers1. Corrective Action Taken for the Resident(s) Found to Have Been AffectedResident #7 was admitted on [DATE] with redness to both heels and subsequently developed bilateral deep tissue injuries, progressing to an unstageable ulcer on the left heel The facility failed to prevent Resident #7 from acquiring DTIs to both heels and from the L heel progressing into an unstageable PU, when she was admitted with only redness to both heels.2. Corrective Action Taken for Residents Having the Potential to Be AffectedOn 8/21/25, immediately upon identification of the Immediate Jeopardy, licensed nurses conducted full head-to-toe skin assessments on all residents in the facility completed on 08/21/25. Two new residents were identified with new pressure areas, one new pressure injury to left medial foot and one new pressure injury to sacrum. Repositioning interventions are in place on each newly identified residents care plan and Kardex, both newly identified residents can reposition self. All Resident's Pressure Injury Risk Assessments were completed on 8/21/2025 by DON/Designee. All findings were documented and reviewed by the Director of Nursing, and physician orders were obtained for any new or existing areas of skin alteration. Preventive interventions, including heel elevation, use of heel boots, and use of pressure-relieving mattresses or cushions, were verified to be in place for all residents identified at risk completed on 8/21/2025 by DON/Designee. Kardex and Care plans were reviewed and updated to reflect individualized risk factors and interventions completed on 8/21/2025 by DON/Designee. In-servicing conducted by DON on 08/21/2025 with all full-time licensed staff included review of Kardex for current interventions in place for residents.3. Measures and Systemic Changes Put into PlaceOn 8/21/25, the Director of Nursing and wound nurse re-educated all fulltime/scheduled nursing staff, including registered nurses, licensed vocational nurses, and certified nursing assistants, on pressure ulcer prevention, early identification of skin changes, proper use of preventive devices, and documentation requirements. In-Servicing completed on 08/21/2025. Nursing staff will be in-serviced prior to start of their next scheduled shift, In-servicing will remain on-going for all new hires/PRN prior to the start of their assigned shift. AD HOC QAPI held with IDT Team and Medical Director, Skin assessment and wound management policies were reviewed and updated to include a comprehensive skin assessment conducted by the Wound Care Nurse on the day after admission or readmission to ensure assessments were completed accurately, completed on 08/22/2025. On 08/21/2025 daily meeting board was updated to include an admission tab ensuring all new admissions will receive a complete skin assessment upon admission, will be reviewed daily Monday thru Friday by DON/Designee and preventive interventions will be initiated and documented immediately. The Director of Nursing and Assistant Director of Nursing/Wound Care Nurse will ensure care plans are updated within 24 hours of any identified skin change or physician order. 4. Monitoring to Ensure Ongoing ComplianceBeginning 8/21/25, the Director of Nursing or Designee will perform audit of completed skin assessments of 5 residents daily for five days Monday through Friday, then two times weekly for four weeks, then weekly for two months, then random audit congoing to ensure continued compliance to confirm preventive interventions are in place, to ensure no residents are developing new pressure ulcers, and ensure that completed skin assessments were performed correctly. In addition, the Director of Nursing/Designee will perform direct observation of nursing staff to ensure heel elevation, turning/repositioning and use of pressure relief devices are consistently completed. Any noncompliance identified during audit will require immediate re-education, by DON/designee, with the Licensed Nurse who completed the skin assessment. Audit results are reported to the QAPI committee monthly, and corrective actions are initiated immediately if deficiencies are identified. Any staff found to be non-compliant with pressure ulcer prevention protocols will receive immediate re-education and disciplinary action if necessary. Compliance will be further validated by corporate clinical support during monthly monitoring visits. Starting 08/22/2025 and continuing forward, per updated Skin Assessment policy, the Wound Care Nurse will perform daily audits Monday-Friday of new admissions and re-admissions to ensure skin assessments were completed and correct. Any variance found will result in immediate re-education of Nursing Staff. Starting 08/22/2025, Certified Nursing Assistants will complete shower sheets on scheduled shower days which will be verified by Licensed Nurses and then turned into Wound Care Nurse for review and follow up as needed. The DON/Designee will review these logs daily during daily clinical meetings Monday through Friday to ensure timely follow up and accuracy. Completion Date - 08/22/2025From 8/22/25-8/23/25 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed:Record review revealed the skin assessments performed on 8/21/25 by the DON, found 2 residents with new pressure ulcers. Resident #8 was found to have an unstageable PU to her L inner foot and Resident #9 was found to have a PU to her sacrum. The facility notified the MDs for both residents and received orders.Record review of Resident #8's chart revealed the Head-to-Toe assessment performed on 8/22/25 that found the new PU, along with the Wound Assessment also performed on 8/22/25. Record review revealed MD orders for the PU found to the L inner foot, entered on 8/22/25. Record review also revealed the Care Plan was updated with the PU.Record review of Resident #9's chart revealed the Head-to-Toe assessment performed on 8/22/25 that found the new PU, along with the Wound Assessment also performed on 8/22/25. Record review revealed the MD orders for the PU found to the sacrum, entered on 8/22/25. Record review also revealed the Care Plan was updated with the PU.In an observation on 8/22/25 at 3:26pm, Resident #8 was asleep on her left side in bed. Her legs were under the covers, so it was undetermined if she had any heel protectors on.In an observation and interview on 8/22/25 at 3:30pm, Resident #9 was sitting up in bed with her heels elevated. She said the staff did find a new wound to her bottom, but it was not bothering her. She said they put new interventions in place like turning and putting her feet up.In an interview on 8/23/25 at 2:37pm, LVN D said she worked the 6am-2pm shift. She said she recently had in-services on wound care and ensuring it was done, assessing for PUs and how to assess for PUs, reporting to the MD and to the Wound MD if any skin issue were found, ensuring accurate skin assessments were done, and ensuring shower sheets were verified by the nurse and then turned over to the Wound Care Nurse if a skin issue was found. She also said the admission assessments were performed by the floor nurse and then the Wound Care Nurse performed them after.In an interview on 8/23/25 at 2:40pm, LVN G, also the Wound Care Nurse, said she worked the 2pm-10pm shift. She said she had in-services on skin assessments, PUs, documenting wounds, and calling the MD for orders. She said there were also in-services on the risk factors for PUs, and interventions for PUs. She said the admission/readmission skin assessment was done by the floor nurse and then re-assessed by the Wound Nurse. She also said if the CNA found skin issues during a shower, the shower sheet was filled out and then given to the nurse then the Wound Nurse.In an interview on 8/23/25 at 2:43pm, CNA I said she worked the 6am-6pm shift. She said she received in-services on ways to prevent PUs like repositioning and floating the heels. She said she also received in-services on ensuring the skin was checked and filling out shower sheets and giving them to the nurse if there were any skin concerns found.In an interview on 8/23/25 at 2:45pm, CNA T said she worked the 6am-6pm shift. She said she received in-services on skin assessments, giving shower sheets to the nurse or Wound Care Nurse if any skin issues were found, and interventions to prevent PUs like floating the heels, and repositioning.In a telephone interview on 8/23/25 at 3:21pm, CNA S said she worked the 6pm-6am shift. She said she received in services on PUs and how to look for them and what to do if she found any on a resident. She said she also received in-services on interventions to prevent PUs like turning, repositioning, and floating heels. She said she was also trained on filling out shower sheets if a skin concern was found and giving them to the supervisor.In a telephone interview on 8/23/25 at 3:50pm, LVN P said she worked the 10pm-6am shift. She said she had in-services on skin assessments, how to do them, what to look for, and that the Treatment Nurse would do the Admission/readmission assessments. She said they also received in-services on interventions to prevent PUs like turning, repositioning, and floating the heels. Also, she had in-services on the CNAs filling out the shower sheets and if they found any skin concerns, they needed to give the sheets to the nurse and then the nurse gave them to the Treatment Nurse.Record reviews performed by the Surveyor on 8/23/25:- Braden Scales (determines risk for skin breakdown) for all residents were completed on 8/21/25 and revealed 17 at risk, 4 at moderate risk, 2 at high risk, and 12 with no risk.- A list of residents whose Kardex and Care Plan had been reviewed by the DON on 8/21/25.- In-services given by the DON on 8/21/25 to the CNAs and Licensed Nurses on Early Identification of PUs with 24 staff signatures.- In-services given by the DON on 8/21/25 top the Nursing Staff on PU Prevention, Skin Audits, and ANE with 23 signatures.- In-services given by the DON on 8/21/25 to the Treatment Nurse, RNs, and LVNs on PU Prevention with 20 signatures.- Ad Hoc QAPI Meeting from 8/21/25-8/22/25 revealed MD M, the Medical Director, the ADM, the SW, the BOM, the HR Director, the Maintenance Director, the AD, the DM, and the Admissions Director were in attendance.- A sheet that said Admissions on the top and had a column starred that said, Skin Issues: Identified on Admission, Assessment with Notification and New Order for Treatment as Applicable. There was another column starred that said, If Skin Issue Identified, Accuracy of Classification/Stage of Wound Confirmed. The log did not have anyone on it yet.- The Skin Assessment Audits log had 3 residents that had been audited on 8/22/25 and were found to have preventative measures in place, the skin assessment was complete and accurate, and no corrective actions needed to be taken.- The Wound Care Nurse Admission/readmission Audits log was blank and did not have anyone on it yet. An Immediate Jeopardy (IJ) was identified on 8/22/2025. The IJ template was provided to the facility on 8/22/2025 at 12:55pm. While the IJ was removed on 8/23/2025 at 4:00pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent elopement.for 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended and was missing for 2 hours on 2/08/24 around 8:00 PM, until hospital staff contacted the facility. This failure could affect residents with diagnose of dementia at risk of elopement thus placing themselves at risk of physical harm, pain and mental anguish or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 2/16/24 at 1:00 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 2/16/24 at 1:00 PM. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal. Findings Included: Record review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of depression, hearing loss, fall, osteoarthritis, morbid obesity, muscle weakness and abnormalities of gait. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 6 cognitively impaired. She required assistance for ADL's, Ambulation and Cognition. In the care assessments interviewed done on 11/21/23 the following care area triggered were Cognitive loss/dementia, communication, ADL functional rehab potential and psychotropic use. Record review of Resident's Wandering and Elopement Risk assessment dated [DATE] revealed score of Nil minimum risk and no current observable evidence of wandering. Record review of Nursing admission assessment dated [DATE] section N wandering and elopement risk assessment revealed that Resident #1 did not have a history of being a regular walker, therefore, Resident's #1's wandering and elopement risks assessment dated [DATE] revealed a score of Nil minimum risk. Record review of Nurses Progress Notes dated 2/08/24 at 9:39 PM revealed: patient left facility and was found at the hospital. Ambulance was called to go to hospital to bring Resident #1 back to the facility. Resident brought back to facility by City Ambulance, awake and alert. First reading vitals: BP 204/78 O2-99, RR 16. On second reading BP 194/84, HR 75 Temp. 99.9, RR16. In an interview with RN A on 2/10/24 at 10:45 AM she stated that on 2/08/24 at 9:00 PM she got a call from the hospital ER Charge Nurse asking was resident #1 in the facility. RN A thought Resident #1 was in her room but when she went to check Resident #1 was gone. She stated that she had arrived at work at 6:00 PM and was helping other residents. She stated that she had seen Resident #1 during the start of her shift. She also stated that Resident #1 requested that she wanted to go to her room and lie down. RN A took Resident #1 to her room and assisted her in bed. RN A stated that she put Resident #1 to bed at around 7:15 PM. Around 9:00 PM she got a call from the hospital. In an interview and observation with Resident #1 on 2/10/24 at 10:10 AM revealed she was in her room, and she was alert and oriented to self. She was confused. She acknowledged and stated that she went out for a walk and did not tell anyone. She stated that she walked outside the back (did not know which door she exited) into the parking lot. She said she did not have her car, so she kept walking towards the hospital where she works. She stated that she did not get hurt and she walked at a steady pace. In an interview with Resident #1's ROP on 2/10/24 at 10:30 AM he stated that last Sunday 2/04/24 he was visiting Resident #1. He stated that Resident #1 was walking all over the facility and he stated that he can't keep up pace with Resident #1. In an interview and observation walk through with the Administrator and Maintenance Director on 2/13/24 at 11:30 AM she stated that Resident #1 must have exited at the door closed to where the slot machines were adjacent to the dining room. She exited the side door and opened gate that was locked in the outside but for safety reason the gate can be open from the inside and makes alarm. It took us eight minutes from the parking lot to the ER . The street was not very busy when we crossed it. There were no cars observed going through the street. Observed the alarm go off and then stop once the gate closed again. The Maintenance Direcror stated that alarms were working; but once the door closes the alarm shuts off automatically. The Maintenance Director stated that he will in-service the staff to check the exit doors when the alarm goes on to make sure that no resident had exited and all residents are accounted for. In an interview with RN A on 2/13/24 at 3:30 PM she stated that she heard the alarm door, but she ignored the alarm because she stated that someone opened the door and when they came in and closed the door, the alarm shut off. Record review of google maps revealed the local hospital was about .3 miles from teh facility, an around a 6 minute walk along the feeder road to a major highway. In an interview on 2/13/24 at 4:10 PM the DON stated that the facility did not have a policy on supervision. An Immediate Jeopardy was identified on 2/16/24 at 1:00 PM. The IJ Template was provided to the facility on 2/16/24 at 1:00 PM. The following Plan of Removal submitted by the facility was accepted on 2/17/24 at 10:45 AM. Date:2/17/2024 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 2/16/2024 an investigation on a self-report was initiated at [Facility] at 1:00 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F689 - Accidents and Supervision The facility failed to ensure Resident #1 received adequate supervision to prevent Resident #1 from eloping from the facility. Immediate action: Immediate assessment of Resident #1 was completed for any bruising and or skin issues, none noted or observed. Family notified. MD notified. Inservice to all nursing and C.N.A staff was completed on 2/16/2024 by DON, regarding rounding on every patient, especially those that like to walk around. Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with resident specific focus, goals and interventions including 1:1 supervision. Any staff not attending will be in-serviced upon their return to work, before their next shift. Identification of Others The Director of Nursing/Designee completed an elopement risk assessment of all residents to determine which residents were an elopement risk. Elopement risk assessment was completed on 2/17/2024. No other resident had any risk of elopement. Resident#1 was the only identified elopement risk and as stated above, her care plan was updated to reflect associated focus, goals and interventions to protect her from elopement by the DON. Systemic Change Hourly rounding orders implemented into system by Director of Nursing on 2/16/2024. Nurses ensured that Resident#1 is in the building every hour during each shift and record the documentation into PCC system until Resident can be transferred to a facility with a memory care unit as per the request of the responsible party. Hourly rounding to be done by CNA and Nurse and recorded on nurse MAR. The patient's responsible party states his mother needs a more secure unit such as memory care, due to wandering. Patient is being transferred to facility with locked memory care unit. Patient evaluated 2/16/2024 by receiving staff. Currently awaiting discharge date from receiving facility. Resident is up and out of bed daily and in communal area where she can be always supervised by nurse and CNA staff, any elopement attempts are redirected by activities and snacks and staff members she can walk around with and will be supervised at all times. Education was provided to all Nurses and CNA's, by the Director of Nursing/Designee regarding the plan to complete and verify accurate head count on each patient by round every two hours and as needed. Education included that the whereabouts of each patient having elopement risks will be documented as needed per shift. All future staff to be in-serviced at time of hire regarding elopement and rounding. The above education was completed on 2/16/2024 by the Director of Nursing/designee Any staff not in attendance l for this Training will be educated upon their return prior to the next shift worked. Monitoring The Director of Nursing/designee will conduct monitoring daily Monday- Friday for 4 weeks then weekly 8 weeks to verify that rounding is being completed and documented as well as head counts and whereabouts of residents at risk for wandering. Any concerns identified through these audits will be addressed and corrected immediately and staff education and resident interventions implemented as needed. Monitoring/one on one begin 2/17/2024 as stated above. Ad hoc QAPI meeting held with the IDT and Medical Director to review policy associated with wandering and elopement risk as well as this Plan of removal/response to Immediate Jeopardy Citation 2/16/2024 @1445. The surveyor confirmed the facility implemented their plan of removal sufficiently from 2/17/24 through 2/19/24 to remove the IJ by: 1. Record reveiw of immediate assessment of Resident # 1 was completed on 02/09/24 at 1:23PM for any bruising and or skin issues, none noted or observed. Family notified and Physician notified. 2. Record reveiw of inservice to all nursing and CNA staff was completed on 2/16/2024 by DON regarding rounding on every resident, especially those that like to walk around. 3. Record review of Resident #1's care plan was updated on 2/17/2024 by the Director of Nursing to reflect elopement risk with specific focus, goals and interventions including 1:1 supervision. 4. The Director of Nursing/Designee completed an elopement risk assessment of all residents to determine which residents were on elopement risk. Elopement assessment risk was completed on 2/17/2024. No other resident had any risk of elopement. Resident #1was the only identified elopement risk and as stated above, her care plan was updated to reflect associates focus, goals and interventions to protect her from elopement by DON. 5. Record review of hourly rounding orders implemented into system by DON on 2/16/2024. 6. Record reviewed of documentation of Nurses ensured that Resident #1 is in the building every hour during each shift record the documentation into the PCC System (Electronic Medical Record) until resident can be transferred to a facility with memory care unit as per the request of the responsible party. 7. Record review of Hourly rounding completed by CNAs and Nurse and recorded on nurse's MAR. 8. Resident #1's responsible party stated that Resident #1 needs a more secure unit such as memory care due to wandering. 9 Resident #1 is being transferred to facility with locked memory care unit. Resident evaluated on 2/16/2024 by receiving staff, currently awaiting discharged date from receiving facility. 10. Observation of Resident #1 is up and out of bed daily and in communal area where nurse and CNA staff can always supervise her. Activities, snack, and staff member redirect any elopement attempts. Resident #1 can walk around with and will be always supervised. 11. Education was provided to all nurses and CNAs by the DON/designee regarding the plan to complete and verify accurate head count on each resident by round every two hours and as needed. 12. Education included that the whereabouts of each residents having elopement risks will be documented as needed per shift. It was verified that Resident #1 was evaluated for discharge on 2/16, but the receiving facility was not ready to admit resident #1 at 2/16/24. Record review completed of Resident #1's Elopement Assessment done on 2/17/2024. Resident #2; Resident #3; Resident #4; Resident #5; Resident #6 and Resident #7 is in the process of being done, completion date will be 2/17/2024. Nurses' interview re- in-services had several in services and most recent in services was 2/18/2024. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, assessing resident for pain, management, gastrostomy tube, dressing. Check exit doors when alarm activated. Do head count to make sure no resident missing. Nurses verified the training received on the updated care plan which includes 1:1 supervision for Resident #1. Interviewed RN C on 2/18/2024 at 10:15 AM; RN B on 2/18/2024 at 1:00 PM; LVN D on 2/18/2024 at 1:15 PM LVN E on 2/18/2024 at 1:30 PM; LVN F on 2/18/2024.at 8:47 PM CNAs interview- Had several in services and most recent in services was on 2/18/2044. CNAs verbalized checked all exit doors when alarm activated and do head counts to make sure no resident missing, check resident every 2 hours, check if resident still breathing, listen to alarm if people are coming in or going out. CNAs verified the training received on the updated care plan which includes 1:1 supervision for Resident #1 Interviewed CNA A on 2/18/2024 at 10:30 AM; CNA B on 2/18/2024 at 10:45 AM; CNAC on 2/18/2024 at 11:00 AM; CNA D on 2/18/2024 at 11:15 AM; CNA E on 2/18/2024 at 8:50 PM; CNA F on 2/18/2024 at 9:00PM Interview with the DON on 2/19/24 at 10:00 AM revealed that training, rounding, walking, talking with confused resident, know where they are, always do rounds, documenting hourly rounds in MAR. As per IJ the facility does not have the Wander Guard System. How the resident exited, no one heard the alarm, dropped the ball. Interview with the Administrator on 2/19/23 at 10:30 AM. As per the IJ we were not aware of Resident # 1's medical diagnosis. She stated that if she had known that resident had Alzheimer's possibility of elopement looked for a secured unit for the resident to be safe. Did not know until spoke to ROP prior to visiting resident when surveyor arrived in the facility for a P1 intake. The ROP stated he was told by a medical provider that Resident # 1 has Dementia Stage 4. Resident's history was not disclosed upon admission in November 2023. She stated that she started to work here three weeks ago. While the IJ was removed on 2/19/24 the facility remained in violation at a scope of Isolated at a severity level of no actual harm with potential for more than minial harm because all staff had not been trained on the facility's newly developed implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to ensure LVN B properly assess CR#1 when he gave medication on [DATE] at 9:00am when CR#1 vomited, aspirated and later died. The facility failed to ensure that CR#1 was checked on every two hours and was not laying in her vomit from 7:15 am until 11:15am on [DATE]. The facility failed to ensure that CNAs report to the charge nurse when they found CR#1 in her own vomit. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE] at 1:18pm, the facility remained out of compliance at a scope of Level 2 (E) Although there was IJ for one person, the potential for more than minimal harm is a pattern due to the number of staff involved, the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are fed via feeding tube at risk for delayed treatment that could lead to severe injury, aspiration and/or death. Findings Included: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1's diagnoses included hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), depression (a medical illness that effect the mood), anemia (condition where the blood does not have sufficient red blood cells( dementia (memory loss), acute cerebrovascular insufficiency (condition that affects the blood flow to the brain), gastrostomy (a surgical procedure where a tube is inserted in the stomach for feeding), chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood), type 2 diabetes (high blood sugar, epilepsy ( is a brain disorder that causes recurring unprovoked seizures). Insomnia (difficulty falling asleep). Record review of CR#1's MDS dated [DATE] revealed the resident was coded for Cognitive Skills for Decision Making as severely impaired, indicating that CR#1 was not able to make sound decision. She was coded as total care for ADL's, incontinent of bowel and bladder and was fed via a feeding tube. Record review of CR#1's care plan revealed the resident was fed via a feeding tube due to dysphagia. CR#1 will be free from aspiration. Intervention: monitor/document and report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Tube dysfunction or malfunction, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Record review of nurse's notes written on [DATE] by LVN T revealed resident returned to facility via ambulance with [family member accompanying resident. Resident in stable condition. Vital signs within normal limit. incontinent b/b. NPO. continues feeding of diabetisource 70ml/hr. 40ml/hr. flush. Antibiotic noted for UTI, resident bedbound. total assist x1. stage 3 wound @ L hip and wound @ ankle. resident lying in bed watching TV. bed in lowest position. call light in reach. will continue to monitor. Record review of Resident #1s' Physician Orders revealed the following orders dated: [DATE]: Check G-tube placement by aspirating gastric contents before feeding or before giving medications, every shift. [DATE] nurses' revealed start date [DATE]: G-tube: h2o 30-50 ml PGT before and after medication administration - monitor q shift. G-tube: h2o 5-10 ml PGT between each medication - monitor q shift. G-tube: check for residual prior to feeding / medication administration q shift. hold feeding / medication & notify MD if residual > 100 ml. Record review of the nurse's progress notes revealed no documentation regarding CR#1's activities on [DATE] in the day until 9:05pm when CR#1 became unresponsive and was sent to the hospital via 911. Record of the CR#1's assessment sheet revealed no assessment for CR#1 during the morning of [DATE]. Record review of the hospital notes dated [DATE] revealed that 911 was called at 9:22pm and CR#1 was sent to the hospital as per family request, the resident coded and was rerouted to a hospital closer to the facility. Record review of the hospital documentation dated [DATE] revealed CR#1 coded CPR initiated, and the cause of the resident death was cardiac arrest. Record review of the Autopsy Report dated [DATE] read in part . date of death [DATE]. Respiratory System: Aspirate foreign material consistent with gastric content - trachea, right and left bronchi and lungs. Pulmonary congestion and edema (combined weight 1105 grams) [PHONE NUMBER] grams (Right and left lobes lungs). Serous effusion (approximately 150 ml) right pleural cavity. Gastrointestinal System: Severe fecal impaction with dilated rectum. Polyp (up to 1.2 cm) descending colon. Status - Post gastrotomy placement in tack Hepatic and Binary System Atrophy (820grams: ref: [PHONE NUMBER]), liver. Cholelithiasis (multiple pigmented gallstones - up to 1.2cm), gallbladder. Genitourinary System: Probable benign nephrosclerosis, right and left kidney. Opinion: Based on the findings of the reasonable medical probability investigation information available at this time it is the opinion the decedent CR#1 died as a result of aspiration complicated of atherosclerotic cardiovascular diseases. In an interview on [DATE] at 1:50pm LVN B said he worked with CR#1 on [DATE] and he did not see any change in her condition. He said she did not vomit on his shift, and no one told him that she was vomiting. Further interview with LVN B, he said he gave CR#1 her medication that morning and he did not see any vomit on her. In an interview on [DATE] at 2:10 p.m. LVN A said she worked with CR#1 on [DATE] and she did not see any change in her condition, and she did not see her vomiting, nor did she see any vomit on her. She said she was new and was working with another nurse but did not remember what time she saw CR#1. In an interview with CNA G on [DATE] at 2:15pm she said she provided care to CR#1 on [DATE] and she did not see her vomiting and she did not see any vomit on her, and she did not see any change in her condition. She said if there was any change in the resident's condition, she would report it to the nurse. She was asked at what time did she see CR#1 and she said the beginning of her shift and the next time was when she was passing breakfast tray around 8.00 am, she peeped at her at from the door of the room and she was okay . She was asked when was next time after 8:00am that she saw CR#1, she said she could not give a direct time. She was asked who turned the feeding pump off when care was provided to residents with a feeding tube. She said, if the nurse was not available, she would turn the pump off and on. When asked if she had permission to turn the pump off and on, CNA G did not answer. Observation on [DATE] at 3:00pm of the motion camera footage (a camera that only records when it detects motion in the field of vision) dated [DATE] at 7:15 am revealed CR#1 was in bed with the head of the bed elevated, her left hand was resting on her stomach and was contacted to the lower extremities. Observation revealed the resident vomited up large amount of brown liquid emesis all over her neck, stomach, and running down her left hand. Further observation revealed the CR#1 was lying in her vomit and no one checked on her every two hours as per facility policy. Observation of the camera footage dated [DATE] at 11:15 am four hours later a CNA that was later identified as CNA H went in the room to check on CR#1. She pulled back the covers and muttered something and left the room. She later returned with three aides who were later identified as CNA G, CNA J and CNA K. Further observation revealed CNA H and G removed the covers and started providing care to CR#1, while CNA J stood, a little way from the resident and CNA J who brought some linen, put it on the table and stood near the doorway. Observation revealed CNA G and H did not call the nurse to turn the pump off. They provided care to the resident and left the room. Further observation revealed no evidence that the nurse entered the room during and after the care. In an interview on [DATE] with LVN B at 1:00 pm, he said when he gave medication to CR#1 she was fine. He said he was never abusive to any resident. He said he took care of CR#1 and he never saw any vomit and he was not aware the resident had vomited. He was then told that there was camera footage. At that point he said he wanted to see the camera footage. Interview with CNA H on [DATE] at 10:20am she said she was assisting CNA G providing care to CR#1 and she saw what looked like milk on her bed. She said she did not report it to the nurse because she thought CNA G reported it to the Charge nurse since CR#1 was her patient. Further interview with CNA H, she said usually if there was a change in a resident's condition, she would have reported it to the nurse. Interview with CNA I on [DATE] at 10:25am, she said she was assisting CNA G and &H she did not see CR#1 vomiting and she did not see any vomit on her. She said if she saw the vomit, she would report it to the nurse. In an interview with CNA G on [DATE] at 10:30am, she said she did not see any vomit on CR#1's body. She said if there was a change in condition, she would report it to the nurse and physician and she insisted she did not see anything on CR#1's body. She said she and CNA H gave CR#1 a bed bath and she was fine. In an interview on [DATE] at 11:00 am with CNA G after she viewed the camera footage dated [DATE] she had a look of shock on her face. When asked if she was the CNA on the camera she said yes. At that point she was asked if the nurse was called to turn the feeding pump off, she said No. Further interview on [DATE] with CNA G after viewing the video, she still insisted she did not see anything wrong with CR#1 even when she saw her vomiting on the video. She was then asked at that point if pump was turned off during care and she said No. Asked if the nurse should be called, during care she said yes. Asked why she did not call the nurse she said the nurse was not around. Interview on [DATE] at 1:00pm with LVN B after viewing the camera footage he said that was a lot of vomit from CR#1. He said he did not smell any vomit, and if he had seen the vomit on CR#1 he would have cleaned her up. He said he gave CR#1 her medication around 9:00am and he assessed her G-Tube site, he checked for residual and did not see any change in her condition. He said he was not called when the staff was providing care. Further interview with LVN B he said when he gives medications to residents who were fed via feeding tubes he usually checked for placement, residual, ensuring that the head of the bed was elevated, and resident was not at risk for aspiration. He said at the end of his shift the resident looked okay. In an interview with the DON on [DATE] at 12:03pm she said she was new to the facility and was not around when the incident took place. She said her expectation was for the CNAs to observe residents and report any changes in their condition to the nurse. She said the expectation of the nurses were to do thorough assessments of residents when they do rounds, and when the CNAs report changes to them they should notify the physician of the change. She said based on the video footage there was no way anyone should have missed the vomit on CR#1. She said they have lots of work to be done and they will have to in-service the staff. She said moving forward she will ensure orders were checked and document on the MARs. Nurses will have to document any changes in resident's condition in the resident's clinical records. She said residents were to be checked on every two hours and as needed and the stop and watch will be put in place. She said there was a form at the nurse's station and the aides were expected to fill them when providing care out and give them to the nurses for follow up. In an interview with the Administrator on [DATE] at 12:10pm she said she was new to the facility but based on the situation, the IJ came because of the lack of education and training. She said some staff were practicing out of their scope of practice and ignoring what needed to be done correctly. She said there were lots of in-servicing to be done. In an interview on [DATE] at 3:52pm the MD said he was CR#1's doctor and he was not aware that she had vomited on the morning of [DATE]. He said he was called on the night of [DATE] that CR#1 had a change in condition and was not responding and he gave orders for the resident to be sent to the hospital 911. He said the resident was sent out and later died. The Administrator and DON was notified on [DATE] at 1:43 p.m ., an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on [DATE] at 1:50 P.M. and a Plan or Removal (POR) was requested. PLAN OF REMOVAL. Immediate Action Patient was discharged from facility on [DATE]. All relevant staff members were removed from the facility pending investigation. All other staff CNAs and nurses were immediately and thoroughly in serviced on G-Tube care (when performing care, a nurse is needed to disconnect patient from feeding and patient is to be pulled up in bed and HOB should be no lower than 30 degrees before having nurse to reconnect feeding. Also, report any findings they believe is vital such as patient color, vomiting or spit up to nurses, and rounding every two hours and as needed, and the degree at which a patient at risk for aspiration should be angled in bed, in-service by DON, and ADON. Signed in-service sheets reflecting education were also completed. On [DATE] and [DATE]. All nurses and nurse assistants verbalized understanding and signed in-service reflecting understanding. 1/26 and 1/ 27 Over the phone in-service completed by ADON for staff not in facility and will have in-service sign in sheets available for signing at their next scheduled work date. All involved parties, CNA, and LVN, suspended pending investigation on [DATE]. Upon further investigation, all allegations of neglect were found substantiated, and both parties were immediately terminated on 1/27. On [DATE], MD was notified of IJ, verbalized understanding. Enteral Feeding/Care Policies reviewed, and all staff, nurses and CNAs received copies and signed confirming receipt on 1/27. No changes were made to the policy. All enterally fed patients assessed by DON and ADON and orders implemented into PCC for Q2hour rounding and as needed and CNA rounding confirming completion of ADLs (Activities of Daily Living) and G-tube care requiring nurse documentation on 1/26. Change of condition in-services requiring nurses to document any change of resident outside of normal status, CNAs required to complete stop and watch forms depicting any change noticed in residents conducted by DON and ADON on 1/26 and 1/27. Orders will be integrated into the system ensuring rounding is complete every two hours, HOB are at the proper height of no lower than thirty degrees and no higher than forty-five. Orders will be implemented into system depicting times for patients to be repositioned and changed as well as any applicable physician orders, ensuring patients are attended to every two hours and as needed. Monitoring the POR on [DATE]: During the survey monitoring, the Administrator was interviewed regarding what she believed was the root cause of the IJ. The Administrator believed that a thorough assessment was not done by the nurse when medications were given to CR#1 and the aides did not report to the nurses when they saw what looked like milk on CR#1. There was a plan in place to monitor this issue, and the retraining of nursing staff and checking on residents every two hours avoid this issue occurring again. The Administrator expects the Director of Nursing to monitor all the systems daily as it relates to the IJ tags, physician notification and ensuring thorough and immediate documentation in resident medical records. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed if CR#1 was assessed properly and the CNAs reported what they saw when they were providing care the outcome might have been different. The DON plans to monitor this issue by assessing all residents that were fed via a feeding tube and document in PCC. Residents were checked every two hours and as needed. Residents that were fed via a feeding tube, bed should be set no lower than at 30 degrees angle. The DON expectations of the RN's and LVN's to follow protocols, document and report any change in condition to the doctor. The DON indicated she personally evaluated each resident, who were fed via a feeding tube. On [DATE] In-Service trainings initiated by the ADON to licensed nurses on Enteral Feeding and changes in condition. In an interview on [DATE] at 3:17pm LVN C said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:51 pm CNA B said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:57pm CNA K said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 4:00pm CNA D said he was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. He verbalized understanding of in-service provided. In an interview on [DATE] at 10:08 pm CNA E said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 10:23pm LVN D said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. The staff verbalized understanding of in-service provided. In an interview on [DATE] at 12:26pm LVN S said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 1:30pm with RN B she said she was in-service on change in condition, G-tube feeding, report to the doctor and assessing residents who are fed via a feeding tube. She verbalized understanding of the in-service provided. In an interview on [DATE] at 4:05pm LVN F said he was in-serviced on abuse neglect, change in condition, policies and regulations on what CNAs are allowed to do that is not to turn on and off the feeding pump and report change in condition to the nurses. He verbalized understanding of in-service provided. In an interview on [DATE] between 11:00am and 3:00pm with CNA I, CNA J, CNA L and CNA N they all said were in-serviced on change in condition, abuse and neglect, G-T (CNAs not to touch the pump because that was the nurse's job), reporting and documentation. They all verbalized understanding. Record review of the POR revealed in-service signatures of all medical personnel on change of condition, abuse neglect, G-tube care, charting documentation, and reporting. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 1:18pm. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm 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 interviews, observations, and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (CR #105) reviewed for treatment and services to prevent and heal pressure ulcers. 1. CR #105 was not provided wound care from 6/2/2023 through 6/10/2023 although the wound was identified as present prior to his admission on [DATE] . 2. CR #105 was not identified with wounds upon admission; skin assessments were not completed upon admission/re-admission. CR was transferred to the hospital on 6/27/23 resulting in a wound evaluation that revealed severe erythema (redness of the skin), edema (swelling caused by excess fluid accumulation in the body tissues), necrosis (premature death of body tissue), induration (an increase in the fibrous elements in tissue, usually due to inflammation or swelling, making the tissue less elastic and pliable), malodor (distinctive odors that are offensively unpleasant). The resident also required debridement (the removal of damaged tissue or foreign objects from a wound) and the wound was unstageable and measured 6.9cm long by 7.2cm wide An IJ was identified on 7/29/2023. The IJ template was provided to the facility on 7/29/2023 at 11:14 AM. While the IJ was removed on 8/4/2023, the facility remained out of compliance at a scope of pattern and a severity level of immediate jeopardy to resident health or safety because the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of further development of pressure ulcers, infections, injury, and death. Findings include: CR #105 CR #105 Record review of CR #105's admission record dated 7/28/2023 revealed a [AGE] year-old resident admitted initially on 6/2/2023 and readmitted on [DATE]. The record documented his diagnoses included congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), gastroparesis (condition that affects the normal muscle movements of the stomach), hypertension (high blood pressure), protein-calorie malnutrition (an imbalance of nutrients from your food and drinks that are needed to keep the body healthy and functioning properly), and acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days). Record review of CR #105's census report dated 9/15/2023 revealed he was admitted on [DATE]. The report documented billing stopped on 6/26/2023, resumed on 6/28/2023, and ended on 6/30/2023. Record review of CR #105's Medicare/5-Day MDS dated [DATE] revealed he had a pressure ulcer upon admission. The MDS revealed the pressure ulcer was unstageable, and it was present upon entry to the facility. The MDS documented he had three total venous (a wound caused by blood flow problems in the leg veins)/arterial ulcers (wounds caused by poor delivery of nutrient-rich blood to the lower extremities). The MDS indicated he had a pressure reducing device for his chair and bed, received nutritional or hydrational therapy for the pressure ulcer, received pressure ulcer care, and received applications of non-surgical dressings and ointments and/or medications for the injury. Record review of CR #105's admission MDS dated [DATE] with an ARD of 6/19/2023 revealed no BIMS was conducted but he had no short or long-term memory concerns, and he was able to recall the current season, the location of his room, staff names and faces, and that he was in a nursing facility. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, refusal of care, or wandering and/or elopement behaviors. Per the MDS, CR #105 required one-person assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene, and he had not walked with or without assistance. The MDS revealed he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS documented he had one unhealed, unstageable, pressure ulcer or injury upon admission. Per the MDS, CR #105 received nutrition and/or hydration interventions, pressure ulcer/injury care, application of non-surgical dressings, and application of ointments/medications as interventions to the pressure ulcer. The MDS revealed he received dialysis care. A search of the facility's EMR revealed no care plan for CR #105. The admission and 5-day MDS assessments both noted sacral ulcers upon admission. There was no documentation of location. Record review of CR #105's medical records from the discharging hospital dated 5/17/2023 revealed an ICU checklist dated 5/17/2023. The checklist documented CR #105 had a pressure ulcer and/or wound. Record review of CR #105's admission note created by The facility's PA on 6/6/2023 revealed a foot ulcer. The note did not document any other wounds. Record review of CR #105's NP/PA note dated 6/7/2023 created by The facility's PA revealed CR #105 had a left heel wound. No other wounds were noted on the record. Record review of the facility's EMR revealed the care plan dated 6/8/2023 revealed no care plan areas were created. Record review of CR #105's nurse's note created by ALVN M on 6/12/2023 revealed she had observed CR #105 on 6/10/2023 with an unstageable sacral wound. The note documented the wound was malodorous (smelling very unpleasant) with eschar (a piece of dead tissue that sheds off from the surface of the skin after an injury) and slough (layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation) and had erythema (redness) around the border. Per the note, ALVN M placed a Mepilex border (absorbent foam wound dressing) the wound bed. The note concluded CR #105 could benefit from an immediate wound care consultation. No orders related to the Mepilex were identified during the survey. Record review of CR #105's nurse's note created by ALVN M on 6/12/2023 revealed she had observed CR #105 on 6/11/2023 with an unstageable sacral wound. The note documented the wound was malodorous with eschar and slough and had erythema around the border. Per the note, ALVN M placed a Mepilex border on the wound bed. The note concluded CR #105 could benefit from an immediate wound care consultation. No orders related to the Mepilex were identified during the survey. Record review CR #105's dialysis communication record created by the dialysis facility and dated 6/12/2023 revealed an admission/readmission charge nurse report dated 6/1/2023 noting he had an unstageable sacral wound . Record review of a NP/PA note created 6/13/2023 by The facility's PA revealed he had observed CR #105's sacral wound on 6/12/2023 and called for continued local care. Record review of a physician's order dated 6/13/2023 revealed The facility's MD ordered a wound consultation from The WC physician for CR #105's sacral wound. Record review of a physician's order dated 6/18/2023 revealed The facility's MD ordered CR #105's sacral wound be cleansed with normal saline, patted dry, and have calcium alginate (non-woven, absorbent dressings made from seaweed used to treat pressure wounds)and a dry dressing applied. Record review of CR #105's Braden Scale for predicting pressure sore risk dated 6/22/2023 revealed a score of 16. The score indicated CR #105 was at risk for development of pressure injuries. Record review of CR #105's weekly skin assessment dated [DATE] revealed his skin color was normal, was warm, and the tugor was normal. The assessment documented a wound to CR #105's sacrum. The note did not document the size of the wound, but documented it was unstageable. Record review of CR #105's physician's order dated 6/22/2023 revealed The facility's MD ordered CR #105's unstageable sacral wound be cleansed with saline, patted dry, and have Santyl (product used to treat and aid in the healing of burns and skin ulcers) and dry dressing applied daily. Record review of CR #105's nurse's note created 6/23/2023 by LVN D revealed CR #105 sacrum was evaluated by The WC physician. The note documented The WC physician removed dead tissue and ordered Med-i-Honey (wound and burn dressing), alginate, and an air mattress. There was no documentation of the cause of the delay in the evaluation by the wound care physician. Record review of CR #105s's progress note from the facility's contracted wound physicians dated 6/27/2023 revealed CR #105 was not seen due to a non-wound related hospitalization. The note documented CR #105's physician was the facility's wound care physician. Record review of CR #105's after visit summary and discharge instructions from an unrelated hospitalization dated 6/29/2023 revealed a wound care evaluation and treatment plan with a date of service of 6/27/2023. The wound care evaluation documented his diagnosis was impaired integumentary integrity associated with skin involvement extending into fascia (thin, fibrous connective tissue), muscle or bone, and scar formation. The evaluation noted the consultation was ordered for CR #105 for an unstageable sacral pressure injury. Per the evaluation, the wound had severe erythema (redness), edema (swelling caused due to excess fluid accumulation in the body tissues), necrosis (premature death of body tissue), induration (an increase in the fibrous elements in tissue commonly associated with inflammation and marked by loss of elasticity and pliability), and malodor. The evaluation revealed a recommendation of a surgical consultation for CR #105. The evaluation documented he had precautions for fragile skin and a high risk of obtaining future pressure injuries. Per the evaluation CR #105's pressure injury was debrided of non-viable tissue. The evaluation revealed CR #105 reported he was unable to lay on his back due to severe pain from the sacral wound. The evaluation documented he reported his pain in the sacrum was an eight out of ten. Per the evaluation the sacral pressure injury was unstageable and measured 6.9cm long by 7.2cm wide. The evaluation documented the wound tissue was 80% eschar (a collection of dry, dead tissue within a wound) and 20% slough (layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation). The evaluation revealed the wound treatment included copious irrigation with wound cleanser (washing the wound with wound cleanser) and sharp debridement (procedure to remove debris or infected/dead tissue from a wound) to the subcutaneous (under the skin) tissue. Per the evaluation, CR #105 was educated on the wound care plan, the wound's appearance, choices in wound dressings, and the need to make frequent position changes to prevent further skin break down. Record review of CR #105's weekly skin assessment dated [DATE] revealed he had a sacral pressure wound and an IV port in his left shoulder. The assessment documented his skin was normal colored, warm, and had normal tugor. The note did not document the size of the wound, but documented it was unstageable. Record review of CR #105's nurse's note dated 6/29/2023 revealed it was created by the WN. The note documented he was assessed by the WN and was observed with an ongoing wound to the sacral area with dark slough. Per the note, the WN cleansed the wound and treated it with a dry dressing. Record review of CR #105's nurse's note created by LVN E and dated 6/30/2023 revealed he was observed by the nurse lying in his bed with chils. The note documented vital signs were taken and his oxygen saturation levels were unable to be obtained. Per the note, CR #105 was having shortness of breath and was confused. The note revealed the facility's PA ordered CR #105 be taken to the emergency room for possible sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). The note documented 911 was called, EMS arrived, and he was transported to a local hospital for treatment and care. Record review of CR #105's June TAR revealed his sacral wound was cleansed with normal saline, patted dry, and calcium alginate and a dry dressing were applied on 6/20, 6/21, and 6/22/2023. The TAR documented that order was discontinued on 6/22/2023. Per the TAR, CR #105's unstageable sacral wound was cleansed with normal saline, patted dry, and Santyl and a dry dressing were applied on 6/23, 6/25 and 6/29/2023. The TAR revealed an order for Medihoney to be applied daily beginning 6/24/2023 and it was applied on 6/25 and 6/29/2023. CR #105 was not present at the facility on 6/26 and 6/27/2023, and he returned on 6/28/2023. CR #105 discharged on 6/30/2023. Review of the TAR revealed no physician's orders for wound care prior to 6/19/2023. Record review of the medication report dated 7/28/2023 revealed prescriptions active on 6/30/2023 Ecotrin 325mg delayed release tablet one tablet once daily for congestive heart failure, Gabapentin 300mg tablet one tablet three times daily for convulsions, Metoprolol Tartrate 25mg tablet give ½ tablet (12.5mg) once daily for hypertension, Plavix 75mg oral tablet one tablet once daily for congestive heart failure, and Ultram 50mg tablet once every twelve hours as needed for pain. The Ultram was prescribed on 6/21/2023. Record review of CR #105's June MAR revealed he was administered one 325mg tablet of Ecotrin daily from 6/2/2023 through 6/26/2023 and on 6/29/2023 at 9:00 AM. The MAR documented he was administered one 300mg tablet of Gabapentin daily at 9:00 AM, 1:00 PM, and 5:00 PM from 6/2/2023 through 6/26/2023 and on 6/29/2023. Per the MAR he was administered ½ of a 25mg tablet of Metoprolol Tartrate for a total of 12.5 mg of the medication daily at 9:00 AM from 6/15/2023 through 6/26/2023 and 6/29/2023. The MAR revealed CR #105 was administered a 75mg tablet of Plavix at 9:00 AM from 6/2/2023 through 6/21/2023, it was held on 6/22 through 6/25/2023, and was administered on 6/26 and 6/29/2023. The MAR had no documentation of administration of Ultram during the month. Record review of CR #105's medical records from the hospital he was admitted to dated 8/4/2023 pages one through three revealed his admission form reported information for services provided between 6/30/2023 and 7/31/2023. Per the admission form, his diagnoses included ESRD (End Stage Renal Disease, occurs when chronic kidney disease, or the gradual loss of kidney function, reaches an advanced state), septic shock (widespread infection causing organ failure and dangerously low blood pressure), pressure injury of the sacral region (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), and pressure injury of the buttock stage 4 unspecified laterality (full thickness ulcer with the involvement of the muscle or bone). The admission form documented CR #105's admission type was emergency, he was admitted [DATE] at 6:25 AM, he was transferred from an outside hospital. The admission form documented surgery was performed on CR #105 on 7/1, 7/3, 7/4, 7/6, 7/8, and 7/26/2023. Record review of CR #105's medical records dated 8/4/2023 page four included admission orders from 6/26/2023 through 7/31/2023. The orders revealed his admitting diagnosis was sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). The orders documented his level of care was critical care and his expected level of care was three to four days. Record review of CR #105's medical records dated 8/4/2023 page thirty-three through page forty-one included H&P notes dated 6/30/2023. The H&P (History and Physical) notes revealed CR #105's problem list included septic shock with a likely source of a sacral decubitus ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) infection versus UTI (Urinary Tract Infection, infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). The note documented CR #105's sacral decubitus ulcer was present at admission. Per the note, a recent previous hospitalization for sepsis/pneumonia put him at a higher risk for drug resistant organisms. The note read in part .This patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently . Record review of CR #105's medical records dated 8/4/2023 page 42 through page 116 included a consult group 1 notes from 6/30/2023 through 7/12/2023. The notes revealed on 6/30/2023 nephrologist (medical doctor of the branch of medicine that deals with the physiology and diseases of the kidneys) documentation read in part .CR #105 is a [AGE] year old male with history of ESRD on HD [hemodialysis (treatment for ESRD in which the blood is filtered via an external machine)], CHF [congestive heart failure (condition in which the heart cannot pump enough blood to the body's other organs)], CAD [Coronary Artery Disease (condition where the major blood vessels supplying the heart are narrowed)], DM [Diabetes Mellitus] admitted with septic shock from sacral decubitus ulcer vs UTI . The note documented CR #105's diagnosis was septic shock. The notes included a wound care note from 7/1/2023, beginning on page 50, documenting a photo of an unstageable necrotic sacral decubitus wound. The photo was documented by a hospital wound care RN as appearing to be covered with 95% black unstageable necrotic tissue. The wound care note documented recommended a general surgical consultation for debridement or pulse lavage therapy (delivery of an irrigating solution under pressure that is produced by an electrically powered device). The wound care notes included an order for application of Vashe (medication used for pressure ulcers) wet to dry dressing daily. The consult group 1 notes also included an attestation by a Doctor of Osteopathic Medicine dated 7/1/2023, on page 51, which read in part .We would recommend emergent OR [operating room] for debridement of infection decubitus ulcer as possible cause of his septic shock . The consult group 1 notes revealed an assessment and plan dated 7/1/2023 documenting a surgical debridement on 7/1/2023 beginning on page 57. The assessment and plan documented significant findings including necrotic tissue (premature death of body tissue) with purulence (consisting of, containing, or discharging pus) down to sacral periosteum (the sheath outside your bones that supplies them with blood, nerves and the cells that help them grow and heal) undermining (a separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface) with tracks interior down both gluteal muscles, and on right lower back. The consult group 1 notes included radiology results dated 7/1/2023 on page 62 through page 66. The results revealed CR #105's radiological examination impression documented a sacral decubitus ulcer with gas extending to the level of the dorsal aspect of the distal scrum/coccyx without discrete collection or osseus destructive change. The impression further documented there were foci of gas extending into the gluteal musculature bilaterally. The consult group 1 notes included a palliative care consult note dated 7/10/2023 on page 99 through page 104. The palliative care note revealed he had been intubated and was extubated on 7/10/2023. The note documented CR #105 had surgical debridement of his sacral wound on 7/3, 7/4, and 7/6 2023. Interview on 7/28/2023 at 10:24 AM with CR #105's family member, she said she had multiple concerns related to the care provided to CR #105 by the facility staff . CR #105's family member said he had been left in his feces for hours at a time on multiple occasions. CR #105's family member said because of this lack of care CR #105 developed an infection which progressed to sepsis . CR #105's family member said she was unsure if he had any open wounds and/or injuries when he admitted to the facility. CR #105's family member said CR #105 had scar tissue from cancer treatments in the past, and that skin was less stable than the surrounding skin. CR #105's family member said CR #105 developed a large open wound while in care at the facility. The family member said CR #105 was sent to the local hospital due to the sepsis. CR #105's family member said when CR #105 was admitted to the hospital, the hospital staff immediately called her and requested permission to perform surgery . CR #105's family member said she was informed by the hospital if the surgery was not completed CR #105 would likely die. CR #105's family member said CR #105 was not doing well currently, had five surgeries on the wound, and remained hospitalized . CR #105's family member said she was especially upset because when CR #105 had admitted , he was at the facility for skilled nursing and therapy to return home and he was not provided appropriate care and ended worse than when he admitted . Interview on 7/28/2023 at 11:51 AM with DON C, she said her expectations were for an assigned wound care nurse to compete the wound care for all residents with wounds. DON C said she would also expect the wound care nurse to address resident treatment plans to ensure compliance, monitor weights, and complete assessments and audits for other areas of concern. DON C said the assigned wound care nurse would be responsible for all wound care on Monday through Friday, and that the Weekend RN supervisor would be responsible for wound care on Saturdays and Sundays . DON C said there were six wounds in the building . DON C said the admission information which should be obtained and signed on admission included consents, financial information, baseline information from the referring hospital and an admission assessment . DON C said the facility's EHR included a list of items needed at admission, and it allowed the admitting staff to attach those files and upload them to the EHR. DON C said this should be done within 24 hours. DON C said the nurse on the hall the resident is admitted to is responsible for completion of the admission information. DON C said the ADON should be responsible for skin integrity sweeps at the facility. DON C said CAN's CNA's should communicate changes of condition, including skin issues, with their charge nurse who would in turn report that to the wound care nurse, DON, and/or ADON. DON C said a wound care physician should evaluate and create wound care orders. DON C said an assigned wound care nurse would then inform the staff of the orders. DON C said she preferred a wound care company to provide wound care. DON C said a Braden assessment should be done on admission and then quarterly. DON C said the Braden assessment should be completed within the first week the resident was admitted . DON C said if a resident with a pressure wound did not receive wound care that would be neglect of the resident. DON C said if a wound did not receive care, it could get worse, and infection could set in. DON C said the infections could include MRSA and staff infection. Telephone interview was attempted with the former wound care nurse on 7/28/2023 at 12:17 PM. The call was unsuccessful as there was no answer and no voice message was available. Telephone contact was attempted on 7/28/2023 at 2:24 with personnel at the temporary staffing agency whom the facility contracted with, to obtain the telephone number for the temporary nurse who created the nurse's notes on 6/10 and 6/11/2023. The telephone contact was unsuccessful as there was no answer. A voice message was left requesting a return call. Interview on 7/29/2023 at 9:29 AM with DON C, she said she would expect a resident returning from the hospital with an open unstageable wound to have new physician's orders, or the facility to obtain new physician's orders for wound care . Observation on 8/1/2023 at 2:01 PM of CR #105 revealed he was sleeping on an air mattress in the ICU of a local hospital CR #105 had a catheter and IV in place. CR #105 was covered by a sheet . Interview on 8/1/2023 at 2:30 PM with Hospital RN A, RN at the hospital CR #105 was admitted to, she said she had been assigned to provide care to CR #105 on 8/1/2023. Hospital RN A said a palliative care meeting was held with CR #105's family earlier on 8/1/2023 and she was unsure of the outcome of the meeting, or the decisions the family made regarding CR #105's care. Hospital RN A said her understanding of CR #105's current condition was that the wound would not heal and was most likely terminal. Hospital RN A said CR #105 was no longer a candidate for surgery. Hospital RN A said CR #105's sacral wound would not heal without an ostomy (surgery to create an opening, or stoma, from an area inside the body to the outside). Hospital RN A said she was unsure of the decisions the family would make regarding CR #105's wound and possible end of life care. Hospital RN A said she could not say if CR #105's lack of wound care at his previous placement could have led to the current, possible, terminal sacral wound. Email received on 8/7/2023 at 9:28 AM from CR #105's family member revealed that CR #105 died at the hospital on 8/6/2023. The following Plan of Removal submitted by the facility was accepted on 7/14/23 at 2:24 p.m. Date: 07/13/2023, Revision Date: 7/14/23 The following are the Action Plan for Plan of Removal for F692: Weights 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. 1. Immediate action: Resident #31 was seen and assessed by Registered Dietician (RD) on 7/12/2023 and reviewed current condition and weight loss of resident. Per RD, Resident #31 has a history of dementia, AMS, Type 2 diabetes , Constipation, Dysphagia leading to PEG dependence. Resident #31 per RD has chronic disease state that made it difficult to improve PEM / inflammation state despite being on a higher basal energy expenditure (BEE ) Peg feeding schedule. Resident #31 per RD 's review includes 3 month a decline of 7.5% wt.= 126.4lbs, BMI= 21.4 and a staff report of enteral formula tolerance of Fibersource @60ml/hr added protein 30ml twice a day and water to provide 1500 calories/ 70 gm protien,1.2 L free water. Per RD, current intervention Resident #31 is to provide his BEE needs goals. The plan of care for Resident #31 was updated to reflect new goals of treatment to meet BEE goals. Attending physician and responsible party have been notified on 7/13/2023. 2. Immediate action: Resident #32 was seen and assessed by Registered Dietician (RD) on 7/12/2023 and reviewed current condition and weight loss. Resident #31's current weight is 127lbs which reflects a 7.5% weight loss in 3 months. Per RD, Resident #32 has a history of losing weight due to liking high carbohydrates & eating less Protein. Per RD, Resident #32 is currently on appetite stimulant and supplement (Remeron & Med pass) to help improve nutritional status. Per RD recommendations on 7/12/23, Resident #32 will be provided with a fortified food plan based on food preferences and to also add Multivitamin with Iron and Fish Oil 1,000 mg. The plan of care for Resident #32 was updated to reflect new interventions for weight loss. Attending physician and responsible party have been notified on 7/13/2023. 3. Immediate action: Resident #18 was seen and assessed by Registered Dietician (RD) on 7/12/2023 and reviewed current condition and weight loss of resident. Per RD, Resident #18 has a history of chronic disease, diabetes mellitus Type 2 uncontrolled, CHF , edema, constipation, anemic, down syndrome with limited mobility and uses a wheelchair with current weight of 239lbs, with an initial weight on 4/14/23 of 303 lbs. which is about 164% IBW , BMI 38.6. Per RD, Resident 18's recommendation is to improve mobility and decrease caloric intake. Per RD, Resident #18's intervention is working due to a decrease of 10% in the last 3 months with noted increase in energy and to continue current interventions. The care plan for Resident #18 has been updated to include weight loss planned diet. Attending physician and responsible party have been notified on 7/13/2023. 4. Immediate action: Resident #4 was seen and assessed by Registered Dietician (RD) on 7/12/2023 and reviewed current condition and weight loss of resident. Per RD, Resident #4 has a history of chronic disease, Alzheimer's disease, behavior issues, HTN, CVD with a small appetite. Per RD, Resident #4 is currently on Remeron and medpass already with weight of 128 lbs., IBW 83% and BMI of 19.5. Per RD, Resident #4 will be monitored at this time and make adjustments to intervention as needed. Attending physician and responsible party have been notified on 7/13/2023. 5. Immediate action: Resident #89 was seen and assessed by Registered Dietician (RD) on 7/12/2023 and reviewed current condition and weight loss of resident. Per RD, Resident #89 has a history of chronic disease and no teeth and is unwilling to eat puree diet at this time. Resident #89's meal intake is being monitored with alternatives being offered. Per RD, Resident #89 had a decline of 5% in 30 days with a current weight of 134 lbs., IBW is 83% with BMI of 19.7. Per RD recommendations on 7/13/23, offer Medpass of 90ml if Resident #89 eats less than 70% of meals. Attending physician and responsible party have been notified on 7/13/2023. 6. Immediate action: Registered Dietician has been hired with contract signed and RD began seeing patients as of 7/12/23. 2. Governing Body - QAPI committee a. NHA will monitor corrective actions through on-going compliance and results of audit for weight management and assessment of nutrition and hydration management and intervention monthly. The DON and NHA will report the results of monitoring to the Quality Assurance Performance Improvement (QAPI) Committee for review and recommendations at least every 3 months during QAPI meetings until compliance is achieved. b. Monitoring of the implementation of the Plan of Removal shall be done by the DON and or Designee and Administrator weekly for one month until compliance is achieved. c. RCA: A root cause analysis will be conducted by the QAPI team to determine further interventions for the deficient practice on weight loss prevention and management completed on 7/13/23 during the QAPI Ad Hoc Meeting. d. Immediate Action: Review of nutritional program and policies, including the new procedures with IDT meeting and review to be completed weekly was reviewed on 7/13/2023 through an ad hoc meeting via telephone conference with the Medical Director, DON, ADON/IP and NHA. e. The QAPI Committee will monitor the process every month for 3 months until compliance is achieved. 3. Specific staff involved in implementing the corrective actions. a. Medical Director, Administrator, Director of Nursing, Assistant Director of Nurses, Maintenance Staff, Registered Dietician, Dietary Manager, Social Services and Activity Director 4. Identification of other residents who may need to be included (who may have been affec[TRUNCATED]