**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents. The facility failed to ensure Resident #1 who was a fall risk, had precautions in place to prevent Resident #1 from falling in the dining room on 10/30/2024. Resident #1 was left alone in the dining room by staff and fell out of his wheelchair. He sustained a bilateral subdural hematoma and was hospitalized . Resident #1 had a fall on 10/28/24 from his bed in which he sustained a hematoma. The noncompliance was identified as PNC IJ. The noncompliance began on 10/30/24 and ended on 10/31/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet printed 11/01/2024, reflected an [AGE] year-old male who was admitted to the facility initially on 10/14/2022 and readmitted on [DATE] with diagnoses to include but not limited too Dementia, unspecified severity without behavioral disturbance , psychotic disturbance, mood disturbance ( term used to describe a group of symptoms affecting memory, thinking and social abilities), acute kidney failure( a condition in which the kidney stops working suddenly) and difficulty in walking. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 3 which indicated severe cognate impairment. Functional abilities included supervision/ touching assistance with eating, oral hygiene, toileting, upper body dressing and person hygiene. Resident#1 required partial/moderate assistance with shower/baths, lower body dressing, putting on/taking off footwear. Review of section J health conditions revealed Resident #1 had two or more falls since admission/ reentry. Record review of Resident #1s care plan revised 08/05/2024 reflected, Resident #1 at risk for multiple falls with interventions that included educate resident, family and caregivers about safety, floor mat while resident is in bed, remind resident to use call light for assistance, therapy evaluation as needed. Review of nursing notes dated 10/28/24 at 4:49 AM authored by LVN A revealed CNA went in to do his rounds and noted resident on the floor beside his floor mate. Upon assessment, nurse noted a hematoma and some bleeding at the right side of resident's forehead. Resident was restless and agitated, refusing first aid. Resident report pain to his head. EMS was called in for resident to be transported for further evaluation in the Hospital. Vitals were, BP 149/107, Pulse 77, 02 96, R 20 and T 97.9. Dr [name of Dr], DON and Family notified. Record review of Resident #1's fall risk assessment dated [DATE], reflected a score of 16, which indicated a high risk for falling. Review of hospital records dated 10/28/2024 revealed Resident #1 had a fall 10/28/24 due to rolling out of bed and hitting his head, resident was transferred to hospital and diagnosed with Hematoma of the scalp. Review of Resident #1's nursing notes dated 10/30/24 at 4:40PM authored by LNV A revealed BP-143/48. T-97.8. P-80. R-18. BS-na{Sic].Resident had a fall. Location: Dining Room. Fall information: Unwitnessed, Hit Head, Cognition / Behavior at Time of Event: Cognitive Impairment, The fall caused a skin tear to Lateral forehead. New / bleeding, At 14:40 staff was taking residents to dining room for dinner. While bringing other residents to the dining room they noted [Resident #1] on the floor. Other residents stated he stood up from his w/c in attempt to walk and stumbled. Resident is sometimes impulsive and forgets his gait is unsteady. Resident was lying on his left side in the dining area. Laceration noted to left forehead with some bleeding. Emergency first aid rendered and 911 called. Neuro [SIC] implemented. Resident sent [SIC] ER Appears and/or states to be in pain. Describes the pain as: Initial Treatment/New Orders: Resident has UTI and is being treated with antibiotics. Resident Statement: Resident has dementia and unable to state what happened .Name of MD/NP notified:[physician name] Date/time of notification: 10/30/2024 4:43 PM . Name of RP notified:[family member name] Date/time of notification: 10/30/2024 2:42 PM. Review of the nursing notes dated 10/01/2024- 11/01//2024 revealed the resident had fall on 02/19/2024, 4/13/2024, 9/19/2024, 10/28/2024 and 10/30/24. Review of hospital records dated 10/30/2024 revealed Resident #1 went to hospital and was diagnosed with bilateral subdural hematoma due to a fall in the dining area and was asymptomatic however due to having advance dementia and DNR resident was unlikely a candidate for operative intervention if needed. Per hospital notes resident was transferred to another hospital for higher level of care due to two falls which resulted in Hematomas. Interview on 11/01/2024 at 12:30 PM with LVN D revealed there was typically a nurse sitting at the dining area during meal times and CNA's on the hall assiting residents to the dining area. LVN D stated she was not on shift when Resident #1 fell in the dining area. LVN D stated she did particpate in a in- service yesterday regarding fall prevention and change in condition. LVN D stated all residents who were a fall risk had fall mats beside, lowered beds and call ligts within reach. Interview on 11/01/2024 at 1:38 PM with CNA D revealed she was not working when Resident #1 fell. CNA D stated she particpated in the in-service regarding fall prevention and change in condition. CNA D stated for residents who were a fall risk fall mats were beside, bed at lowest position and call lights were within reach. Interview on 11/01/2024 at 2:14PM with LVN B revealed he was the nurse working on 10/30/2024. He stated CNA C and himself were taking residents to the dining area. He stated he and CNA C were out of the dining area around the same time getting other residents and a resident pulled the fire alarm. He stated when he got back to the dining area Resident#1 was on the floor. He stated he assessed Resident #1 for injures and called 911 due to bleeding from the head. LVN B stated Resident #1 tried to stand up from his wheelchair and fell according to other residents in the dining area. LVN B stated typically there was one person always in the dining area with residents however it just happened that he and CNA C were out of the dining area at the same time. LVN B stated Resident #1 was a fall risk and always wanted to stand up however LVN B stated he was not aware that Resident #1 had strength to stand on his own. LVN B stated Resident #1 did have a fall mat beside his bed due to being a fall risk. LVN B stated the facility conducted a in- service regarding fall prevention and change in condition. LVN B stated for residents that were a fall risk, fall mats were bedside, beds at the lowest position and call lights were within reach. Interview on 11/01/2024 at 2:24 PM with the administrator revealed Resident #1 had a fall from his bed on 10/28/2024 however interventions such as fall mat, lowered bed and call light within reach were in place and no new interventions were added. The Administrator stated on 10/30/2024 Resident #1 fell from his wheelchair attempting to stand up which was different from previous falls. The administrator stated the interventions that were in place were due to falls from the bed or sitting and not standing falls. The Administrator stated following the fall on 10/30/2024 new interventions would be put in place to include a helmet for Resident #1. The Administrator stated Residents do not have one on supervision and there was no way staff could always have eyes on Resident #1. In phone interview on 11/05/2024 at 11:48 AM via phone with CNA C revealed she had worked in the facility for 1 year. She stated she did not always work on Resident #1's hall however when she had worked with him she did not know that he was a fall risk. CNA A stated she was not sure if Resident #1 had a fall mat beside his bed. CNA C stated Resident #1 was in the dining area while she left to get another resident changed and transferred to the dining area. She stated she was gone about 5-7 minutes and when she returned Resident #1 was on the floor. CNA C stated she alerted the nurse immediately and the resident was assessed by the nurse. The facility self-reported the 10/30/2024 fall and completed a quapi meeting on 10/31/2024. On 10/31/2024 the facility updated fall risk assessments and care plans for all residents who were fall risk. The facility completed in- services all staff on 10/31/2024 on preventive strategies to reduce falls, falls/ ambulation difficulty, change in condition. Review of the facility policy Preventive Strategies to Reduce Fall Risk revised October 5, 2016, revealed After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement of (Resident #6) 1 of 7 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to adequately assess, supervise, and implement care interventions for Resident #6 to prevent an elopement from the facility on 11/05/2023 for approximately 10-20 minutes. 2. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. An IJ was identified on 11/16/2023 at 5:30 PM. The IJ template was provided to the Administrator and DON on 11/16/2023 at 5:46 PM. While the IJ was removed on 11/18/2023 at 4:13 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm. This failure could place residents requiring supervision at risk for serious injury and death. Findings included: Review of Resident #6's Face Sheet on 11/16/2023 at 10:34am revealed he was a [AGE] year-old male re-admitted to the facility 01/07/2022 from an inpatient psychiatric facility. Relevant diagnoses included Alzheimer's disease (progressive memory loss,) Parkinson's Disease (progressive movement disorder of the nervous system,) Bipolar Disorder(mental health condition that causes mood swings, and emotional high and lows,) Unspecified Psychosis (loss of reality,) Schizophrenia (mental illness that affects the perception of reality,) Major Depressive Disorder (persistent low or depressed mood,) Type 2 Diabetes (dysfunction of the way the body regulates sugar as fuel,) Unspecified Mood Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, and Contractures of hand. Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed he was assessed as severely cognitively impaired with a BIMS score of 00. Resident utilized a walker and a manual wheelchair for mobility. He required partial/moderate assistance with transfers and ADL care (eating, dressing, and bathing, etc.) Resident required routine monitoring that included daily wound care and antipsychotic administration. Review of Resident #6's Comprehensive Care Plan dated 10/11/2023, revealed: Wandering: [Resident #6] wanders and is at risk for injury. (approach exit doors) Wandering behaviors are related to Dementia, Sun downing ( a state of confusion occurring in the late afternoon and lasting into the night) . Date Initiated: 06/09/2021 Revision on: 06/09/2021 . with a goal that included: [Resident #6] will not leave facility unattended through the next review date. Date Initiated: 06/09/2021 Revision on: 01/26/2022 Target Date: 12/31/2023 . with intervention that included to Monitor location every (15/30/60) min./PRN Document wandering behavior and attempted diversional interventions in behavior log . Date Initiated: 06/09/2021 Revision on: 09/13/2022 . Review of Resident #6's GRNTX-Wandering Risk Assessment, dated 02/15/2022 at 4:59am revealed Resident #6 was a low elopement risk at 04. The risk assessment stated he was forgetful/short attention span, ambulates with one assist, has dementia with psychosis, and received antidepressants. During a look back period of 02/16/2022 and 11/04/2023, no evidence of ongoing or quarterly assessments were completed related to Resident #6's wandering and/or elopement risk. Review of Resident #6's Elopement Risk Assessment - V4 completed post elopement on 11/05/2023, stated Resident #6 was scored as high risk at 12. The risk assessment stated he was not bedfast, was not on a secured unit, and could self-propel himself in a wheelchair. The assessment further stated that he had made statements and/or threats to leave the facility, made requests to go home, has confused expressions, and verbalized anger and frustration related to his placement. His cognitive skills for daily decision making were severely impaired. He exhibited aggressive behavior. Attempts to interview Resident #6 were made on 11/14/2023 at 10:43 AM, 11/15/2023 at 11:10 AM and 1:51 PM, and 11/16/2023 at 10:05 AM and the resident was not able to recall his elopement. In interview with RN F on 11/16/2023 at 11:20 AM, she stated Resident #6 exhibited wandering behaviors and agitation the night prior to his elopement on 11/05/2023 and required re-direction from her and other staff members to return to his room. She stated during her overnight shift, she was rounding on Resident #6 every two hours. She stated the next morning, she observed Resident #6 in his room at approximately 5:00am. RN F stated she went to provide care to another resident and then heard the side door alarm approximately 10-20 minutes later. At this time, she observed local paramedics returning Resident #6 to the facility via the side door that was alarming. She stated that he did not have wandering behaviors that would warrant more frequent monitoring, additional assessment, or intervention. She stated she did not know if Resident #6 was high risk for elopement or had any elopements in the past. When asked how Resident #6 got out of the facility, she stated she could not say . She stated if a resident elopes, it could risk resident safety. In interview with DON on 11/16/2023 at 12:23 PM, she stated she received notification from her staff that Resident #6 was brought in by paramedics after a neighbor had called in a concern that a resident was outside of the building. She stated that the evening before his elopement on 11/04/2023, Resident #6 was going into other rooms, he was confused, and required staff to re-direct him back to his room. She stated she was not aware of his elopement risk as she had not been the DON at the facility for that long. She stated pre-elopement, staff were rounding on Resident #6 every two hours; but he was put on more frequent monitoring only after his elopement. She stated Resident #6 was then placed in their secured unit and has not eloped from the facility again . She stated that elopements put residents at risk and should be prevented if possible. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for staff to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on wandering behavior, elopement risk, and effective implementation of resident's care plans . She stated that elopements put residents at risk and should be prevented if possible. Review on 11/18/2023 at 11:11 AM of the weather the day of the elopement revealed a high of 79 and a low of 59 degrees Fahrenheit. < https://www.accuweather.com/en/us/rockwall/75087/november-weather/335874> Review of facility policy, Elopement Prevention, rev. 10/27/2010, revealed: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission .The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition. Review of facility policy, Comprehensive Care Planning, undated, provided by Administrator on 11/18/2023 at 9:00 AM revealed facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. On 11/16/2023 at 5:30 PM, the Administrator and DON was informed an IJ situation was identified, due to the above failures. The IJ template was provided to the facility on [DATE] at 5:46 PM and a POR was requested. The POR was accepted on 00/00/00 at 00:00 and indicated the following: Plan for Removal [Facility] November 16, 2023 An Immediate Jeopardy was cited on November 16, 2023, at 5:45 pm - F689 Accident and Hazards On 11/5/23 Resident #6 eloped from the facility via the side ambulance door. He did not have an Elopement Risk Assessment completed upon readmission to the facility. There was no evidence that he was assessed quarterly per facility policy. Resident #6 was placed in the facility's secured unit on 11/7/23. Immediate Interventions: An Ad Hoc QAPI Meeting was held on 11/16/23, attended by the Director of Nursing, Administrator, Assistant Director of Nursing, and Regional Compliance Nurse. The Medical Director participated by telephone. The Medical Director was notified of the Immediate Jeopardy on 11/16/23 at 5:50 pm. The Administrator, Director of Nursing, and Assistant Director of Nursing were in-serviced on 11/16/23 by the Regional Compliance Nurse on the following: Elopement Prevention Policy and Elopement Response Policy Elopement Risk Assessments were completed on all residents on 11/16/23 by the DON, ADON, and Regional Compliance Nurse. The Charge Nurses will be responsible for completing the Elopement Risk Assessments on admission, quarterly, and a change of condition beginning on 11/17/23 and thereafter. The DON, ADON, and Regional Compliance Nurse initiated Care Plan updates to reflect elopement risk scores on 11/16/23. Elopement Risk Assessments were set up to automatically trigger in PCC on admission and quarterly by the Regional Compliance Nurse, DON, and ADON on 11/16/23. The Director of Nursing and the Assistant Director of Nursing began in-servicing all Licensed Nurses on 11/16/23 on the following: Elopement Prevention Policy and Elopement Response Policy. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. The in-servicing will be completed by 11/17/23. No nurse will be allowed to work until the education is provided and acknowledged. The code was changed on all exit doors in the facility on 11/16/23 by the Maintenance Director. The Administrator verified that the codes have been changed. The codes will be changed monthly going forward. All staff will be notified via a message on Paycom each time the code is changed. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk assessments daily x 6 weeks to identify any residents with increased risk of elopement. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflects the risk for elopement. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments weekly for 60 days and quarterly thereafter. Beginning 11/16/23, the Administrator will verify all door codes have been changed on the 1st of each month and document such on a monthly monitoring form. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Review of facility's Elopement Prevention/Elopement Response in-service conducted by RDC dated 11/16/2023, revealed Administrator, DON, and ADON, received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility leadership revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Leadership confirmed they were in-serviced regarding ensuring elopement risk assessments are completed quarterly per facility policy and/or the significance of the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Elopement Prevention and Elopement Response in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 of staff received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding the importance of quarterly elopement risk assessments and/or the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Record review conducted on 11/18/2023 at 10:27 AM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had quarterly elopement risk assessments completed on 11/16/2023. Record review conducted on 11/18/2023 at 12:00 PM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had care plans sufficiently reflecting resident elopement risk based on the quarterly elopement risk assessments. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /16/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments daily x 6 weeks to identify and resident with increased risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes of condition to ensure Care Plans accurately reflect and risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The Administrator and DON will review Elopement Risk Assessments weekly x 60 days. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility's DON, ADON and/or designee with monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Interviews were conducted with facility staff across multiple shifts on 11/18/2023 between 9:13 AM and 12:14 PM. Administrator, DON, ADON, RN A, RN F, LVN D, LVN E, LVN H, LVN I, CNA L, CNA M, CNA N, MA O, MA P, MA Q, HSK S, Dietary Manager, and Maintenance Director were interviewed and verbally reported skills that included recognizing wandering behaviors and appropriate interventions per facility policy, protocol, and procedures. The Administrator and DON were notified the IJ was removed on 11/17/2023 at 09:35 AM, however the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being of (Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59) 7 of 14 comprehensive care plans and elopement risk assessments reviewed. 1. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. 2. The facility failed to conduct quarterly elopement risk assessments on Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 to identify any elopement risk, and the determination of any need for interventions on their comprehensive care plan to prevent elopements and ensure resident safety. An IJ was identified on 11/17/2023 at 9:30 AM. The IJ template was provided to the facility on [DATE] at 9:38 AM. While the IJ was removed on 11/18/2023 at 4:13 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because all staff had not been in-serviced/trained at the time of exit on 11/18/2023 at 4:13 PM. This failure placed residents at risk of elopement resulting in injury or death. Findings include: 1. Review of Resident #6's Face Sheet on 11/16/2023 at 10:34am revealed he was a [AGE] year-old male re-admitted to the facility 01/07/2022 from an inpatient psychiatric facility. Relevant diagnoses included Alzheimer's disease, Parkinson's Disease, Bipolar Disorder, Unspecified Psychosis, Schizophrenia, Major Depressive Disorder, Type 2 Diabetes, Unspecified Mood Disorder, Anxiety Disorder, Muscle Weakness, Lack of Coordination, and Contractures of hand. Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed he was assessed as severely cognitively impaired with a BIMS score of 00. Resident utilized a walker and a manual wheelchair for mobility. He required partial/moderate assistance with transfers and ADL care (eating, dressing, and bathing, etc.) Resident required routine monitoring that included daily wound care and antipsychotic administration. Review of Resident #6's Comprehensive Care Plan dated 10/11/2023, revealed: Wandering: [Resident #6] wanders and is at risk for injury. (approach exit doors) Wandering behaviors are related to Dementia, Sun downing ( a state of confusion occurring late in the afternoon and lasting into the night) . Date Initiated: 06/09/2021 Revision on: 06/09/2021 . with a goal that included: [Resident #6J] will not leave facility unattended through the next review date. Date Initiated: 06/09/2021 Revision on: 01/26/2022 Target Date: 12/31/2023 . with intervention that included to Monitor location every (15/30/60) min./PRN Document wandering behavior and attempted diversional interventions in behavior log . Date Initiated: 06/09/2021 Revision on: 09/13/2022 . Review of Resident #6's GRNTX-Wandering Risk Assessment, dated 02/15/2022 at 4:59am revealed Resident #6 was a low elopement risk at 04. The risk assessment stated he was forgetful/short attention span, ambulates with one assist, has dementia with psychosis, and received antidepressants. During a look back period of 02/16/2022 and 11/04/2023, no evidence of ongoing or quarterly assessments were completed related to Resident #6's wandering and/or elopement risk. Review of Resident #6's Elopement Risk Assessment - V4 completed post elopement on 11/05/2023, stated Resident #6 was scored as high risk at 12. The risk assessment stated he was not bedfast, was not on a secured unit, and could self-propel himself in a wheelchair. The assessment further stated that he had made statements and/or threats to leave the facility, made requests to go home, has confused expressions, and verbalized anger and frustration related to his placement. His cognitive skills for daily decision making were severely impaired. He exhibited aggressive behavior. Attempts to interview Resident #6 were made on 11/14/2023 at 10:43 AM, 11/15/2023 at 11:10 AM and 1:51 PM, and 11/16/2023 at 10:05 AM and the resident was not able to recall his elopement. In interview with RN F on 11/16/2023 at 11:20 AM, she stated Resident #6 exhibited wandering behaviors and agitation the night prior to his elopement on 11/05/2023 and required re-direction from her and other staff members to return to his room. She stated during her overnight shift, she was rounding on Resident #6 every two hours. She stated the next morning, she observed Resident #6 in his room at approximately 5:00am. RN F stated she went to provide care to another resident and then heard the side door alarm approximately 10-20 minutes later. At this time, she observed local paramedics returning Resident #6 the facility via the side door that was alarming. She stated that he did not have wandering behaviors that would warrant more frequent monitoring, additional assessment, or intervention. She stated she did not know if Resident #6 was high risk for elopement or had any elopements in the past. She stated she was not sure if it was on his care plan. When asked how Resident #6 got out of the facility, she stated she could not say. In interview with DON on 11/16/2023 at 12:23 PM, she stated she received notification from her staff that Resident #6 was brought in by paramedics after a neighbor had called in a concern that a resident was outside of the building. She stated that the evening before his elopement on 11/04/2023, Resident #6 was going into other rooms, he was confused, and required staff to re-direct him back to his room. She stated she was not aware of his elopement risk as she had not been the DON at the facility for that long. She stated pre-elopement, staff were rounding on Resident #6 every two hours; but he was put on more frequent monitoring after his elopement. She stated Resident #6 was then placed in their secured unit and has not eloped from the facility again. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for staff to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on wandering behavior, elopement risk, and effective implementation of resident's care plans. 2. Review of Resident #5's Face Sheet on 11/18/2023 at 12:16 PM revealed she was a [AGE] year-old female re-admitted to the facility 01/20/2022 from an acute care hospital. Relevant diagnoses included dementia, Alzheimer's disease, Parkinson's Disease (neurodegenerative disorder that results in tremors, slow movement, stiffness, and loss of balance) and post-traumatic stress disorder. Review of Resident #11's Face Sheet on 11/18/2023 at 12:15 PM revealed he was a [AGE] year-old male admitted to the facility 06/27/2023. Relevant diagnoses included dementia, Alzheimer's disease, and schizoaffective disorder - bipolar type (feelings of euphoria, racing thoughts, and risky behavior.) Review of Resident #20's Face Sheet on 11/18/2023 at 12:22 PM revealed he an [AGE] year-old male re-admitted to the facility 07/10/2023 from an acute care hospital. Relevant diagnoses included dementia, bipolar disorder, and drug induced subacute dyskinesia (movement disorder.) Review of Resident #40's Face Sheet on 11/18/2023 at 12:10 PM revealed she was a [AGE] year-old female admitted to the facility 08/05/2022. Relevant diagnoses included dementia, bipolar disorder, schizoaffective disorder (combination of depression and bipolar disorder that affect your mood,) schizophrenia, manic episode, and nicotine dependence. Review of Resident #46's Face Sheet on 11/18/2023 AT 12:11 PM revealed she was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Relevant diagnoses included schizoaffective disorder, major depressive disorder, anxiety disorder, and sleep disorder. Review of Resident #59's Face Sheet on 11/18/2023 at 12:10 PM revealed he was a [AGE] year-old male admitted to the facility 08/03/2022 from home. Relevant diagnoses included dementia, major depressive disorder, depression, anxiety disorder, and sleep disorder. During review on 11/16/2023 at 3:30 PM of Resident #5, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59's revealed no evidence of ongoing, quarterly assessments for wandering and/or elopement risk. In interview and record review with the ADON on 11/16/2023 at 3:30 PM, Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 EMR was reviewed for quarterly assessments for wandering and/or elopement risk. ADON was given the opportunity to review each resident's EMR. She stated that she could not provide or locate each resident's most recent quarterly assessment for review, and stated she did not know why it was not completed. She stated it was the DON and her responsibility to ensure it was completed on an ongoing, quarterly basis. She stated the quarterly wandering and/or elopement risk assessments assess resident risk for elopement and if scored as a high-risk, it would then trigger comprehensive care plan interventions to be implemented to prevent resident elopement. She stated if this was not completed on a quarterly basis, it could result in a resident elopement. In interview with Administrator on 11/17/2023 at 12:36 PM, she stated that her expectations were for the DON and ADON to complete assessments per company policy, care plans to be updated accordingly, and effective interventions to be implemented to prevent resident elopement. She stated that Resident #6's wandering behavior should have been reported to the DON, so she could have guided them on what interventions should be in place. She stated it was the DON's responsibility to ensure the staff were trained and educated on identification of wandering behavior, assessment of elopement risk, and effective implementation of resident's care plans. She further stated that it wasn't flagging in the EMR to complete these assessments and did not prompt leadership to re-assess each resident quarterly for wandering and/or elopement risk. She stated these assessments and interventions were important to identify residents at risk to prevent elopement. On 11/17/2023 at 9:30 AM the Administrator was informed an IJ situation was identified, due to the above failures. The IJ template was provided to the facility on [DATE] at 9:38 AM and the POR was requested. The POR was accepted on 11/17/2023 at 04:13 PM and indicated the following : Plan for Removal [Facility] November 17, 2023 An Immediate Jeopardy was cited on November 17, 2023, at 9:38 am - F656 Develop/Implement Comprehensive Care Plans. Resident #6's comprehensive care plan was revised 06/09/2021 identifying his wandering behaviors. Effective interventions were not implemented to prevent his elopement on 11/05/2023. Immediate Interventions: An Ad Hoc QAPI Meeting was held on 11/17/23, attended by the Director of Nursing, Administrator, Assistant Director of Nursing, and Regional Compliance Nurse. The Medical Director participated by telephone. The Medical Director was notified of the Immediate Jeopardy on 11/17/23 9:45 am. The Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were in-serviced on 11/17/23 by the Regional Compliance Nurse on the following: Comprehensive Care Planning Proof of training and acknowledgement of understanding is evidenced by signatures on the in-service sign-in sheet. The DON, ADON, and Regional Compliance Nurse will review all residents' Care Plans and ensure they are correctly reflecting any risk of elopement as identified on the Elopement Risk Assessments completed for every resident on 11/16/23. Elopement Risk Assessments were set up to automatically trigger in [EMR] on admission and quarterly by the Regional Compliance Nurse, DON, and ADON on 11/16/23. The DON, ADON, and/or Regional Compliance Nurse will in-service all CNAs on 11/17/23 on Care Plans; including how to access them on the POC kiosks and the importance of implementing them. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. The DON, ADON and/or the Regional Compliance Nurse will in-service all nurses on 11/17/23 on Care Plans; including how to access them in PCC and on the POC kiosks and the importance of implementing them. Proof of training and acknowledgement of understanding will be evidenced by signatures on the in-service sign-in sheet. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments and corresponding daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflect the current needs of the resident. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments and corresponding Care Plans weekly x 60 days and quarterly thereafter. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Beginning 11/17/23, the DON, ADON and/or designee will monitor all new and updated Elopement Risk assessments daily x 6 weeks to identify any residents with increased risk of elopement. Beginning 11/17/23, the DON, ADON and/or designee will monitor Care Plans weekly x 6 weeks for new admissions, quarterly reviews, and changes of condition to ensure the Care Plan accurately reflects the risk for elopement. Beginning 11/17/23, the Administrator and DON will review Elopement Risk Assessments weekly for 60 days and quarterly thereafter. Beginning 11/16/23, the Administrator will verify all door codes have been changed on the 1st of each month and document such on a monthly monitoring form. Findings will be reviewed in the monthly QAPI Meeting by the Interdisciplinary Team for no less than 60 days or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring: Review of facility's Elopement Prevention/Elopement Response in-service conducted by RDC dated 11/16/2023, revealed Administrator, DON, and ADON, received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility leadership revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Leadership confirmed they were in-serviced regarding ensuring elopement risk assessments are completed quarterly per facility policy and/or the significance of the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Comprehensive Care Plan, in-service conducted by RDC dated 11/17/2023 revealed Administrator, DON, ADON, MDS, and SW received an in-service related to the facility policy, protocol, and procedure related to resident comprehensive care plans. Interviews with facility leadership revealed they verbalized comprehension and understanding of in-service training. They stated they have been in-serviced on the importance of the development and implementation of resident comprehensive care plans. Review of facility's Elopement Prevention and Elopement Response in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 staff received an in-service related to facility policy, protocol, and procedure on elopement response. Interviews with facility staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced on elopement response (what to do if a resident elopes) and prevention (monitoring and interventions in place for residents at risk for elopement) for all residents, including those that are at risk of elopement, monitoring, and interventions for those at risk. Relevant staff were in-serviced regarding the importance of quarterly elopement risk assessments and/or the identification of and/or monitoring for exit seeking behaviors and appropriate interventions to put in place in response. Review of facility's Care Plan, in-service conducted by RDC, DON, and ADON dated 11/17/2023 revealed 30 staff received an in-service related to facility policy, protocol, and procedure on care plans. Interviews with facility staff revealed they verbalized comprehension of the in-service training. Nurses and CNAs received training on how to access resident care plans in the EMR and how to follow and implement a resident's plan of care. Interviews were conducted with facility staff across multiple shifts on 11/18/2023 between 9:13 AM and 12:14 PM. Administrator, DON, ADON, RN A, RN F, LVN D, LVN E, LVN H, LVN I, CNA L, CNA M, CNA N, MA O, MA P, MA Q, HSK S, Dietary Manager, and Maintenance Director were interviewed on the content of the in-services related to recognizing wandering behaviors and appropriate interventions per facility policy, protocol, and procedures. Additionally, relevant staff verbalized understanding of how to access resident care plans and the effective implementation of interventions listed on resident care plans. Record review conducted on 11/18/2023 at 10:27 AM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had quarterly elopement risk assessments completed on 11/16/2023. Record review of Resident #5 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:34 PM completed by the RDC revealed resident was scored as 12. Record review Resident #6 Elopement Risk Assessment - V 4 dated 11/16/2023 at 1:31 PM completed by the DON revealed resident was scored as 20. Record review of Resident #11 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:43 PM completed by the RDC revealed resident was scored as 6. Record review of Resident #20 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:57 PM completed by the RDC revealed resident was scored as 16. Record review of Resident #40 Elopement Risk Assessment - V4 dated 11/16/2023 at 12:30 PM completed by the RDC revealed resident was scored as 7.Record review of Resident #46 Elopement Risk Assessment - V4 dated 11/16/2023 at 11:58 AM completed by the RDC revealed resident was scored as 5. Record review conducted on 11/18/2023 at 12:00 PM revealed Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59 had care plans sufficiently reflecting resident elopement risk based on the quarterly elopement risk assessments. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /16/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments daily x 6 weeks to identify and resident with increased risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes of condition to ensure Care Plans accurately reflect and risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/16/2023 revealed The Administrator and DON will review Elopement Risk Assessments weekly x 60 days. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility's DON, ADON and/or designee with monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x 6 weeks to ensure any residents with increased risk of elopement are properly care planned. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11 /17/2023 revealed The facility's DON, ADON and/or designee will monitor all new and updated Elopement Risk Assessments and corresponding Care Plans daily x6 weeks to ensure any residents with increased risk of elopement are properly care planned. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The facility DON, ADON or designee will monitor Care Plans weekly x6 weeks for new admissions, quarterly reviews, and changes in condition to ensure Care Plans accurately reflect any risk of elopement. Review of facility monitoring tool, [Facility] Validation Tool - Plan of Removal dated 11/17/2023 revealed The Administrator and DON will review Elopement Risk Assessments and corresponding Care Plans weekly x60 days. The Administrator and DON were notified the IJ was removed on 11/18/2023 at 04:13 PM, however the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for one (Resident #1) of five residents reviewed for physician notification. 1) The ADON failed to consult the wound care physician on 01/03/2023 about altered skin integrity to Resident #1's left calf and discoloration of toe on Resident #1's left foot per PCP-M.D. telephone order. 2) On 01/10/2023, the ADON failed to notify the primary physician or wound care physician that Resident #1's left calf wound increased in size. 3) The facility failed to identify, monitor, assess, and evaluate Resident #1's response to treatment, revise the interventions as appropriate, or coordinate care with physicians/physician designees, resulting in complications from gangrene {death of body tissue due to a lack of blood flow or a serious bacterial infection} that led to an above-the-knee amputation. On 03/07/23 at 2:54 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 3/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving treatment, developing sepsis, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses of DM (a group of diseases that result in too much sugar in the blood), HTN (High blood pressure that is higher than normal), Non-Pressure Chronic Ulcer of other part of Left Foot with Unspecified Severity, Chronic Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and Thrombosis (a blood clot within blood vessels that limits the flow of blood) of Left Femoral Vein, and CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Resident #1's BIMS score was 13, which suggested the resident was cognitively intact. The Quarterly MDS indicated Resident #1 required one-person physical support to accomplish activities of daily living. Section M - Skin conditions of the Quarterly MDS indicated Resident #1 had a stage 4 pressure ulcer and a venous/arterial ulcer. Review of Resident #1's comprehensive care plan dated 04/16/19 - PRESENT indicated Resident #1 had a skin integrity r/t arterial vascular wound to left lower distal foot and calf leg entered/revised on 02/27/23 to reflect an initiated date of 01/05/23. The goal stated [Resident #1] has a skin integrity r/t open area Arterial Vascular Wound of the left lower leg will be monitored closely by wound care management through the next review date. Interventions/Tasks included: - Follow facility protocols for treatment of injury, do treatments per order. - Identify potential causative factors and eliminate/resolve when possible. - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. - Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. - Provide pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin. A review of Resident #1's clinical physician orders reflected: Start date 1/04/23: Apply skin prep to left great toe QD. LOTA until resolved every evening shift for wound care. Start date 1/04/23: Collagenase Ointment. Apply to left lower leg open area topically every evening shift for wound care. Cleanse wound to left lower leg with NS, pat dry, apply Santyl ointment, apply collagen powder, apply calcium alginate, cover with dry drsg QD until resolved. Start date 1/16/23: Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr. Apply 1 patch transdermally at bedtime for wound care and remove per schedule. Start date 1/27/23: Apply betadine to arterial wound to left distal foot QD wrap with gauze roll until resolved in the evening. Start date 1/27/23: Apply betadine to arterial wound to left posterior calf QD wrap with gauze roll until resolved in the evening. Review of Resident #1's January 2023 TAR reflected initials that indicated skin prep was applied to the left great toe and treatment of open area to left lower leg were performed starting 1/4/23. The January 2023 TAR reflected initials that indicated the Nitroglycerin Transdermal Patch was placed nightly as ordered beginning 1/16/23. Review of a weekly skin assessment dated [DATE] entered and signed by the ADON on 1/4/23 indicated Resident #1 had an open area to area, redness to peri-wound to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. The ADON documented the identified areas reflected a change in skin status and each of the area identified above had a treatment order in place. The ADON also documented that she notified the MD and RP. There were no identified areas of skin impairment to these areas noted in weekly skin assessments before 1/4/23. Review of the weekly skin assessment dated [DATE] entered and signed by LVN A identified an open area, treatment in progress to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. Review of the weekly skin assessment dated [DATE] entered and signed by LVN B on 1/17/23 identified a dark purplish discoloration to left great toe bottom and left lower leg top to [Site - Other (specify)]. LVN B did not document if the MD or RP were notified. Review of Resident #1's nurse progress notes (December 2022 - January 2023) revealed: Entered by the ADON, dated 01/04/23: N/O left lower leg open area Santyl ointment, collagen powder, calcium alginate, cover with dry drsg QD until resolved. N/O skin prep to left great toe QD LOTA until resolved. Wound consult faxed off to [The WMD]. RP phoned left VM to return call back to facility. LATE ENTRY note entered by the ADON on 1/17/23, dated 1/16/23: Resident left foot discoloration ischemic like in appearance. Per WMD, N/O Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr place at ankle level QPM rotating sites. MAR updated. RP phoned left VM to call facility. LATE ENTRY note entered by the ADON on 3/06/23, dated 1/19/23: Weekly wound rounds with [The WMD]. Arterial wound to left posterior calf. Review of a Physician Progress Note dated 1/17/23 completed by PCP-M.D., indicated chief complaint/nature of presenting problem: ischemic left lower extremity/foot, wound left calf. Documentation further indicated during physical exam of Resident #1 left calf dressing in place, left foot with purplish hue. Diagnosis and assessment reflected: purple toe syndrome of left foot, Diabetic vasculopathy, peripheral angiopathy in diseases, and wound of left leg. The plan was to continue present medical management. PCP-M.D. documented nursing home records and medications were reviewed, conferred with nursing staff, and with the MDS coordinator. Review of a Wound Evaluation & Management Summary dated 1/18/23 completed by the WMD, indicated Resident #1 had multiple wounds. A thorough wound care assessment and evaluation revealed an arterial wound of the left, posterior calf for greater than 3 days duration and an arterial wound of the left, distal foot for greater than 6 days duration. The wound to the left, posterior calf measured at 12.0 cm x 5.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. The wound to the left, distal foot measured at 8.0 cm x 9.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan for both wounds included betadine application and wrap with gauze roll once daily for 30 days. Review of a Physician Progress Note dated 1/19/23 completed by NP, indicated Resident #1 had an arterial wound to left foot being managed by wound physicians. NP documented no s/sx of infection on exam. The plan was to continue current plan of care and wound care, monitor and report change in condition to provider, and adjust treatment plan as needed. Review of a Wound Evaluation & Management Summary dated 1/25/23 for Resident #1 completed by the WMD, indicated no change to the arterial wound of the left, posterior calf. The wound to the left, distal foot deteriorated and measured 16.0 cm x 10.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan remained the same for both wounds. The dressing treatments for both wounds ordered by the WMD on 1/16/23 and 1/25/23, betadine application and wrap with gauze roll once daily for 30 days, were not entered as ordered until 1/27/23 to start 1/27/23 at 2:00 PM. A record review of a new patient consult dated 01/27/23 with provider VMD revealed Resident #1 presented with 2 weeks of class 6 (major tissue loss) gangrene of the left leg. Assessment and evaluation by VMD indicated leg pain and leg swelling to left leg. A record review of a Discharge Summary for Resident #1 from an acute care facility dated 02/03/23 reflected a discharge diagnoses S/P AKA (above knee amputation), left; resolved problems - Gangrene of left foot. Reason for Hospitalization per admission history and physical dated 01/30/23 - Left foot gangrene. A hospital course/summary indicated [Resident #1] had a past medical history of CAD (a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), DM (a group of diseases that result in too much sugar in the blood), and PAD (a common condition in which narrowed arteries reduce blood flow to the arms or legs), admitted electively for vascular surgery of left above knee amputation which was done on 01/30/23. Review of the Weekly Pressure/Non-Pressure Logs dated 1/04/23, 1/11/23, 1/18/23, and 1/25/23 provided by the ADON on 2/27/23 revealed Resident #1 on the 1/18/23 and 1/25/23 Weekly Non-Pressure Logs. The information on the 1/18/23 Weekly Non-Pressure Log indicated Resident #1 developed a facility acquired non-pressure wound [date opened 1/18/2023] to left posterior calf and left distal foot. Left posterior calf - Arterial Ulcer: 12.0 x 5.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. Left distal foot - Arterial Ulcer: 8.0 x 9.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. On 03/07/23, the RCC reviewed the Weekly Non-Pressure Logs dated 1/04/23, 1/11/23, 1/18/23, and 1/25/23 that she received from the ADON with the Investigator. The Weekly Non-Pressure Log dated 1/4/23 revealed Resident #1 and onset of left posterior calf and left distal foot wounds on 1/4/2023. The Weekly Non-Pressure Log dated 1/4/23 reflected the Family, Dietician, and MD were first notified on 1/4/23. Left posterior calf - Arterial Ulcer: 4.0 x 2.0 x 0.2 (LxWxD) with moderate serous drainage. Treatment: Santyl/Collagen/Calcium Alginate. Left distal foot - Arterial Ulcer: 1.0 x 1.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. Date Family, Dietician, and MD first notified on 1/18/23. The Weekly Non-Pressure Log dated 1/11/23 reflected: Left posterior calf - Arterial Ulcer: 6.0 x 3.0 x UTD (LxWxD) with moderate serous drainage. Treatment: Santyl/Collagen/Calcium Alginate. Left distal foot - Arterial Ulcer: 2.0 x 2.0 x UTD (LxWxD) without tunneling, odor, or drainage. Treatment: Betadine. During an interview on 2/27/23 at 11:03 AM, LVN B said the primary nurse assigned to a resident was responsible for completing the weekly head to toe skin assessment and performing wound care. LVN B described Resident #1 as bedbound, dependent of ADLs, and required two-person assistance. LVN B stated Resident #1 was discharged from hospice services a couple months ago. LVN B said that during a weekly skin assessment [1/16/23] she discovered Resident #1 had a dark purplish discoloration to the bottom left great toe and the top of the left lower leg. LVN B stated she notified the ADON for a wound care consultation per facility protocol, and treatment was started. LVN B said changes in skin condition should be reported to the primary doctor as soon as discovered, document the communication, and any new orders or recommendations. During an interview on 2/27/23 at 1:03 PM, CNA K said that she helps with ADL care. CNA K stated that when caring for a resident she makes sure they don't need any incontinent assistance, bed in low position, call light, water, and bedside table in reach. CNA K stated she does showers for residents and if she noticed any skin issues, she would notify the charge nurse. CNA K stated that Resident #1 received wound care to his leg and foot. CNA K stated that she repositioned Resident #1 to prevent bed sores. CNA K stated that a pillow is placed under the left foot to offload pressure. CNA K stated that she follows the care plan of the resident to know what care is needed. CNA K stated that if she sees a resident wound dressing needs changing (soiled) she would notify the nurse as soon as possible for further assessment. During an interview on 2/27/23 at 1:25 PM, CNA L said she assisted residents with ADLs who need help eating, who are incontinent, and with bathing. CNA L stated that she would notify the charge nurse of a resident's change in condition or any skin issues. CNA L said that she makes sure residents are turned and repositioned to keep the resident off areas that are risk for skin breakdown or areas that need attention. CNA L stated that she ensured sheets and covers are straight underneath residents to help prevent bed sores. During an interview on 2/27/23 at 1:58 PM, the ADON said that the nurses were to complete a weekly head-to-toe assessment of resident skin weekly and document their findings in the weekly skin assessment. The ADON also stated the CNAs observe for any skin issues while bathing and dressing residents and should notify the nurse. The ADON stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Wednesday. The ADON said that she documented the purple discoloration to toe and the open area to the back of Resident #1's left lower leg and obtained orders from the physician. The ADON stated that she was informed about [Resident #1's] skin impairment on 1/16/23 and immediately consulted the wound MD. The ADON said that the PCP-M.D., NP, and the WMD discussed and agreed that Resident #1 needed a vascular consultation. The ADON stated she spoke with the RP about Resident #1 on or about 1/19/23 and the RP wanted to continue any care needed. The ADON stated a vascular consultation was scheduled [on 1/23/23] for January 27, 2023. During an interview on 2/27/23 at 2:48 PM, CNA N said that he assisted residents with ADLs. CNA N stated if he discovered an open area, redness, or a rash on a resident, he would notify the nurse. CNA N said that he provided direct care to Resident #1 in the past and indicated he [Resident #1] had skin issues. CNA N stated that the nurses provided wound care by changing the dressing but did not know what treatment was done to the wound(s). CNA N stated that he would notify the charge nurse if he discovered the wound dressing came off or was soiled. During an interview on 2/27/23 at 3:03 PM, LVN A stated Resident #1 was getting wound care treatment on [DATE], but she was not sure if he [Resident #1] had wounds prior. LVN A stated that she was required to provide weekly skin assessment. LVN A stated that the wound came in the blink of an eye. LVN A stated that Resident #1 was discharged from hospice and did not receive wound care because he had no wounds. LVN A stated that when she discovered the wound in January, she notified the DON. During an interview on 2/27/23 at 4:09 PM, the DON indicated the WMD was consulted by the ADON when Resident #1's wound(s) to the left lower extremity were discovered on 1/03/23. The DON said that the WMD did not round on 1/04/23 or 1/11/23, however, the PCP-M.D. oversaw the wound care needs of Resident #1 in the absence of the WMD. When asked if the PCP-M.D. or WMD were notified of Resident #1's wounds increasing in size between 1/04/23 and 1/16/23, the DON replied, No . that the physician was notified only if a wound does not improve in 2 - 3 weeks. The DON denied it when asked if a wound increasing in size was considered not improving or deteriorating. During an interview on 03/06/23 at 1:49 PM, the ADON said the skin of residents with known altered skin integrity was assessed during weekly skin assessments. The ADON stated the nurses can describe the wound condition on the weekly skin assessment, but not required to document when performing daily wound care. The ADON stated that she notified the PCP-M.D. of Resident #1's altered skin integrity on 01/03/23 and consulted the WMD per the PCP-M.D. orders. The ADON was unable to locate the copy of the wound consultation sheet or provide proof of faxing the consult to the WMD. The ADON stated she did not think she needed to follow up with the WMD when Resident #1 was not seen during the WMD rounds on 1/04/23 (or the following week - 1/11/23). The ADON stated Resident #1 had a vascular skin issue that presented suddenly on 1/16/23 and spread quickly. The ADON could not describe the difference between a pressure ulcer {an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure (over bony areas) and vascular ulcers {wounds on the skin that develop because of problems with blood circulation - common on limbs}. The ADON could not explain why there were different Weekly Non-Pressure Logs presented to the Investigator on 2/27/23 and to the RCC on 03/06/23. The Investigator reviewed with and pointed out to the ADON that the reprinted Weekly Non-Pressure Logs dated 1/04/23 and 1/11/23 reflected Resident #1's wounds increased in size. When the ADON was asked if the physician(s) should be notified about the increase in size, the ADON replied No, the physician(s) are only notified if there is no improvement with the current treatment and the wound measurements did not mean that the treatment was not working. During a phone interview on 3/06/23 at 10:32 AM, the PCP-M.D. recalled Resident #1. The PCP-M.D. stated he assess and evaluate all residents and refer residents with wounds to the WMD. The PCP-M.D. said he recalled Resident #1 had a wound to the left calf and gave treatment orders during his last visit to start until seen by the WMD. The PCP-M.D. stated he did not have his notes in front of him and could not state for sure dates or actual orders. The PCP-M.D. said that the WMD was responsible for wounds once consulted and follows through until healed. The PCP-M.D. indicated coordination of care between providers often occur through progress notes in a resident's chart. Additionally, IDT/QAPI meetings were held to ensure quality care, coordination of care and services. The PCP-M.D. did not recall how Resident #1's wound appeared or any immediate observation concerns. The PCP-M.D. stated if he noted a purplish discoloration of the lower extremity that was not being treated or followed by the WMD, he would have ordered a doppler to determine any vascular issues. The PCP-M.D. said that he did not have his notes in front of him and could not state for sure what treatments, labs, or diagnostics were ordered. The PCP-M.D. described gangrene as the end result and before then would notice ischemia {a condition in which blood flow (and thus oxygen) is restricted or reduced} in the affected extremity that would be black. The PCP-M.D. said he would have ordered a Doppler to determine the condition of the wound had he noted any of the signs or symptoms. During a phone interview on 3/06/23 at 11:13 AM, the WMD said he had provided care to Resident #1 on and off for the past couple years. The WMD stated that Resident #1 had a history of PAD and [Resident #1] nearly lost his left leg in the past, but treatments made the left leg viable again. The WMD stated he saw Resident #1 on the first weekly visits after receiving a wound consult to see Resident #1. The WMD said he was informed of a new onset of a vascular event when received the wound consult to see Resident #1, so he ordered a nitroglycerin patch as used as a past treatment until seen during the next weekly rounds. The WMD described gangrene as not much that can be done once set in. The WMD described signs and symptoms of gangrene are shiny, smooth, dry skin of the legs or feet, absent or diminished pulse in the legs or feet, open sores, skin infections or ulcers that will not heal, purplish to black skin, and swelling of the affected area. The WMD indicated compression therapy was often standard of care for vascular wounds. The WMD stated once the wound present with superficial necrosis (the death of tissue due to failure of the blood supply), treat with betadine. At that point the outcome was unavoidable. Venous ulcers usually occur just above the ankle on the inside of the leg, if left untreated, can quickly become infected, leading to cellulitis or gangrene and the risk of foot or leg amputation. The WMD said that the facility could always request a tele-medicine visit (a way to allow the physician to visit primarily online with internet access on your computer, tablet, or smartphone if unable to visit in-person) if concerned about a wound status or needed alternate treatment options to ensure timely treatment. The WMD stated he never received a request to see Resident #1 via telemedicine or consulted before the visit on 1/18/23. The WMD said he could have assessed and evaluated Resident #1's wound(s) and decide on what treatment would be appropriate or refer to a vascular physician for further recommendation. Record review of the facility's Change of Condition and Physician/Family Notification policy, revised 03/25/21, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 2:54 PM. The NFA and RCC were notified. The NFA was provided with the IJ template on 03/07/23 at 2:54 PM. The facility's Plan of Removal was accepted on 03/08/23 at 11:37 AM and included: - The DON under the guidance of the RCC in-serviced nursing staff on importance of physician notification immediately of a resident change in condition (03/07/23) - The DON/DON Designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that a Physician must be notified immediately of changes of condition (03/07/23) - Competency and knowledge will be established via verbal quizzes (03/08/23) - The NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) - Training for all licensed nurse staff and newly hired staff will include importance of and expectation that all licensed nurses notify the physician of a significant change in any resident's physical status that requires a need to alter treatment; acknowledge and demonstrate changes of condition to be reported to the attending physician immediately, and standard operating procedure if unable to contact physician. (03/08/23) - The DON, ADON, Designee will conduct audits of 24-hour Summary in PCC to include review of all progress notes with emphasis on validating that all changes in condition have been identified (03/08/23) - NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) On 03/08/23 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with seven nurses on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts, including a PRN nurse on 03/08/23 [LVN B at 12:08 PM; LVN C (PRN nurse) at 12:24 PM; LVN D at 12:57 PM; LVN E at 1:28 PM; LVN O at 1:54 PM, RN G at 3:03 PM; LVN AA at 10:10 PM; and RN F at 10:14 PM] indicated they participated in an in-service training about notification of physician, documentation, and follow up orders. The nurses summarized the topic of discussion - physician notification protocol. Each nurse stated in their own words the procedure was to notify physicians immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee and the wound physician, including what actions to take if unable to contact a physician. Each nurse demonstrated in a test chart how to complete a weekly skin assessment, document skin observations in a daily skilled note, how to enter an order for a wound consultation, and how to fax to the wound physician. Interviews conducted with seven CNAs on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts on 03/08/23 [CNA Q B at 1:05 PM; CNA H at 1:09 PM; CNA R at 1:20 PM; CNA M at 1:43 PM; CNA S at 2:00 PM; CNA I at 2:20 PM; CNA J at 2:34 PM; and CNA L at 10:25 PM] indicated they participated in an in-service training about skin issues and resident change in condition. The CNAs summarized the topic of discussion - Concerns about resident skin and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about a resident change in condition or discovered skin issues. Record review on 03/09/23 of the In-Service Training Sheet titled Changes in Condition or Skin Issues for all Certified Nurses Assistants dated 03/08/23 reflected CNA Q, CNA I, CNA R, CNA S, CNA T, CNA J, and CNA U signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of an attestation of in-service participation on the facility expectation that all changes in a residents condition are immediately discussed with the residents physician reflected signed acknowledgements by the DON on 3/07/23 at 5:30 PM; LVN A on 3/08/23 at 7:53 AM via phone (signed by the DON); the ADON on 3/08/23 at 7:08 AM; LVN EE on 3/08/23 at 5:45 AM; LVN D on 3/08/23 at 6:15 AM; LVN E on 3/08/23 at 6:30 AM; LVN V on 3/08/23 at 6:12 AM via phone (signed by the DON); RN W on 3/08/23 at 6:21 AM via phone (signed by the DON); LVN X on 3/07/23 at 6:04 PM via phone (signed by the DON); LVN Y on 3/07/23 at 6:03 PM via phone (signed by the DON); LVN B on 3/07/23 at 5:45 PM; LVN C on 3/07/23 at 5:40 PM; RN G on 3/07/23 at 5:47 PM; LVN Z on 3/08/23 at 6:07 AM via phone (signed by the DON; LVN AA on 3/08/23 at 5:55 AM; RN BB on 3/07/23 at 8:20 PM via phone (signed by the DON); LVN CC on 3/07/23 at 6:30 PM via phone (signed by the DON); and LVN DD on 3/07/23 at 7:57 PM via phone (signed by the DON). Record review on 03/09/23 of the In-Service Training Sheet titled Resident Change in Condition dated 03/06/23 reflected LVN B, LVN C, RN F, RN G, LVN E, LVN O, LVN D, and the ADON signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of the In-Service Training Sheet titled Wound Care Consults Require an Order dated 03/06/23 reflected the ADON, LVN C, LVN B, RN G, RN F, LVN EE, RN P, LVN DD, LVN E, LVN O, and LVN D signatures on the In-Service Sign-in Sheet. Record review on 03/09/23 of the In-Service Training Sheet titled Notifying Physician and Coordinating Care dated 03/07/23 reflected LVN B, LVN C, RN G, RN F, LVN E, LVN O, LVN D, and the ADON signatures on the In-Service Sign-in Sheet. The NFA was informed the Immediate Jeopardy was removed on 3/09/23 at 11:37 AM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #1) of three residents reviewed for wounds. 1) The ADON failed to consult the wound care physician on 01/03/2023 about altered skin integrity to Resident #1's left calf and discoloration of toe on Resident #1's left foot per PCP-M.D. telephone order. 2) On 01/10/2023, the ADON failed to notify the primary physician or wound care physician that Resident #1's left calf wound increased in size. 3) The facility failed to identify, monitor, assess, and evaluate Resident #1's response to treatment, revise the interventions as appropriate, or coordinate care with physicians/physician designees, resulting in complications from gangrene {death of body tissue due to a lack of blood flow or a serious bacterial infection} that led to an above-the-knee amputation. On 03/07/23 at 2:54 PM an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the NFA. While the IJ was removed on 3/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place the residents at increased risk for serious complications, hospitalization, or amputation. The findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses of DM (a group of diseases that result in too much sugar in the blood), HTN (High blood pressure that is higher than normal), Non-Pressure Chronic Ulcer of other part of Left Foot with Unspecified Severity, Chronic Embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and Thrombosis (a blood clot within blood vessels that limits the flow of blood) of Left Femoral Vein, and CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Resident #1's BIMS score was 13, which suggested the resident was cognitively intact. The Quarterly MDS indicated Resident #1 required one-person physical support to accomplish activities of daily living. Section M - Skin conditions of the Quarterly MDS indicated Resident #1 had a stage 4 pressure ulcer and a venous/arterial ulcer. Review of Resident #1's comprehensive care plan dated 04/16/19 - PRESENT indicated Resident #1 had a skin integrity r/t arterial vascular wound to left lower distal foot and calf leg entered/revised on 02/27/23 to reflect an initiated date of 01/05/23. The goal stated [Resident #1] has a skin integrity r/t open area Arterial Vascular Wound of the left lower leg will be monitor closely by wound care management through the next review date. Interventions/Tasks included: - Follow facility protocols for treatment of injury, do treatments per order. - Identify potential causative factors and eliminate/resolve when possible. - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. - Obtain blood work such as CBC with Diff, Blood Cultures and C&S of any open wounds as ordered by Physician. - Provide pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin. A review of Resident #1's clinical physician orders reflected: Start date 1/04/23: Apply skin prep to left great toe QD. LOTA until resolved every evening shift for wound care. Start date 1/04/23: Collagenase Ointment. Apply to left lower leg open area topically every evening shift for wound care. Cleanse wound to left lower leg with NS, pat dry, apply Santyl ointment, apply collagen powder, apply calcium alginate, cover with dry drsg QD until resolved. Start date 1/16/23: Nitroglycerin Transdermal Patch 24-hour 0.2 mg/hr. Apply 1 patch transdermally at bedtime for wound care and remove per schedule. Start date 1/27/23: Apply betadine to arterial wound to left distal foot QD wrap with gauze roll until resolved in the evening. Start date 1/27/23: Apply betadine to arterial wound to left posterior calf QD wrap with gauze roll until resolved in the evening. Review of Resident #1's January 2023 TAR reflected initials that indicated skin prep was applied to the left great toe and treatment of open area to left lower leg were performed starting 1/4/23. The January 2023 TAR reflected initials that indicated the Nitroglycerin Transdermal Patch was placed nightly as ordered beginning 1/16/23. Review of a weekly skin assessment dated [DATE] entered and signed by the ADON on 1/4/23 indicated Resident #1 had an open area to area, redness to peri-wound to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. The ADON documented the identified areas reflect a change in skin status and each of the area identified above have a treatment order in place. The ADON also documented that she notified the MD and RP. There were no identified areas of skin impairment to these areas noted in weekly skin assessments before 1/4/23. Review of the weekly skin assessment dated [DATE] entered and signed by LVN A identified an open area, treatment in progress to [Site 44 - Left Lower Leg (rear)] and dark skin discoloration to toe to [Site 52 - Left Toe(s)]. Review of the weekly skin assessment dated [DATE] entered and signed by LVN B on 1/17/23 identified a dark purplish discoloration to left great toe bottom and left lower leg top to [Site - Other (specify)]. LVN B did not document if the MD or RP were notified. Review of Resident #1's nurse progress notes did not reveal documentation of the wound appearance, including wound bed, edges, presence of drainage at time when wound care was performed. There was no assessment data that indicated wound inspection during dressing changes, how Resident #1 tolerated the procedure, or any problems/complaints made by Resident #1 related to wound care. Review of a Physician Progress Note dated 1/17/23 completed by PCP-M.D., indicated chief complaint/nature of presenting problem: ischemic left lower extremity/foot, wound left calf. Documentation further indicated during physical exam of Resident #1 left calf dressing in place, left foot with purplish hue. Diagnosis and assessment reflected: purple toe syndrome of left foot, Diabetic vasculopathy, peripheral angiopathy in diseases, and wound of left leg. The plan was to continue present medical management. PCP-M.D. documented nursing home records and medications were reviewed, conferred with nursing staff, and with the MDS coordinator. Review of a Wound Evaluation & Management Summary dated 1/18/23 completed by the WMD, indicated Resident #1 had multiple wounds. A thorough wound care assessment and evaluation revealed an arterial wound of the left, posterior calf for greater than 3 days duration and an arterial wound of the left, distal foot for greater than 6 days duration. The wound to the left, posterior calf measured at 12.0 cm x 5.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. The wound to the left, distal foot measured at 8.0 cm x 9.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan for both wounds included betadine application and wrap with gauze roll once daily for 30 days. Review of a Physician Progress Note dated 1/19/23 completed by NP, indicated Resident #1 had an arterial wound to left foot being managed by wound physicians. NP documented no s/s of infection on exam. The plan was to continue current plan of care and wound care, monitor and report change in condition to provider, and adjust treatment plan as needed. Review of a Wound Evaluation & Management Summary dated 1/25/23 for Resident #1 completed by the WMD, indicated no change to the arterial wound of the left, posterior calf. The wound to the left, distal foot deteriorated and measured 16.0 cm x 10.0 cm (length x width), depth was not measurable. There was 100% of thick adherent devitalized necrotic tissue. Dressing treatment plan remained the same for both wounds. The dressing treatments for both wounds ordered by the WMD on 1/16/23 and 1/25/23, betadine application and wrap with gauze roll once daily for 30 days, were not entered as ordered until 1/27/23 to start 1/27/23 at 2:00 PM. A record review of a new patient consult dated 01/27/23 with provider VMD revealed Resident #1 presented with 2 weeks of class 6 (major tissue loss) gangrene of the left leg. Assessment and evaluation by VMD indicated leg pain and leg swelling to left leg. A record review of a Discharge Summary for Resident #1 from an acute care facility dated 02/03/23 reflected a discharge diagnoses S/P AKA (above knee amputation), left; resolved problems - Gangrene of left foot. Reason for Hospitalization per admission history and physical dated 01/30/23 - Left foot gangrene. A hospital course/summary indicated [Resident #1] had a past medical history of CAD (a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), DM (a group of diseases that result in too much sugar in the blood), and PAD (a common condition in which narrowed arteries reduce blood flow to the arms or legs), admitted electively for vascular surgery of left above knee amputation which was done on 01/30/23. During an interview on 2/27/23 at 11:03 AM, LVN B said the primary nurse assigned to a resident was responsible for completing the weekly head to toe skin assessment and performing wound care. LVN B described Resident #1 as bedbound, dependent of ADLs, and required two-person assistance. LVN B stated Resident #1 was discharged from hospice services a couple months ago. LVN B said that during a weekly skin assessment [1/16/23] she discovered Resident #1 had a dark purplish discoloration to the bottom left great toe and the top of the left lower leg. LVN B stated she notified the ADON for a wound care consultation per facility protocol, and treatment was started. LVN B said changes in skin condition should be reported to the primary doctor as soon as discovered, document the communication, and any new orders or recommendations. During an interview on 2/27/23 at 1:58 PM, the ADON said that the nurses were to complete a weekly head-to-toe assessment of resident skin weekly and document their findings in the weekly skin assessment. The ADON also stated the CNAs observe for any skin issues while bathing and dressing residents and should notify the nurse. The ADON stated she stays informed of the treatment and care needs of residents with wounds because she must be notified by nurses of any new skin issues, and she rounds with the WMD every Wednesday. The ADON said that she documented the purple discoloration to toe and the open area to the back of Resident #1's left lower leg and obtained orders from the physician. The ADON stated that she was informed about [Resident #1's] skin impairment on 1/16/23 and immediately consulted the wound MD. The ADON said that the PCP-M.D., NP, and the WMD discussed and agreed that Resident #1 needed a vascular consultation. The ADON stated she spoke with the RP about Resident #1 on or about 1/19/23 and the RP wanted to continue any care needed. The ADON stated a vascular consultation was scheduled [on 1/23/23] for January 27, 2023. During an interview on 2/27/23 at 2:48 PM, CNA N said that he assisted residents with ADLs. CNA N stated if he discovered an open area, redness, or a rash on a resident, he would notify the nurse. CNA N said that he provided direct care to Resident #1 in the past and indicated he [Resident #1] had skin issues. CNA N stated that the nurses provided wound care by changing the dressing but did not know what treatment was done to the wound(s). CNA N stated that he would notify the charge nurse if he discovered the wound dressing came off or was soiled. During an interview on 2/27/23 at 3:03 PM, LVN A stated Resident #1 was getting wound care treatment on [DATE], but she was not sure if he [Resident #1] had wounds prior. LVN A stated that she was required to provide weekly skin assessment. LVN A stated that the wound came in the blink of an eye. LVN A stated that Resident #1 was discharged from hospice and did not receive wound care because he had no wounds. LVN A stated that when she discovered the wound in January, she notified the DON. During an interview on 2/27/23 at 4:09 PM, the DON indicated the WMD was consulted when the wound(s) to the left lower extremity were discovered on 1/03/23. The DON said that the WMD did not round on 1/04/23 or 1/11/23, however, the PCP-M.D. oversaw the wound care needs of Resident #1 in the absence of the WMD. The DON said that the physician is notified only if a wound does not improve in 2 - 3 weeks. When asked if a wound increasing in size is considered not improving or deteriorating, the DON denied. During an interview on 03/06/23 at 1:49 PM, the ADON said the skin of residents with known altered skin integrity is assessed during weekly skin assessments. The ADON stated the nurses can describe the wound condition on the weekly skin assessment, but not required to document when performing daily wound care. The ADON stated that she notified the PCP-M.D. of Resident #1's altered skin integrity on 01/03/23 and consulted the WMD per the PCP-M.D. orders. The ADON was unable to locate the copy of the wound consultation sheet or provide proof of faxing the consult to the WMD. The ADON stated she did not think she needed to follow up with the WMD when Resident #1 was not seen during the WMD rounds on 1/04/23 (or the following week - 1/11/23). The ADON stated Resident #1 had a vascular skin issue that presented suddenly on 1/16/23 and spread quickly. The ADON could not describe the difference between a pressure ulcer {an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure (over bony areas) and vascular ulcers {wounds on the skin that develop because of problems with blood circulation - common on limbs}. During a phone interview on 3/06/23 at 10:32 AM, the PCP-M.D. recalled Resident #1. The PCP-M.D. stated he assess and evaluate all residents and refer residents with wounds to the WMD. The PCP-M.D. said he recalled Resident #1 had a wound to the left calf and gave treatment orders during his last visit to start until seen by the WMD. The PCP-M.D. stated he did not have his notes in front of him and could not state for sure dates or actual orders. The PCP-M.D. said that the WMD was responsible for wounds once consulted and follows through until healed. The PCP-M.D. indicated coordination of care between providers often occur through progress notes in a resident's chart. Additionally, IDT/QAPI meetings were held to ensure quality care, coordination of care and services. The PCP-M.D. did not recall how Resident #1's wound appeared or any immediate observation concerns. The PCP-M.D. stated if he noted a purplish discoloration of the lower extremity that was not being treated or followed by the WMD, he would have ordered a doppler to determine any vascular issues. The PCP-M.D. said that he did not have his notes in front of him and could not state for sure what treatments, labs, or diagnostics were ordered. The PCP-M.D. described gangrene as the end result and before then would notice ischemia {a condition in which blood flow (and thus oxygen) is restricted or reduced} in the affected extremity that would be black. The PCP-M.D. said he would have ordered a Doppler to determine the condition of the wound had he noted any of the signs or symptoms. During a phone interview on 3/06/23 at 11:13 AM, the WMD said he had provided care to Resident #1 on and off for the past couple years. The WMD stated that Resident #1 had a history of PAD and [Resident #1] nearly lost his left leg in the past, but treatments made the left leg viable again. The WMD stated he saw Resident #1 on the first weekly visits after receiving a wound consult to see Resident #1. The WMD said he was informed of a new onset of a vascular event when received the wound consult to see Resident #1, so he ordered a nitroglycerin patch as used as a past treatment until seen during the next weekly rounds. The WMD described gangrene as not much that can be done once set in. The WMD described signs and symptoms of gangrene are shiny, smooth, dry skin of the legs or feet, absent or diminished pulse in the legs or feet, open sores, skin infections or ulcers that will not heal, purplish to black skin, and swelling of the affected area. The WMD indicated compression therapy was often standard of care for vascular wounds. The WMD stated once the wound present with superficial necrosis (the death of tissue due to failure of the blood supply), treat with betadine. At that point the outcome was unavoidable. Venous ulcers usually occur just above the ankle on the inside of the leg, if left untreated, can quickly become infected, leading to cellulitis or gangrene and the risk of foot or leg amputation. The WMD said that the facility could always request a tele-medicine visit (a way to allow the physician to visit primarily online with internet access on your computer, tablet, or smartphone if unable to visit in-person) if concerned about a wound status or needed alternate treatment options to ensure timely treatment. The WMD stated he never received a request to see Resident #1 via telemedicine or consulted before the visit on 1/18/23. The WMD said he could have assessed and evaluated Resident #1's wound(s) and decide on what treatment would be appropriate or refer to a vascular physician for further recommendation. Review of the facility's Pressure Ulcer Treatment protocol, revised September 2013 provided as the written policy for all wounds treatment, indicated the purpose of the procedure is to provide guidelines for the car of existing pressure ulcers and the prevention of additional pressure ulcers. General guidelines focus on the strategies of assessing the resident and the status of the pressure ulcer, current support surfaces, pressure ulcer care, managing bacterial colonization and infections, education, and quality improvement. Documentation should reflect the following information in the resident's medical record, treatment sheet, or designated wound form: 1) The date and time the dressing was changed, 2) wound appearance, 3) name and title of the individual changing the dressing, 4) type of dressing used and wound care given, 5) all assessment data, 6) how the resident tolerated the procedure, and 7) any problems, complaints, or if the resident refused treatment. This was determined to be an Immediate Jeopardy (IJ) on 03/07/23 at 2:54 PM. The NFA and RCC were notified. The NFA was provided with the IJ template on 03/07/23 at 2:54 PM. The facility's Plan of Removal was accepted on 03/08/23 at 11:37 AM and included: - The NFA, DON, and ADON were trained by the RCC on Changes in Condition, expectation and best practice, standard operating procedure, and expectations of interventions, follow up and physician notification of new/reopened/deterioration of wounds discovered (03/07/23) - The NFA, DON, and ADON were trained by the RCC on proper techniques of Monitoring and Assessing Wounds (03/07/23) - Facility DON/ADON or Designee will conduct training with all licensed nurses including agency nursing: Changes in condition in skin, Assessing and treating wounds, Appropriate interventions when skin issues are found, and Monitoring and assessing progression of wounds (03/07/23) - The DON and RCC initiated an in-service with all licensed nurses on duty to cover the topics of: Changes in Condition, abnormal skin issues that deviate from baseline, and care attention warranted by the patient's physical condition. - RCC/Nurse Designee will contact all licensed nurse staff and get a verbal acknowledgement of understanding Abnormal skin issues - The NFA, DON, and RCC held an ad hoc QAPI meeting with the Medical Director via phone to discuss the IJ cited on 3/07/23 (03/07/23) - The DON, ADON, Designee will conduct audits of 24-hour Summary in PCC to include review of all progress notes, PRN medication/intervention with emphasis on validating that all changes in condition have been identified (03/08/23) On 03/08/23 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Interviews conducted with seven nurses on the schedule across the 6a - 2p, 2p - 10p, and 10p - 6a shifts, including a PRN nurse on 03/08/23 [LVN B at 12:08 PM; LVN C (PRN nurse) at 12:24 PM; LVN D at 12:57 PM; LVN E at 1:28 PM; LVN O at 1:54 PM, RN G at 3:03 PM;, LVN AA at 10:10 PM; and RN F at 10:14 PM] indicated they participated in an in-service training about changes in condition of skin, assessing and treating wounds, appropriate interventions when skin issues are found, and documenting skin assessments in daily skilled nurses notes. The nurses summarized the topic of discussion - Identifying, assessing, and monitoring wounds clinical protocol. Each nurse stated in their own words the difference between pressure and vascular/arterial ulcers, appropriate interventions when abnormal skin issues are discovered, procedure to notify physicians immediately of resident change in condition, and actions to take if unable to contact a physician. Observation on 03/08/23 at 2:05 PM revealed RN G, RN P, LVN B, LVN C, LVN A, ADON, LVN E, RN F, and the DON participating in a Wound Education training. The training detailed wound identification, infection prevention, and best care practices. The training was conducted by a health care service provider that provides wound care solutions. An interview with the ADON on 03/09/23 at 11:05 AM indicated understanding between pressure and vascular/arterial wounds, when and how to contact the physician. The ADON demonstrated entering an order for a wound consultation. Record review on 03/09/23 of the In-Service Training Sheet titled Characteristics/Describing Wounds dated 03/07/23 reflected LVN B, LVN C, LVN D, RN G, RN F, LVN E, LVN O, and the ADON signatures on the In-Service Sign-in Sheet. In-Service presentation handouts provided Wound Dressing Selection references, Skin and Wound Care Quick Guideline, Types of Wound Exudate, and pictures of Tailoring Wound Care to Wound Color. Record review on 03/09/23 of the In-Service Training Sheet titled Types of Wounds dated 03/07/23 reflected LVN B, LVN C, LVN D, RN G, RN F, LVN E, LVN O, and the ADON signatures on the In-Service Sign-in Sheet. In-Service presentation handouts provided pictures key statements and references describing Types of Wounds and Wound Identification. The NFA was informed the Immediate Jeopardy was removed on 3/09/23 at 11:37 AM. On 03/07/23, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 03/07/23 at 2:54 PM. While the IJ was removed on 03/09/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's in-service training was not conducted with all nursing staff on when to, the reasons to notify the physician, and the facility's needs to evaluate the effectiveness of the corrective systems that were put into place.