**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to protect the residents right to be free from physical abuse by Resident #83 and #55, for 3 of 13 residents (Residents #55, #61, and #83) reviewed for physical abuse and neglect. 1. On 1/11/2025 on or about 11:00 AM Resident #61 was physically battered by Resident #83, to include a face punch, his hair pulled, and drug by his foot across the floor. 2. On 4/9/2024 Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. 3. On 4/22/2024 Resident #61 was punched in the nose by Resident #55. 4. On 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. An IJ was identified on 1/29/2025. The IJ template was provided to the facility on 1/29/2025 at 3:15 PM. While the IJ was removed on 1/30/2025 at 9:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm. These failures placed residents at risk for physical abuse. The findings included: 1. Resident #61 A record review of Resident #61's admission record dated 1/27/2025, revealed an admission date of 1/2/2024 with diagnoses which included dementia with moderate agitation (a group of symptoms affecting memory, thinking and social abilities. further review revealed Resident #61 resided in the facility's secured Memory Care Unit (MCU). A record review of Resident #61's annual MDS assessment dated [DATE] revealed Resident #61 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 4 out of a possible 15 which indicated severely impaired cognition. Resident #61 was reviewed for the 6 days prior to the assessment and Resident #61 was assessed with a history of wandering, has the Resident wandered? Behavior of this type occurred 1 to 3 days. does the wandering place the Resident at significant risk of getting to a potentially dangerous place? Yes Resident #61 was diagnosed with cataracts (a gradual progression of vision problem, eventually, if not treated, may result in vision loss.) Further review revealed Resident #61 was 5 foot and 5 inches tall and weighed 129 lbs. A record review of Resident #61's care plan dated 1/29/2025 revealed, Behavioral Complex Care Plan Physically Abusive Behavior, Socially Inappropriate Behavior, Wandering, verbally abusive and/or resisting care. 12/24/24 pacing back/forth ready to go to work attempted to go out-door pushing bar. 1/11/25 Another Resident (Resident #83) entered this Res room. Staff heard yelling other resident was found dragging (Resident #61) by the hair as per CNA, then that resident began to drag Resident (#61) by the legs . revision 1/16/2025 . Resident move to different room. Date Initiated: 01/14/2025 Refer to behavioral health Date Initiated: 08/13/2024 Revision on: 8/14/2024 Separate Residents. Date Initiated: 01/11/2025 . Resident #61 uses anti-anxiety medications r/t agitation. Resident #61 is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor every shift for safety A record review of Resident #61's physicians orders, dated 6/10/2024, revealed the physician prescribed for staff to have Frequent monitoring throughout the shift staff to attempt to anticipate some of residents needs as tolerated. A record review of Incident reports indicated the following: A record review of the facility's incident report dated 4/9/2024 revealed Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. Further review of the report revealed the previous administrator and the previous DON had been notified. A record review of the facility's incident report dated 4/22/2024 revealed the previous DON documented Resident #61 was punched in the nose by Resident #55. Resident #61 was presented to the nurse with a bloody nose after exiting Resident #55's room. Resident #61 took the nurse to Resident #55 room and stated, this is the bathroom, and he won't let me use it. He hit my nose. Resident #55 stated, He came in here to take a shit. I told him to get out. He peed in the corner, so I hit him on the nose. A record review of the facility's incident report dated 8/12/2024 revealed the LVN C documented on 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. Resident #55 stated, I hit him because he came into my room. Resident # 83 A record review of Resident #83's admission record dated 1/30/2025 revealed an admission date of 11/4/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), psychotic disturbance (a cluster of symptoms, not an illness. It's sometimes described as losing touch with reality), mood disturbance, and anxiety. Further review revealed Resident #83 resided in the MCU. A record review of Resident #83's admission MDS assessment dated [DATE] revealed Resident #83 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 6 out of a possible 15 which indicated severely impaired cognition. Resident #83 was reviewed for the 6 days prior to the assessment and Resident #83 was assessed with a history of behavioral symptoms, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . behavior of this type occurred 1 to 3 days. verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . behavior of this type occurred 1 to 3 days. impact on others? Put others at significant risk for physical injury? Yes Further review revealed resident #83 was six foot tall and weighed 179 lbs. A record review of Resident #83's care plan dated 1/29/2025 revealed, Behavioral Complex Care Plan Physically Abusive Behavior, Verbally Abusive Behavior 1/1/25 noted standing in doorway of another resident, both residents with raised voices. 1/11/25 Another Resident went into his room this resident. This resident is kept separated from other resident and redirected as necessary Date Initiated: 11/06/2024 Revision on: 01/28/2025 . Look for alternative placement. Date Initiated: 01/14/2025 Residents were separated. Date Initiated: 01/01/2025 Staff to explain cares to resident prior to and during process of cares. Date Initiated: 11/07/2024 Revision on: 11/14/2024 A record review of Resident #61's provider investigation report dated 1/20/2024 revealed the operations manager documented an incident on 1/11/2025 at 11:00 AM, where Resident #83 physically battered Resident #61. The operations manager documented Resident #83 as the perpetrator and identified CNA A and RN S as witnesses. The operations manager documented, Resident was hit by another Resident, dragging by his hair and his leg per CNA. Resident stated he accidentally walked into wrong room. after interviewing staff and Resident(s) it was found Resident wandered into wrong room and was the cause of the altercation and we moved residents' room to avoid future issues. (Resident #61) is extensive supervision and needs constant redirection due to dementia diagnosis During an observation and interview on 01/26/25 at 3:55 PM revealed the MCU where Resident # 61 was asleep in room [ROOM NUMBER] (which was not his assigned room.) CNA A was the only staff in the MCU. CNA A was alerted by the surveyor that Resident #61 was not in his assigned bedroom. CNA A discovered Resident #61 in another bedroom and redirected him to his bedroom. CNA A stated on 1/11/2025 at 11:00 AM she heard screams from the end of the hall and ran to the sounds and witnessed Resident #83 in his room and had Resident #61 by his hair and was dragging him to the floor. CNA A attempted to separate them but Resident #83 was a large man and CNA A was herself threatened so she ran down the hall, exited the MCU to gather emergency assistance, and upon her return to the MCU, she witnessed Resident #83 had Resident #61 by his foot and drug him out of Resident #83's room and into the hallway. CNA A stated, I am often alone in the MCU, the nurse works this MCU and another hall outside of the MCU. CNA A stated Resident #83 was very aware of his room and becomes violent when anyone was in his room. Resident #61 was very confused and often goes into different rooms and Resident #83 becomes aggressive towards Resident #61. During an interview on 1/30/2025 at 5:35 PM RN S stated she was a nurse who worked at the facility as needed and could work the MCU during the 10P-6A shift. RN S stated she had received the in-service for the MCU which included the addition of 2 CNAs would staff the MCU. RN S stated she appreciated the addition of 2 CNAs for the MCU since she was on duty on 1/22/2025 at 11:00 AM when Resident #61 was battered by Resident #83 and CNA A had to leave the residents and the MCU to alert her to the resident-to-resident abuse. RN S stated she was on the adjacent hall providing care when CNA A exited the MCU and called out for help in the MCU. RN S stated she ran after CNA A and entered the MCU to the end of the hall to Resident #83's bedroom and witnessed Resident #83 dragging Resident #63 by his legs out of the room into the hall. RN S stated the residents were separated for safety and assessed head to toe, no injuries were assessed for Resident #83, and Resident #61 was assessed with a right cheek redness, slight swelling, and discoloration. The physician received a report and Resident #61 was supported with x-rays which revealed no deep injuries. RNS stated residents were monitored frequently and ultimately Resident #61 was relocated to a bedroom away from Resident #83's bedroom. During an interview on 1/27/2025 at 4:05 Resident #61's emergency contact stated Resident #61 was a full code and would often visit him. Resident #61's emergency contact stated she often observed the MCU was staffed by 1CNA and 1 nurse and was not aware the nurse would leave the MCU to care for residents outside of the MCU. Resident #61's emergency contact stated she received a report from Resident #61's Representative that Resident #61 was punched in the face by Resident #83 but was not aware Resident #61 was left alone with Resident #83 while the CNA left to get help. During a joint interview on 1/28/2025 at 11:47 AM Resident #61's representative and emergency contact stated they had not received a full report for the Resident-to-Resident aggression on 1/11/2025 when Resident #61 wandered into a different bedroom, I only knew that another Resident had hit Resident #61 in the face and he had received x-rays. Resident #61's representative and emergency contact stated they were unaware the MCU was staffed by one CNA and were unaware Resident #61 was left alone while Resident #83 was beating Resident #61, (Resident #61) is profoundly confused and needs redirection to his bedroom . he often goes to lay down . and needs to be monitored for safety and never left alone During a joint interview on 1/28/2025 at 8:55 AM the DON and the operations manager stated the facility operates 3 shifts: 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM to include the MCU. The operations manager stated she investigated an incident of Resident-to-Resident aggression between Resident #61 and Resident #83 on 1/11/2024 at 11:00 AM when CNA A witnessed Resident #83 pulled Resident #61 out of his room when Resident #61 wandered into the bedroom. The DON stated currently 13 residents resided in the MCU to include Residents #61 and Resident #83. The DON stated the MCU was staffed by 1 CNA and 1 nurse during every shift. The DON stated the nurse was also assigned another set of residents to care for outside of the MCU and stated, she would leave the MCU to care for residents in the C hall. The administrator stated the facility provided for Resident #61's safety, post the aggression incident, by moving Resident #61 to a different bedroom away from Resident #83 and continued with the 1 CNA to monitor and redirect the MCU residents. The operations manager and the DON stated the IDT met Monday - Friday mornings and they were responsible for leading the meeting. The DON and the operations manager stated the previous day's care was reviewed and the team would be responsible for developing and implementing any further care to keep residents healthy and safety. The operations manager stated on 1/13/2025 the IDT met and decided to move Resident #61 to a different bedroom and continue with the level of supervision for the MCU. During an interview on 01/28/2025 at 3:00 PM, the MDS nurse stated she was responsible for updating Residents care plans to include Resident #61's care plan on 01/14/2025. The MDS nurse stated the IDT met during the morning meeting on 01/13/2025 and again on 01/14/2025 and reviewed the aggression incident on 01/11/2025 for Residents #61 and #83 and decided to add interventions for Resident #61 to be moved to a different bedroom and for Resident #83 to be safely discharged to another facility. The MDS nurse stated residents in the MCU had a history of Resident-to-Resident physical aggression and prior to the 01/13/2025 and 01/14/2025 meetings, there were no interventions for monitoring for wandering safety for residents #61 and #83 to include the history of physical aggression between the two. Resident #55 A record review of Resident #55's admission record revealed an admission date of 2/4/2021 with diagnoses which included corneal ulcer of the right eye, generalized anxiety disorder, dementia with behavioral disturbance. A record review of Resident #55's annual MDS assessment dated [DATE] revealed Resident #55 was a [AGE] year-old male admitted for long term care and resided in the MCU. Resident #55 was assessed with a BIMS score of 00 which indicated severe cognitive impairment as evidenced by his inability to participate in the assessment. A record review of Resident #55's care plan dated 1/28/2025 revealed, (Resident #55) has a behavioral concern of increased agitation physical and verbal aggression with the possibility of throwing things. 1/8/25: yelled and cursed at SW Date Initiated: 12/22/2022 Revision on: 01/09/2025 Intervene as needed to ensure resident safety. Date Initiated: 12/22/2022 Leave additional activities to keep resident engaged. (psych provider) eval/tx for psychological services. Refer to behavioral health. Date Initiated: 08/13/2024 Revision on: 08/13/2024 . Staff to redirect resident to other activities Date Initiated: 12/22/2022 Revision on: 12/22/2022 2. During an interview and observation on 01/26/25 at 4:00 PM revealed LVN C entered the MCU and to exit the MCU and attended residents in the C-hall. LVN C stated she was assigned to work the MCU and the c-hall (rooms 34-46) which were located outside of the MCU. LVN C stated the MCU was also staffed by 1 CNA, who would stay in the MCU. During an observation and interview on 1/27/2025 at 3:32 PM revealed CNA B exited the MCU, continued observation revealed the MCU was unattended. At 3:54 PM revealed CNA B returned to the MCU. CNA B stated he was the only staff in the MCU and had left the MCU briefly to return a meal tray to the kitchen. CNA B stated he was the CNA for the MCU and there was no nurse until 4:30 PM. CNA B stated the current nurse on duty was the DON and he was not in the MCU. CNA B stated if a Resident had aggression, he would be by himself, he would attempt to separate residents and then leave the MCU to go get help. CNA B stated if a Resident was discovered unresponsive, he would have to leave the unit to ask for help because he would not know who was a full code and/or a DNR. CNA B stated it was routine to be by himself due to the routine schedule which had a nurse to work 2 halls to include the MCU. CNA B stated his concern for aggressive and confused residents was for Resident #61 and Resident #83 history of physical aggression. During an interview with DON and Administrator on 01/28/2025 at 4:10 PM, their plan for keeping residents safe was for staff to monitor wandering residents, separate aggressive residents, and leave the memory care unit to call for help. A record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed, Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The Administrator was notified on 1/29/2025 at 3:15 PM an IJ was identified on 1/29/2025 due to the above failures. The IJ template was provided to the facility on 1/29/2025 at 3:15 PM and was accepted on 1/30/2025 at 9:00 PM. Plan of removal Date 1/29/2025 (the Facility) PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 1/29/2025 sic(1/26/2025) annual survey was initiated at (The Facility). On 1/29/2025, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to residents' health. The notification of the alleged immediate jeopardy states as follows: F600 Abuse and Neglect The facility neglected to have measures in place to keep residents in the memory care unit free from abuse. Problem On 01/11/2025 at 11 AM, Resident #61 wandered into Resident #83's room on the memory care unit. Resident #83 punched Resident #61 in the face, pulled Resident #61's hair, and dragged Resident #61 across the floor by his foot. Immediate Corrections Implemented for Removal of Immediate Jeopardy. Once the facility was made aware of the deficient practice, the Director of Nursing/ designee immediately ensured a second team member would be staffed in the memory care unit as of 1/28/2025. The facility Director of Nursing/designee completed a 100% in-service for nursing staff over ensuring two staff members need to be in the memory care unit at all times, that one staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. Walkie Talkies will be held by nursing staff member, as emergency communication back up, in the unit and the second by the licensed nurse that is floating between two units. Identification of Others: Residents identified at risk for deficient practice are the resident population residing in the memory care unit. Systemic Changes The Director of Nursing/ designee initiated immediate education with all licensed/certified nursing staff over staffing requirements for memory care unit, that one facility staff member needs to remain in memory care unit in the case of emergencies, and utilization of walkie talkies to promote communication between unit and general population. These educations are at 100% completion as of 1/28/2025. Staff who are on leave or off-site have been notified and provided education via phone call. The Director of Nursing /designee initiated immediate education, by neuropsychologist, with all licensed/certified nursing staff over managing difficult behaviors, de-escalation strategies, and wandering/elopement on 1/29/2025. This education will be at 100% completion by 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. The Director of Nursing/designee initiated immediate education with all facility staff over the Abuse, Neglect, Exploitation or Misappropriation Prevention Program on 1/29/2025. Staff who are on leave or off-site have been notified and provided education via phone call. Administrator/designee will conduct monthly all-staff meetings, beginning on 2/12/25, during monthly in-service a specific aspect of behavioral care will be addressed: focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities. All education and training was sic(were) started on 1/28/2025 and will continue until all nursing staff have received training prior to the start of their work shift. The facility Director of Nursing, Corporate Clinical Director and Administrator met on 1/28/2025 to evaluate the facility's staffing schedules and requirements regarding the memory care unit and general population. All residents have access to behavioral health services. Residents with increased behaviors are identified by staff and provided with comprehensive behavioral health services to include medication management, counseling services, cognitive behavioral therapy, and neuropsych sic(neuropsychic) therapy. The Director of nursing/designee will complete education and training with all licensed/certified nursing staff and newly hired licensed/certified nursing staff over facility's memory care unit staffing requirement. The education will be provided by DON or designee and be kept in the employees' HR file. The Director of nursing/designee will complete Preferences for Activity and Leisure (PAL) Cards for all residents in the memory care unit to assist in managing challenging behaviors and de-escalation strategies such as providing triggers, providing comfort and familiarity, offering calming strategies, encouraging positive redirection, supporting non-verbal communication, building trust and rapport, etc. By integrating PAL Cards into daily care, staff can proactively prevent agitation and respond effectively when challenging behaviors arise, fostering a person-centered care environment. PAL Cards will be completed for all residents in memory care unit by 1/29/2025. All nursing staff will receive education on purpose and utilization of PAL Cards by 1/29/2025. The Administrator, DON, and designee will develop and ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600. Monitoring will include a system to ensure deficient practice is prevented and residents in the memory care unit will have sufficient supervision. The monitoring and oversight system will gather measurable data for review of patterns or trending. Concerns identified will be provided by the DON or designee to the QAPI committee monthly, for a minimum of 6 months, for the discussion of sustaining compliance or correction of concerns identified. Monitoring The DON or designee will develop a short-term monitoring system for all areas of deficient practice identified for this deficiency. Monitoring will include a system to observe all residents especially in the memory care unit are under appropriate supervision. This monitoring system will begin 1/29/2025. All concerns identified during the monitoring process will be addressed timely and staffing will be adjusted appropriately. The monitoring process, findings, and corrections will be presented to the facility QAPI committee each month for a minimum of 3 months for this plan of correction. The administrator will be responsible for monitoring DON compliance with the system weekly. System compliance will be documented and discussed. Administrator/designee will monitor use of walkie talkies every shift x 7 days then random audit daily x 3 months. Sign out log will be completed every shift to validate staff responsible for carrying and utilization of walkie talkies. The Administrator/ designee will develop or ensure an ongoing long-term monitoring and oversight system is in place by 1/29/2025 to review and address concerns related to the deficient practices identified in F600, to include monitoring of PAL card use and compliance with utilization and updating as appropriate. Clinical Director of Operations will in-service Admin and DON over deficient practice F600 Abuse and Neglect on 1/29/2025. Monitoring will be conducted weekly for 4 weeks to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. Social Services/designee will attend daily meeting Monday - Friday to be made aware of any newly identified behaviors or concerns. Social Services/designee will assure necessary notification to behavioral health services are in place or make necessary appointments to have residents in need seen as soon as possible. The QAPI committee will meet monthly, and facility interdisciplinary team will meet daily to review the ongoing status of the corrections for this deficiency with the purpose to identify, evaluate, plan, implement, and address concerns or deficient practices identified as it relates, or to determine if compliance is being sustained. All corrections or steps taken and identified by QAPI will be documented. Ad Hoc QAPI meeting will be held on 1/29/2025 with the Medical Director, Administrator and Director of Nursing to review and validate the plan of removal. Involvement of Medical Director The Director of Nursing notified the facility's Medical Director, of the Immediate Jeopardy tag on 1/29/2025. The Administrator will be responsible for implementation of ensuring the adequate process regarding staffing requirements for increased supervision and minimize to support accident management. The new process/systems were initiated on 1/29/2025. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 1/29/2025. Plan of Removal Verification Intermittent observations on 1/26/2025, 1/27/2025, 1/28/2025, and 1/29/2025 from 8:00 AM to 10:00 PM revealed 13 residents resided in the MCU to include residents #55, #61, and #83. During an observation and interview on 1/29/2025 at 1:30 PM it was revealed that CNA D and MA E were staffing the MCU. MA E and CNA D stated they were assigned to the MCU and if they needed help, they would stay in the MCU and call via the 2-way radios provided. MA E stated LVN C had the radio while she was out of the MCU providing care for other residents. Observation on 1/30/2025 at 5:25 PM in the memory care unit had 2 CNA's and 1 nurse/CNA. Observation and interview on 1/30/2024 at 5:26 PM revealed LVN R had the other walkie talkie and could use to communicate with the CNAs in the MCU. Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU, they can use the walkie talkie for emergency as well. Dr. x During an observation on 1/29/2025 at 10:40 AM revealed Dr. X provided the in-service topic Understanding Dementia to staff in the facility's living room. During an interview on 01/29/25 at 11:09 AM, Dr. X revealed he conducted an in-service to the facility staff on helping residents with dementia. He revealed some interventions he taught to include getting to know residents, getting to know their triggers, and adjusting resident care accordingly. Record review of in-service/sign in sheet, dated 1/29/2025, reflected in-service topic Understanding Dementia with Facilitator Dr. X. further review revealed 54-staff signed the document. Observation and interview on 1/30/2025 at 5:24 PM revealed CNA U had a walkie talkie on her, and CNA B stated if one leaves the MCU can use the walkie talkie for emergency as well. During an interview on 1/30/2025 5:29/2025 the DON stated he would hold an all-staff monthly meeting, beginning 2/12/2025, to cover aspects of behavioral care with a focus on de-escalation of behaviors, behavior management, wandering, dementia care and activities. During an interview on 1/30/2025 at 5:38 PM the DON stated all the in-services have been completed for all staff and stated any staff who had not received the in service i.e., new staff, no one would be able to accept a work shift until they received the in service. During an interview on 01/30/25 at 07:00 PM, the Administrator revealed he informed the DON will ensure 2 CNAs will be always staffed back in MCU. They revealed when a staff member did not come in as scheduled, they would make sure to fill this position in. They further revealed they were actively hiring and searching for new staff members to be adequately staffed. Record reviews of facility schedules, from 1/26/2025 to 1/30/2025, revealed the following staff usually worked the following shifts: 6:00 AM - 2:00 PM LVNs RNs: DON ADON LVN C CNAs: CNA G CNA F CNA A MA E CNA H CNA I 2:00 PM - 10:00 PM LVN J RN K LVN L LVN W CNAs CNA B CNA M CNA N CNA O CNA P CNA Q 10:00 PM to 6:00 AM Nurses LVN R RN S CNAs CNA T CNA U During an observation on 1/30/2025 at 1:55 PM of the MCU revealed CNA B and CNA U staffed the MCU. It was observed CNA B had on his person the 2-way radio and RN K had the other 2-way radio while she documented at the nurse's station located outside of the MCU. Record review of Resident - to Resident Altercations (2022) and unmanageable residents (2010) policy, in- service, dated 1/11/2025, indicated there is to be 2 CNA's on A hall at all times. If there is an emergency, 1 aide needs to always stay with the resident /residents, while the other aide goes to help, there will be a walkie talkie to communicate with A hall nurse and A hall CNAs in case of emergency. The Walkie talkie needs to always stay with the employee during their shift. Walkie talkies will be checked every shift to ensure they are working properly. There will be a walkie talkie log to be initialed by nurses and CNA documenting they are working properly every shift signed by 53 staff, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in- service dated 1/29/2025 titled Abuse and Neglect had 89 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in- service dated 1/29/2025 titled Understanding Dementia had 44 staff signatures, to include CNA A, CNA B, LVN C, CNA D, and MA E. A record review of the facility's in-service dated 1/29/2025 titled PAL (preference for activity and leisure) had 28 staff signatures. Observation on 1/30/2025 at 7:03 PM revealed the MCU nurse station where the PAL (preference for activity and leisure) binder was located. The PAL (preference for activity and leisure) binder reve[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. 2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for serious harm, disability, or death. The findings included: Observations 1/8/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. Observation on 1/9/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. Observation on 1/10/2024 at 9 AM revealed a staff member was placed at the front door to monitor people coming in and out of the facility. 1. Record review of Resident #1's admission Record dated 1/7/2025 revealed he was admitted on [DATE] with diagnoses of vascular dementia ( type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen supply), epilepsy ( chronic brain disorder that causes seizures, which are brief episodes of involuntary movement.), language deficits, unsteady on feet, anxiety, major depressive disorder, and psychotic disorder with hallucinations (severe mental illnesses that can cause hallucinations and delusions). Record review of Resident #1's admission Record revealed he was discharged on 7/19/24. Record review of Resident #1's consolidated physician orders for January 2025 revealed he had an order for wander guard dated 7/2/2024, device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering. Record review of Resident #1's MAR (medications administration record) revealed device alarm change every 90 days, device alarm check via electronic machine every day every shift, device alarm visually check every shift for wandering and monitoring every 15 minutes. Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 4 (severely impaired cognition), epilepsy, behaviors of rejecting care and has a walker. After elopement the new interventions for Resident #1 was placed on q 15 minutes, visited by psychological MD and moved to a secure unit. Record review of Resident #1's care plan (initiated 6/12/23 and prior to 5/25/24 incident) revealed he was at risk for elopement with interventions including Assess for distress; Contact family to sit with resident or deescalate situation; Device alarm change every 90 days; Visual check wander guard to left wrist q shift due to elopement risk; Wander guard check via electronic check every day due to elopement risk; Encourage resident to stay in common areas of building for observation if needed; Provide resident with safe place to wander if necessary. Following the elopement on 5/25/24, new intervention for Resident #1 was Monitor resident closely for signs/symptoms of increased wandering and desire to keep walking. New interventions were Resident #1: Resident will be monitored every 15 minutes until evaluated by psych on 5/29/24 (5/28/24); Redirect patient from doors (5/28/24); Involve patient in decision making regarding daily choices (5/28/24); Involve patient in preferred activities (5/28/24); Assess for risk of elopement per living center policy (5/28/24); Use wander guard placed on right ankle (6/11/24); Wander guard place on bottom of wheelchair seat as tolerated (7/12/24). Record review of Resident #1's Wandering assessment dated [DATE] revealed he was forgetful/short attention span, mobility was independent, known wanderer/history of wandering and had a wander guard- scored a 12.0- high risk. Record review of Resident #1's head to toe assessment dated [DATE] revealed no skin issues. Record review of Resident #1's Pain assessment dated [DATE] revealed he was resistant to care/medication aggressiveness/physically or verbally abusive and had no pain. Record review of Resident #1's progress note Interdisciplinary Team dated 5/25/2025 revealed elopement, due to Resident #1's diagnosis of dementia and baseline cognitive status resident #1 is a poor decision maker with poor impulse control resident can ambulate and likes to walk and venture around facility. Resident #1 stated he was trying to take a walk with no distress or agitations noted prior to exiting. intervention were abuse/neglect in service, and elopement in services. The MD and family were notified by DON, ADON, MDS staff. Record review of Resident #1 psychological consult dated 5/2/2024 stated he was oriented to person, time, impaired to place and was to assess Resident #1's safety and comfort with no concerns of any type. Record review of intake 506765, on 5/25/24 at 5:45 PM revealed, Resident #1 left the building. An off-duty staff member informed the facility the resident was seen outside. The resident was found at a bus station (less than a mile away) stating he was going to work. Staff were able to get the resident to come back to the facility. Resident #1's responsible party, ADM, DON, ADON and physician were notified. Record review of intake 506765 had a provider investigation and staff were in-serviced on abuse/neglect, elopement. Record of in-services was completed by all staff on 5/26/2024. Record review of Resident #1's intake, on 5/26/24 at 7:30 PM revealed, Resident #1 attempted to leave the building, and his wander guard sounded. Staff responded to the alarm and found resident outside of the facility. They were able to redirect him back inside, and there were no injuries. 2. Record Resident #2's admission Record dated 1/8/2025 revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), major depressive disorder (a serious mental illness that causes a persistent low mood, loss of interest, and other symptoms that can affect daily life), cognitive communication deficit, dementia (a general term for a group of diseases that cause severe memory and thinking loss), and asthma (a chronic lung disease that causes inflammation and tightening of the muscles around the airways.). Record review of Resident #2's physician orders dated 6/7/2024 for resident to wear a wander guard at all times due to elopement risk. visual check wander guard to right ankle every shift due to elopement risk. Record review of Mar (medication administration record revealed this was completed. Record review of Resident #2's optional state assessment MDS dated [DATE] revealed she had a BIMS score of 5 out of 15 (severely impaired), she mobilized with walker. Record review of quarterly MDS dated [DATE] revealed she had a wander/elopement alarm. Record review of Resident #2's care plan (initiated 10/10/18 and prior to 6/6/24 incident) revealed she was at risk for elopement with interventions including Distract resident from wandering by offering structured activities; Wander guard alarm: Change every 90 days and as needed. New intervention was Resident #2: Check placement and function of safety monitoring device every shift; Visual check wander guard to right ankle every shift due to elopement risk (6/10/24); Wander guard check via electronic machine every day due to elopement risk (6/10/24). Record review of intake # 509407, Per facility self-report, on 6/6/24 between 4 and 5 PM, Resident #2 had family visiting and was attending an activity. The resident's [family member]informed staff she was missing. Resident #2 was found down the street in front of a church (less than a mile away) and said she was looking for her [family member]. The temperature was 93 that day. Resident #2 was given a head-to-toe assessment upon return to the facility and was sent to the ER for further assessment. Resident #2's ER paperwork revealed heat exhaustion, unspecified, and no other injury. She returned to the facility the same night. Record review of Resident #2's Elopement Risk assessment dated [DATE] revealed she scored an 8-high risk and care plan was initiated/updated to reflect interventions. Record review of Resident #2's 6/6/2024 and 6/12/2024 Head to toe Assessment revealed no injuries. Record review of in-services dated on 6/6/2024 revealed in was on Abuse/Neglect/Explotation, Elopement, Front door, and Resident Rights with all staff. Observation on 1/9/2025 at 2:25 PM revealed Resident #2 had her wander guard on her ankle. Interview on 1/7/25at 1:14 PM with LVN F stated they kept a binder of residents that were wander/elopement for staff to check, but most staff know which resident have wandering behaviors. Resident #1 would sundown at night and be more confused. Staff monitored him, but she was not sure how he eloped out of facility. LVN F stated she was not sure how Resident #2 eloped, maybe a family member let her out. LVN F stated no other residents had eloped. Staff try to re-direct residents that wander towards the exits, now they have a staff person near the front door. Interview with previous DON G stated #1 was found at the bus stop and not sure how he left the facility and was not gone more than 15-20 minutes. The previous DON G stated they started the elopement protocol to find Resident #1, he was not injured when they found him. Resident #1 was discharged to another facility that could be more appropriate for his aggressive behaviors and a secure unit. The previous DON G stated Resident #2 had left the building and the family had alerted them, the staff started the elopement protocol, they found Resident #2 less than a mile, at a church. The previous DON G stated they conducted a head to toe and decided to take her to the local clinic, she had heat exhaustion with no other injuries. The previous DON G stated her new interventions was a wander guard bracelet to wear in her ankle. Resident #2 had not had any previous elopements. The previous DON G stated she did conduct in-services with all staff for elopement. Interview 1/8/2025 at 11:19 AM with the previous Maintenance supervisor H stated he found Resident #1 at the church nearby. He was trained on the elopement protocol. Maintenance supervisor H stated Resident #2 had no injuries and offered her water due to a warm day. Maintenance supervisor H stated he tested the wander guard monitors frequently and documented Interview 1/9/2025 at 1:46 PM with the previous Administrator A stated Resident #1 was aggressive, so they worked with family/Ombudsman to get him transferred to a safe facility, since it was not safe for him at this facility. The Administrator stated she had reported the elopements to the STATE and trained staff on elopements. Administrator A stated there were new interventions in place for Resident #1 and #2. The new interventions for Resident #1 was to transfer him to a secure unit q 15 minute checks, and psychological MD visit Intervention for Resident #2 was a wander guard. Interview 1/8/2025 AT 1:32 pm with Resident #2's family stated Resident #2 was found in 30-45 minutes and they took her to the local clinic for evaluation, she was dehydrated. The Family stated the facility acted immediately to Resident #2 missing, she had dementia and felt safer with her wander guard. Interview 1/10/2025 at 4:29 PM with the medical director stated she was aware of the elopements and facility discussed in AD Hoc meeting. Record review of in-services dated 5/26/2024 on Wandering/Elopement, Abuse/Neglect protocol/door alarm/ Resident Rights were completed with all staff. Record review of check operations of door monitoring and resident, and test for doors and locks dated the week of 5/27/2024 and 6/7/2024. Record review of Policy Wandering and Elopement dated 2019 revealed the facility will identify residents who are a t risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation l. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f document relevant information in the resident's medical record. Record review of the Policy Wander guard (no date) revealed: Identification: Identify residents who are at risk of wandering Consent: Obtain consent from residents, family members. Monitoring: Regularly check on residents to ensure they are safe Response Facility Protocol: Staff is to respond to alarms immediately. Ensure resident is Safe. Redirect Resident to safe environment. Maintenance: Ensure the monitoring system works properly, even during power outages Wander guard devices Wristbands: Electronic bracelets Door controllers: Devices that monitor doors and send alerts if they are opened without authorization were completed, before surveyor entered the facility. The AIT-Administrator was notified on 1/10/25 at 4 PM, an PNC IJ situation had been identified due to the above failures. The PNC IJ template was given to the administrator on 1/10/24 at 4 PM. Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 1/10/2025. Interventions: Interviews with staff total was 35 all staff were in serviced on Elopement/Wandering, Abuse/Neglect, Door Alarms and to check resident devices (wander guards every shift) and understood the elopement protocol. Interviews on 1/8/2025 at 1:21 PM-5pm and 1/9/2025 at 1 PM-6 PM. Scheduled shift were 6-2 PM, 2-10 PM. 10pm-6 AM. 1. CNA J, 2. LVN F 3. CNA K 4. CNA L 5. CNA M 6. LVN N 7. CNA O 8. CNA P 9. CNA Q 10. CMA R 11. MDS 12. LVN S 13. LVN T 14. DOR (director of rehabilitation) 15. CNA U 16. CNA V 17. ADON 18. Maintenance Director 19. CNA Y 20. CNA Z 21. CNA AA 22. CNA BB 23. RN CC 24. CNA DD 25. LVN EE 26. CNAFF 27. [NAME] GG 28. Dietary HH 29. Hsk II 30. Hsk JJ 31. HSK KK 32. Laundry LL Record review of the facility Elopement Binder had 7 current residents for wandering behavior, it contained face sheet and care plans for wandering. Observations on 1/10/2025 at 10am of residents in the elopement binder were checked for wander guard and were randomly checked at the door alarm throughout the day. Observations and interview with the Maintenance Supervisor on 1/9/25 at 745 am-8:05 am stated he began employment in October at the facility; he stated that all of the facility doors were alarmed but the front door and the exit door for C-hall needed more attention for better security and are working properly now; the Maintenance Director stated that he checks all facility exit doors for security purposes twice a day-at the beginning of his shift and the end of his shift; all of the facility exit doors were observed by Surveyor with the Maintenance Director as noted: Facility Front door-alarmed and working D-hall exit door-alarmed and working; the Maintenance Director stated that a new mag lock was installed and he will provide paperwork for Surveyor E-hall-exit door at the end of the hallway was alarmed and worked; door in lounge on hallway was alarmed and opened to outside open smoking area with two locked gates that were checked and secure. A-hall-the door leads to a small courtyard area and was alarmed; the MD stated that the alarm is turned off and back on when he enters for the day and leaves at night and stays on during the w/c; the door stays locked without the alarm being on; the MD stated that the door stays alarmed on the w/e. B-Hall- the exit door was alarmed; the MD stated he plans to purchase another mag lock for this door; he stated that he had been also turning this alarm on/off during his work hours to allow for multiple deliveries thru out the day and the door stays locked; Surveyor suggested that he keep this door alarmed at all times. C-Hall-exit door alarmed and working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for one of six residents (Resident #5) reviewed had a change of condition. The facility failed to notify the wound care physician, primary care physician, and Resident #5's resident representative of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough(debris that appears tan, yellow, green or brown in color) and eschar (hard plaque that is tan, brown or black in color). An Immediate Jeopardy (IJ) situation was identified on 09/17/2024 at 4:57 p.m. While the IJ was removed on 09/19/2024 at 6:05 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diabetes mellitus (a chronic disease that affects how the body uses insulin and glucose), end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and hypertension (high blood pressure in the arteries that carry blood from the heart to the resident of the body). Record review of Resident #5's quarterly MDS, dated [DATE], reflected Resident #5 had short-term and long-term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired. Section GG Functional Abilities and Goals reflected Resident #5 used a wheelchair for mobility and required partial to moderate assistance with rolling left and right in bed and transferring from bed to wheelchair. Section H Bladder and Bowel reflected Resident #5 was frequently incontinent of bowel and bladder. Section M Skin Conditions reflected Resident #5 was at risk for developing pressure ulcers and had moisture associated skin damage (MASD; incontinence-associated dermatitis, perspiration, drainage). Record review of Resident #5's care plan, initiated 05/22/2024 and revised 05/30/2024, reflected Resident #5 had a pressure ulcer or potential for pressure ulcer development related to needing assistance with repositioning, diabetes, end stage renal disease and dialysis, 3 days a week. The goal was Resident#5 would have intact skin, free of redness, blisters or discoloration by/through review date, 09/12/2024. The intervention was Resident #5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #5 had an additional care plan, initiated on 08/01/2024 and revised on 08/02/2024, stating Resident #5 had altered skin integrity, non-pressure related to MASD on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). The goal was for the affected area to heal without complications, target date 09/21/2024. Interventions included: a) evaluation for pain prior to cleansing or dressing changes b) monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor and notify physician of significant findings c) notify practitioner if symptoms worsen or do not resolve d) nutritional and hydration support e) provide thorough skin care after incontinent episodes and apply barrier cream f) skin assessment to the complete per living center policy g) treatments as ordered - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing as needed if soiled or removed at every day shift every Tuesday, Thursday and Saturday. Record review of Resident #5's progress note, written by LVN A on 07/28/2024, reflected resident has skin breakdown to sacrum, will have wound care evaluate, notify doctor, daughter, and DON, per [nurse name] with [physician name], she ordered cleanse with n/s pat dry apply hydrocolloid change q 72 hours, add vitamin c 500 mg bid x 30 days. MVI with Mineral 1 tab daily, zinc sulfate 220mg 1-tab daily x 14 days. Record review of Resident #5's progress note written by the Treatment Nurse, dated 08/01/2024, reflected the treatment nurse rounded with the wound care physician and the area is MASD to sacrum, new orders are to apply Medi honey, alginate, dry foam dressing T. TH. S, prn if soiled. Record review of Resident #5's weekly head to toe skin check, completed by the treatment nurse, dated 08/01/2024, reflected Resident #5 had a MASD - 3.0 x 1.4 x .2, pink, serous, moderate drainage on the sacrum. Wound documentation reflected Medi honey, alginate, dry foam dressing. Record review of Resident #5's August 2024 treatment administration record revealed an order for MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. Resident #5 also had an order MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly head to toe skin check, dated 08/12/2024 written by the treatment nurse, reflected Resident #5 had non pressure wound to sacrum- 1.5 x 0.4 x 0.1cm, moderate serous drainage, open areas with exposed dermis. Record review of Resident #5's initial wound evaluation and management summary, dated 08/12/2024 by the wound care physician, reflected Resident #5 was seen for a wound on her sacrum. The focused wound exam listed etiology as moisture associated skin damage. Duration was documented as less than 50 days. The objective was healing/maintaining healing. The wound size was documented as 1.5 x 0.4 x 0.1 cm and surface area was 0.60 cm. Exudate (fluid released by an organism through pours or a wound) was documented as moderate serous (clear or pale-yellow water fluid that is found in the body especially in the spaces between organs and membranes) and dermis (middle layer of skin) was documented as open areas with exposed dermis. Record review of Resident #5's progress note, by the treatment nurse, dated 08/12/2024, reflected Resident #5's wound care orders remained the same for non-pressure wound to sacrum. Record review of Resident #5's weekly wound review by the treatment nurse, dated 08/19/2024, reflected Resident #5 had a non-pressure wound on her sacrum measuring 2 x 1 x .2 cm. Resident #5 had 30% slough and 0% eschar and serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's daughter was notified. Record review of Resident #5's wound care physician progress note, dated 08/19/2024, revealed signing off without visit- in house. Record review of Resident #5's wound care physician progress note, dated 08/26/2024, reflected Resident #5's weekly visit was rescheduled due to Resident #5 being gone from the facility at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 08/28/2024, reflected Resident #5 had a non-pressure wound on the sacrum measuring 2 x 1 x .03 cm. Resident had 30% slough and 0% eschar with scant serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's family notification was blank. Record review of Resident #5's September 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. MASD on sacrum-cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/04/2024, reflected Resident #5 had a non-pressure wound to the sacrum measuring 2 x 2 x 0.2cm. The slough and eschar percentages were blank, and drainage was marked as scant. The physician and family notification sections were blank, and the treatment plan was blank. Record review of Resident #5's progress note, dated 09/04/2024, by the treatment nurse, reflected resident continues with non-pressure wound to sacrum. Area remains the same at this time. Resident continues to attend dialysis and have extended time sitting in wheelchair. Will continue to encourage and offload and reposition throughout shift. Record review of Resident #5's weekly wound review completed by treatment nurse, 09/09/2024 at 1:41 p.m., revealed Resident #5 has MASD to the sacrum measuring 2 x 0.6 x .2 and had 20% slough and 10% eschar with no drainage. The physician notification was checked as completed but there was no name of physician or date and time of notification. The family notification section was blank. The treatment plan was Medi honey, alginate, board gauze. Record review of Resident #5's wound care physician progress note, 09/09/2024, reflected the patient's visit has been rescheduled. She is at dialysis. Record review of hospital photos reflected a sacrum wound, dated 09/09/2024 at 11:20 p.m. that revealed a wound bed covered in slough and black eschar necrotic tissue, and a left heel purple wound, dated 09/09/2024 at 11:30 p.m. Record review of Resident #5's hospital wound care note, by the hospital wound care RN, dated 09/11/2024 at 1:47 p.m., reflected a wound assessment located on the coccyx, classified as an unstageable pressure injury. The description of the wound was large, foul-smelling wound with dark, boggy necrotic tissue covering wound bed. Necrotic tissue extends down to the perirectal area. Wound measurement is 12.4cm x 8.0cm. A second wound located on the left heel was classified as a deep tissue injury. The wound was described as dark purple, but intact tissue overlying heel and measured 2.5 x 2.3cm. The hospital wound RN stated patient will likely need debridement to this wound but unsure if she is an ideal surgical candidate. Patient with leukocytosis, likely due to wound. Patient was not responsive during assessment and did not wake to movement. Patient being offloaded on specialty bed with bilateral heel protectors. Record review of Resident #5's hospital consult notes, dated 09/11/2024 at 2:19 p.m., reflected Resident #5 presented with leukocytosis and found to have unstageable sacral decubitus ulcer and a general surgery consult for possible debridement. The note also stated Resident #5 had an unstageable sacral decubitus ulcer with necrotic tissue and concern for infection. Under Medical Decision Making the consult note reflected will take her to the operating room tomorrow in the morning for debridement of the area with possible wound vac placement. Patient is a very poor surgical candidate for any other intervention. Will take cultures intraoperatively. Continue neurological workup. Consider hospice discussion. Record review of hospital physician progress note dated 09/11/2024 at 10:05 p.m., reflected Resident #5 had significant metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood that effects to brain) in the context of an acutely infected ulcer. The note also reflected the patient has a significant wound on her buttocks, which is black with foul odor, suggestive of necrosis or infection. Record review of the hospital operative surgeon note, dated 09/12/2024 at 1:01 p.m., reflected Resident #5's surgical procedure performed was incision, drainage and debridement of sacral decubitus ulcer, sacral bone biopsy, substitute skin graft product placement and negative pressure wound VAC therapy (a device that removed pressure over the area of the wound that can help a wound heal and gently pulls fluid from the wound). Post Operative diagnosis stated, unstageable infected sacral ulcer, abscess, concern for osteomyelitis. Findings documented were 9 x 7 x 3cm unstageable infected sacral decubitus ulcer with associated abscess and significant necrotic tissue. Record review of Resident #5's physician progress note, dated 09/15/2024 at 11:41 a.m., reflected Resident #5's sacral decubitus ulcer wound culture collected on 09/12/2024 was positive for E coli, a type of bacteria that can cause diarrhea, vomiting and kidney failure. During an interview with Resident #5's family member on 09/14/2024 at 1:57 p.m., Resident #5's family member stated she was notified by hospital staff when Resident #5 arrived at the hospital and Resident #5 was unresponsive and had one wound on her heel and a bad one on her bottom. Resident #5's family member said she was never notified by the facility that Resident #5 had a wound on her heel or bottom. The family member stated she was told by the facility Resident #5 had a diaper rash. Resident #5's family member said she was told by the hospital the wound on her bottom was black, and the hospital was checking to see if the infection went to her bone. During an interview with Hospital RN Z on 09/14/2024 at 3:20 p.m., Hospital RN Z said Resident #5 admitted with a diagnosis of metabolic encephalopathy (alteration in consciousness) and sepsis. Hospital RN Z said Resident #5 had a DTI to her left heel and she had a very bad sacrum wound and was now on a wound vac. Hospital RN Z stated the hospital took pictures of the wounds upon admission. During an interview with the facility Treatment Nurse on 09/15/2024 at 12:54 p.m., the treatment nurse revealed she began doing treatments at the facility at the beginning of August 2024. She stated her role as the treatment nurse was to assess skin, round with the wound care physician, take orders, notify the doctors and family of changes with the wound and provide wound care daily. The treatment nurse stated wound treatments were documented on the resident TAR and she was notified of changes in the resident skin by the direct care staff and also received copies of the resident shower sheets. The treatment nurse stated she performed skin assessments weekly and the last time she completed a skin assessment for Resident #5 was on the morning of 09/09/2024 around 5am-6am prior to Resident #5 going to dialysis. The treatment nurse described Resident #5's wound on the morning of 09/09/2024 as pink with scant amount of drainage and close to her sacrum. She said Resident #5 had no eschar and the skin was pink and moist. The Treatment Nurse said she did not look at Resident #5's heels that morning and was not aware of Resident #5 having a wound on her left heel. The Treatment Nurse stated she did a treatment on Resident #5 on the morning of 09/09/2024 and said she did not know why it was not documented on Resident #5's TAR as being completed. The Treatment Nurse revealed the Wound Care Physician rounded at the facility weekly and should have seen Resident #5 weekly but stated the Wound Care Physician often rounded while Resident #5 was at dialysis. The Treatment Nurse stated she thought it had been a couple of weeks since the wound care physician had assessed Resident #5's wound. The Treatment Nurse described the wound as MASD and the wound was around 2.0 x1.0 x0.4cm. During an interview with the facility Treatment Nurse on 09/15/2024 at 2:30 p.m., the treatment nurse stated when the wound care physician missed observations of Resident #5 each week she, just told her it was the same each time and she said if it gets worse to send her a picture. The Treatment Nurse stated the wound assessments she completed on 08/12/2024 was the original date the wound care physician assessed the wound so the treatment nurse would write down that date on each of the assessments. The treatment nurse said she did not have any documentation to prove she made notifications each time the wound was assessed and noted to be changing. During an interview with the facility Wound Care Physician on 09/16/2024 at 11:39 a.m., the physician stated she began assessing residents at the facility at the beginning of August 2024 and the facility would request the consult and the resident would get added to her list of residents to assess each week. The Wound Care Physician stated she observed Resident #5 sacrum wound on 08/12/2024 and said the wound measured 1.5 x 0.4 x 0.1cm and looked like dermis and classified as MASD. We do not assign a stage to MASD and cannot really measure a depth less than .1. It was superficial and looked like irritation. The Wound Care Physician stated she was supposed to assess Resident #5 weekly but Resident #5 was always gone to dialysis when she would come by to make rounds. She stated she relied on the treatment nurse to guide her to tell her which patients needed to be seen, if they were not at the facility from her previous visit, then she tried to make accommodations to see the resident. The Wound Care Physician stated she received updates on resident progress if she did not see them, she communicated very closely with [treatment nurse name]. We also have an option to do a telemedicine visit, because I am new, I have not mastered that, but it is something we can do in the future. The Wound Care Physician said there was a discussion about changing Resident #5's dialysis treatment days because I go to multiple facilities and my schedule is not flexible. The Wound Care Physician stated the Treatment Nurse mentioned she noticed some changes on Resident #5's wound on 09/09/2024 but did not say what type of changes. The Wound Care Physician stated she was not notified of the slough and eschar tissue documented on the treatment nurse assessment on 09/09/2024 and said if she was notified of she would have known the wound needed a debridement. The Wound Care Physician said I would have expected to be notified immediately that there is necrotic tissue and slough, that is a big change. I was just notified by [treatment nurse name] that she wanted me to come by and look at the wound sometime that week and we were talking about me coming on 09/11/2024. She did not tell me the current status of the wound. The Wound Care Physician stated she would have changed the treatment order if she was notified about the slough and eschar development on the wound and stated my suspicion is there is tissue that needed to be removed. That is not optimal that it was not removed. Without seeing the wound, I can only say that I think that the non-viable tissue needed to be removed. The Wound Care Physician stated she would have expected to be notified about the change in the wound and she said the facility treatment nurse did not notify her of necrotic tissue The wound care physician was shown a photo of Resident #5's sacrum wound taken at the hospital on [DATE] at 10 p.m. and said that is very different than what I have seen or been notified of. I had no idea it looked like that. Oh geez, that is bad. If I knew it looked like that, I would have come in on a Saturday. I am a surgeon by training, I can smell the wound, I know how it is supposed to look and not look. We do have patients that are more complicated. If I knew it looked even 10% of that I would have debrided it. The Wound Care Physician also stated The honey and alginate did not make it worse; it just would not have done anything to heal it. It needed further treatment. The Wound Care Physician was asked how long it could take a wound to get to that stage and she said It could not happen in 8 hours. People on dialysis and diabetic progress pretty quickly. It could have been a week or 3 weeks but would not develop like that. Yeah, given her diagnosis, I would say a week to 2 weeks. During an interview with the facility Treatment Nurse on 09/16/2024 at 1:00 PM, the Treatment Nurse stated Resident #5 did not have necrotic tissue on her sacrum when she assessed her. The Treatment Nurse was shown her assessment from 09/09/2024 that reflected the Treatment Nurse documented Resident #5 had 10% necrotic tissue and 20% slough and she said yes, there may have been some eschar in there, I told the wound care physician it had gotten larger on 09/09/2024. The Wound Care Physician knew there was slough, I don't know if I mentioned the eschar. When asked if she had any documentation to support her notification, she said no but knew she called her and told her the wound was bigger on 09/09/2024 and she should have told her about the eschar. The Treatment Nurse was asked if she notified the Wound Care Physician about Resident #5 wound changes and slough from her 09/04/2024 assessment and she said I text The Wound Care Physician all the time, we just haven't been able to get together. I guess we could have gotten together and did a video chat. No, I don't have anything documented that I notified her, just verbally and I know I should have documented it. The Treatment Nurse said it was important to notify the physician of changes so we can change something and go in a different direction. Just the size was concerning, and I know she sits up a lot, but we could have changed the order, frequency or done something different. The Treatment Nurse stated she should have also notified Resident #5's primary physician if the wound was changing and Resident #5 was not being assessed by the Wound Care Physician. During an interview with Resident #5's primary facility physician on 09/16/2024 at 2:12 p.m., the Physician stated he last observed Resident #5 approximately two weeks prior to 09/16/2024. The Physician stated he did not see the sacrum wound and a wound care physician followed Resident #5. The Physician stated the Wound Care Physician should be notified of changes in wounds so the treatment orders could have been changed to address the changes in the wound and said I would hope the wound care physician would know about it because it is their responsibility. The physician stated he was not notified of Resident #5's wound having slough or eschar and stated I would expect the wound care doctor to be notified of that. I would be notified if the patient needs other things like antibiotics. If there was no wound care doctor I would want to be notified. The Physician was asked if he was notified of any change in condition with the resident and he said lethargy and altered mental status was not new for Resident #5 and she was declining for the last few months. The Physician was asked what should have been done if the Wound Care Physician was not able to see Resident #5 weekly and he said That is a question for the facility, what do they do when a provider doesn't come? I don't see the patient wounds because the wound care nurse should be following orders from the wound care doctor. During an interview with the facility DON, on 09/16/2024 at 4:07 p.m., the DON said the facility had a treatment nurse Monday - Friday and charge nurses were responsible for wound care on the weekends if the treatment nurse was not there. The DON said the facility had a clinical meeting daily and the charge nurses went to the meeting and gave report on the residents and the facility had a weight and skin meeting weekly on Wednesdays. The DON stated wound care was validated and monitored for wound healing through communication between the DON, Treatment Nurse and Wound Care Physician, and the Treatment Nurse kept a log of wounds which was reviewed weekly by the Corporate Nurse. The DON stated the Treatment Nurse was responsible for notifying the Wound Care Physician of wound changes, documenting the notification in the medical record and following new orders. The DON stated her expectation was for the Treatment Nurse to identify any changes in a resident wound and report those changes immediately so an appropriate treatment was implemented. When asked what harm can happen to a resident if the physician is not notified of changes in their wounds, the DON stated if the intervention is not working and you are not getting the results that you need, a lot of factors can effect wound healing including nutrition or other comorbidities and the physician should be notified so the physician could make a clinical judgement on what to do. The DON said she knew Resident #5 had MASD on her sacrum but never observed the wound. The DON said she was not informed Resident #5's wound had changed or developed slough and eschar and said she would have expected to be notified of these changes immediately. During an interview with the Hospital Wound Care RN on 09/17/2024 at 10:13 a.m., the Hospital Wound Care RN stated she assessed Resident #5 on 09/11/2024 and observed an unstageable pressure ulcer with full eschar, necrotic tissue covering the wound and could not see the depth. The Hospital Wound Care RN said the sacrum wound had a foul odor and Resident #5's laboratory results reflected a high white blood cell count that indicated the wound needed an urgent surgical debridement the Hospital Wound Care RN stated she submitted a surgery consult request and Resident #5 was taken for surgery on 09/12/2024 and received a debridement, skin graft and bone biopsy. The Hospital Wound Care RN also revealed Resident #5 had a wound vac placed on the sacrum wound and an order to leave it on for one week. The Hospital Wound Care RN stated slough usually appeared on a stage 3 wound and if Resident #5 had 10% eschar documented prior to hospitalization, the wound would not have been classified as MASD and should have been classified as a pressure ulcer. The Hospital Wound Care RN also stated Resident #5's wound, in her opinion would take at least a week to develop on a patient who was never turned or repositioned and about 2- 3 weeks for a patient who was repositioned and had other comorbidities. During an interview with the Wound Care Physician on 09/17/2024 at 11:32 a.m., with the DON, Treatment Nurse, Administrator and Corporate RN present, the Wound Care Physician was asked about her assessing Resident #5 on 08/12/2024 and not receiving any updates on Resident #5 until 09/09/2024 and the wound care physicians said, that is because there were no changes with the wound until 09/09/2024. The Wound Care Physician said when she spoke to the Treatment Nurse on 09/09/2024, the treatment nurse told her there were changes in the wound, but she did not remember exactly what the changes were because they discussed so many wound when she was rounding. The Wound Care Physician said whatever the change that occurred prompted her to change her schedule and make a plan to go see Resident #5 outside of her regular schedule, but the resident was sent to the hospital. The Wound Care Physician hung up the call at 11:40a.m. and the other members stayed in the room. The Treatment Nurse was asked where she documented the physician notification of the wound changes, and she said it was not documented. The treatment nurse said she did not call any other physicians, did not notify the DON and did not add any additional interventions to prevent the wound from worsening. The Treatment Nurse states she was responsible for notifications. The Treatment Nurse and DON stated they did not know what N/A meant and the DON stated it was a process she was working on This was determined to be an Immediate Jeopardy (IJ) on 09/17/2024 at 4:55 p.m. The Administrator and the DON were notified, The Administrator and the DON were provided with the IJ Template on 09/17/2024 at 4:57 p.m. The following Plan of Removal submitted by the facility was accepted on 09/18/2024 at 4:52 p.m.: [Facility Name and Address] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On September 14, 2024 an investigation was initiated at [Facility Name and Address]. At approximately 5:00 p.m. on September 17, 2024 a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at [the facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F580 - Notice of Changes Immediate Corrections Implemented for Removal of Immediate Jeopardy. On September 9, 2024 Resident #5 was transferred to the hospital after becoming unresponsive at dialysis. Action: Through review of hospital record, facility identified Resident #5 was at baseline upon being received to dialysis center and became unresponsive during treatment. Intake to emergency department reveals physician plan to address the following diagnosis: seizure-like activity, leukocytosis, ESRD on dialysis On September 17, 2024, at approximately 7:00am the following action was taken: Action: 100% skin sweep of 85 of 85 residents to identify and ensure no new skin pressure areas were observed. Any resident identified to have a skin pressure area had documentation updated in facility electronic medical record system. Responsible party and physicians were notified. Resident care plans were reviewed to ensure care plan was up to date. Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: DON Action: All licensed nursing staff were provided education and in-servicing on requirement to notify responsible party and physician of new or worsening skin pressure conditions. Nursing staff were educated on what conditions constituted a change included but not limited to change in size, color, appearance and smell. Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: DON Action: Facility implemented Stop and Watch notification process. All staff were educated on identification, notification and utilization of stop and watch process. The stop and watch process will utilize a predetermined questionnaire, accessible by all staff, to identify any potential change in condition to include but not limited to, cognition, skin condition, ADL assistance, etc. The questionnaire form will have a carbon copy attached to the original form being completed. Upon staff identification of potential change in cognition, skin condition, ADL assistance, etc., the form will be completed and given to the charge nurse. The charge nurse will review documentation on the Stop and Watch form and follow facility protocol to address any potential change. The carbon copy of the form will be provided to ADON/designee to ensure daily, Monday through Friday, timely follow up, documentation and notification has been completed. ADON/designee will bring copies to daily clinical meetings, Monday through Friday, and provide update to Director of Nursing. Start Date: 9/17/2024 Completion Date: 9/18/2024 Responsible: DON Action: Ad hoc QAPI meeting held with IDT team and MD to review Plan of removal/response to Immediate Jeopardy Citation on 9/17/2024 Start Date: 9/17/2024 Completion Date: 9/17/2024 Responsible: Administrator IDENTIFICATION OF OTHER AFFECTED: All residents experiencing a change in condition have the potential to be affected. Action: Facility conducted 100% skin sweep of 85 of 85 residents to identify and ensure no new skin pressure areas were observed. Any resident identified to have skin pressure area had documentation updated in facility electronic medical record system. Responsible party and physicians were notified. Resident care plans were revi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #5) for pressure ulcers. 1. The facility failed to ensure Resident #5 received services and treatment orders to prevent sacral and left heel pressure ulcers from developing. 2. The facility failed to notify the wound care physician or primary care physician of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough [debris that appears tan, yellow, green or brown in color] and eschar [hard plaque that is tan, brown or black in color]). An Immediate Jeopardy (IJ) situation was identified on 09/17/2024 at 4:57 p.m. While the IJ was removed on 09/19/2024 at 6:05 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included diabetes mellitus (a chronic disease that affects how the body uses insulin and glucose), end stage renal disease (a condition where the kidney reaches advanced stage of loss of function) and hypertension (high blood pressure in the arteries that carry blood from the heart to the resident of the body). Record review of Resident #5's quarterly MDS, dated [DATE], reflected Resident #5 had short-term and long-term memory problems and Resident #5's cognitive skills for daily decision making were moderately impaired. Section GG Functional Abilities and Goals reflected Resident #5 used a wheelchair for mobility and required partial to moderate assistance with rolling left and right in bed and transferring from bed to wheelchair. Section H Bladder and Bowel reflected Resident #5 was frequently incontinent of bowel and bladder. Section M Skin Conditions reflected Resident #5 was at risk for developing pressure ulcers and had moisture associated skin damage (MASD; incontinence-associated dermatitis, perspiration, drainage). Record review of Resident #5's care plan, initiated 05/22/2024 and revised 05/30/2024, reflected Resident #5 had a pressure ulcer or potential for pressure ulcer development related to needing assistance with repositioning, diabetes, end stage renal disease and dialysis, 3 days a week. The goal was Resident#5 would have intact skin, free of redness, blisters or discoloration by/through review date, 09/12/2024. The intervention was Resident #5 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #5 had an additional care plan, initiated on 08/01/2024 and revised on 08/02/2024, stating Resident #5 had altered skin integrity, non-pressure related to MASD on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). The goal was for the affected area to heal without complications, target date 09/21/2024. Interventions included: a) evaluation for pain prior to cleansing or dressing changes b) monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor and notify physician of significant findings c) notify practitioner if symptoms worsen or do not resolve d) nutritional and hydration support e) provide thorough skin care after incontinent episodes and apply barrier cream f) skin assessment to the complete per living center policy g) treatments as ordered - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing as needed if soiled or removed at every day shift every Tuesday, Thursday and Saturday. Record review of Resident #5's progress note, written by LVN A on 07/28/2024, reflected resident has skin breakdown to sacrum, will have wound care evaluate, notify doctor, daughter, and DON, per [nurse name] with [physician name], she ordered cleanse with n/s pat dry apply hydrocolloid change q 72 hours, add vitamin c 500 mg bid x 30 days. MVI with Mineral 1 tab daily, zinc sulfate 220mg 1-tab daily x 14 days. Record review of Resident #5's weekly head to toe skin check, dated 07/28/2024, by LVN A, reflected Resident #5 had skin breakdown quarter size on the sacrum. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's July 2024 treatment administration record reflected an order which stated, cleanse skin breakdown on sacrum with normal saline, pat dry, apply hydrocolloid, change q 72 hours for skin breakdown to sacrum, start date 07/28/2024. Record review of Resident #5's progress note written by the treatment nurse on 08/01/2024, reflected the treatment nurse rounded with the wound care physician and the area is MASD to sacrum, new orders are to apply Medi honey, alginate, dry foam dressing T. TH. S, prn if soiled. Record review of Resident #5's weekly head to toe skin check completed by the treatment nurse, 08/01/2024, reflected Resident #5 had a MASD - 3.0 x 1.4 x .2, pink, serous, moderate drainage on the sacrum. Wound documentation reflected Medi honey, alginate, dry foam dressing. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's August 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. Resident #5 also had an order which reflected MASD on sacrum - cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly head to toe skin check, 08/08/2024 by the treatment nurse, reflected Resident #5 had MASD 1.5 x 0.4 x 0.1cm, pink, no slough, no odor, scant drainage to the sacrum. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's weekly head to toe skin check, 08/12/2024 by the treatment nurse, reflected Resident #5 had non pressure wound to sacrum- 1.5 x 0.4 x 0.1cm, moderate serous drainage, open areas with exposed dermis. The assessment reflected a heel check with no skin issues noted. Record review of Resident #5's initial wound evaluation and management summary, dated 08/12/2024 by the wound care physician, reflected Resident #5 was seen for a wound on her sacrum. The focused wound exam listed etiology as moisture associated skin damage. Duration was documented as less than 50 days. The objective was healing/maintaining healing. The wound size was documented as 1.5 x 0.4 x 0.1 cm and surface area was 0.60 cm. Exudate (fluid released by an organism through pours or a wound) was documented as moderate serous (clear or pale-yellow water fluid that is found in the body especially in the spaces between organs and membranes) and dermis (middle layer of skin) was documented as open areas with exposed dermis. Record review of Resident #5's progress note, by the treatment nurse, dated 08/12/2024, reflected Resident #5's wound care orders remained the same for non-pressure wound to sacrum. Record review of Resident #5's weekly wound review by the treatment nurse, dated 08/19/2024, reflected Resident #5 had a non-pressure wound on her sacrum measuring 2 x 1 x .2 cm. Resident #5 had 30% slough and 0% eschar and serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's daughter was notified. Record review of Resident #5's wound care physician progress note, dated 08/19/2024, reflected signing off without visit - in house. Record review of Resident #5's wound care physician progress note, dated 08/26/2024, reflected Resident #5's weekly visit was rescheduled due to Resident #5 being gone from the facility at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 08/28/2024, reflected Resident #5 had a non-pressure wound on the sacrum measuring 2 x 1 x .03 cm. Resident had 30% slough and 0% eschar with scant serous drainage. The treatment plan was Medi honey, alginate, dressing. The wound care physician was notified of the wound on 08/12/2024 and Resident #5's family notification was blank. Record review of Resident #5's September 2024 treatment administration record reflected an order for MASD on sacrum - cleanse area with wound cleanser or normal saline, pat dry, apply Medi honey, alginate, dry foam dressing every day shift every Tue, Thu, Sat for skin breakdown to sacrum, start date 08/03/2024. MASD on sacrum-cleanse area with wound cleanser or normal saline pat dry, apply Medi honey, alginate, dry foam dressing as needed for if soiled or removed, start date 08/01/2024. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/04/2024, reflected Resident #5 had a non-pressure wound to the sacrum measuring 2 x 2 x 0.2cm. The slough and eschar percentages were blank, and drainage was marked as scant. The physician and family notification sections were blank, and the treatment plan was blank. Record review of Resident #5's progress note, dated 09/04/2024, by the treatment nurse, reflected resident continues with non-pressure wound to sacrum. Area remains the same at this time. Resident continues to attend dialysis and have extended time sitting in wheelchair. Will continue to encourage and offload and reposition throughout shift. Record review of Resident #5's foot check assessment completed at the dialysis clinic, dated 09/06/2024, reflected Resident #5 presented with left heel dressing noted. Dressing clean, dry and intact. Record review of Resident #5's progress note, by LVN C, dated 09/09/2024 at 11:44 a.m., LVN C documented received a call from [name] RN from resident's dialysis center. As per [name] RN resident was transferred to [hospital name] ER for altered mental status as per nephrologist. [Name] RN notified residents daughter prior to transferring resident. Called ER but did not get an answer. Record review of Resident #5's wound care physician progress note, 09/09/2024, reflected the patient's visit has been rescheduled. She is at dialysis. Record review of Resident #5's weekly wound review completed by the treatment nurse, dated 09/09/2024 at 1:41 p.m., reflected Resident #5 has MASD to the sacrum measuring 2 x 0.6 x .2 and had 20% slough and 10% eschar with no drainage. The physician notification was checked as completed but there was no name of physician or date and time of notification. The family notification section was blank. The treatment plan was Medi honey, alginate, board gauze. Record review of Resident #5's dialysis report, dated 09/09/2024 at 11:13 a.m., reflected treatment early due to clotting with minimal blood loss. Post treatment patient hard to arouse and MD order to refer to [hospital name] ER per EMS: AMS. Record review of hospital photos reflected a sacrum wound, dated 09/09/2024 at 11:20 p.m. that revealed a wound bed covered in slough and black eschar necrotic tissue, and a left heel purple wound, dated 09/09/2024 at 11:30 p.m. Record review of Resident #5's hospital admission H&P, dated 09/09/2024 at 7:30 p.m., reflected Resident #5 was admitted due to AMS during dialysis and Resident #5 was dialyzed for 3 hours and went unconscious. Resident #5 was acting normal prior to the start of dialysis. When Resident #5 arrived at the hospital, Resident #5 was completely obtunded (a state of reduced alertness or consciousness) with inability to answer any questions with some deviated gaze as well as significant facial droop. The assessment/plan reflected: 1) seizure-like activity 2) leukocytosis (elevated white blood cell count indicating an infection, inflammation or injury) - treat this patient for possible episode of sepsis (chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body that can damage multiple organs, leading them to fail, sometimes resulting in death) due to pronounced leukocytosis with neutrophilia (caused when a body produces too many neutrophils which are a type of white blood cells). No clear source at this point. Record review of Resident #5's hospital wound care note, by the hospital wound care RN, dated 09/11/2024 at 1:47 p.m., reflected a wound assessment located on the coccyx, classified as an unstageable pressure injury. The description of the wound was large, foul-smelling wound with dark, boggy necrotic tissue covering wound bed. Necrotic tissue extends down to the perirectal area. Wound measurement is 12.4cm x 8.0cm. A second wound located on the left heel was classified as a deep tissue injury. The wound was described as dark purple, but intact tissue overlying heel and measured 2.5 x 2.3cm. The hospital wound RN stated patient will likely need debridement to this wound but unsure if she is an ideal surgical candidate. Patient with leukocytosis, likely due to wound. Patient was not responsive during assessment and did not wake to movement. Patient being offloaded on specialty bed with bilateral heel protectors. Record review of Resident #5's hospital consult notes, dated 09/11/2024 at 2:19 p.m., reflected Resident #5 presented with leukocytosis and found to have unstageable sacral decubitus ulcer and a general surgery consult for possible debridement. The note also stated Resident #5 had an unstageable sacral decubitus ulcer with necrotic tissue and concern for infection. Under Medical Decision Making the consult note reflected will take her to the operating room tomorrow in the morning for debridement of the area with possible wound vac placement. Patient is a very poor surgical candidate for any other intervention. Will take cultures intraoperatively. Continue neurological workup. Consider hospice discussion. Record review of hospital physician progress note dated 09/11/2024 at 10:05 p.m., reflected Resident #5 had significant metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood that effects to brain) in the context of an acutely infected ulcer. The note also reflected the patient has a significant wound on her buttocks, which is black with foul odor, suggestive of necrosis or infection. Record review of the hospital operative surgeon note, dated 09/12/2024 at 1:01 p.m., reflected Resident #5's surgical procedure performed was incision, drainage and debridement of sacral decubitus ulcer, sacral bone biopsy, substitute skin graft product placement and negative pressure wound VAC therapy (a device that removed pressure over the area of the wound that can help a wound heal and gently pulls fluid from the wound). Post Operative diagnosis stated, unstageable infected sacral ulcer, abscess, concern for osteomyelitis. Findings documented were 9 x 7 x 3cm unstageable infected sacral decubitus ulcer with associated abscess and significant necrotic tissue. Record review of Resident #5's hospital MD progress note, dated 09/13/2024 at 10:57 a.m., reflected the resident received a decubitus ulcer debridement, substitute skin graft and wound vac placement on 09/12/2024. The disposition planning note stated continue wound care with negative pressure wound therapy. Wait at least 5 to 7 days for dressing change due to presence of skin graft substitute in the area. Very poor prognosis due to medical comorbidities and location of wound. Record review of Resident #5's physician progress note, dated 09/15/2024 at 11:41 a.m., reflected Resident #5's sacral decubitus ulcer wound culture collected on 09/12/2024 was positive for E coli, a type of bacteria that can cause diarrhea, vomiting and kidney failure. Record review of Resident #5 shower sheets provided by the DON for the month of August and September 2024 reflected one shower sheet marked refused on 09/07/2024, one shower sheet reflected mark on butt/red dated 08/12/2024. All other shower sheets were marked N/A. During an observation in Resident #5's room with hospital RN [NAME] 09/14/2024 at 3:25 p.m., RN A removed Resident #5 left heel dressing to reveal a quarter size purple DTI. Resident #5 did not arouse during the observation. During an interview with Resident #5's family member on 09/14/2024 at 1:57 p.m., Resident #5's family member stated she was notified by hospital staff when Resident #5 arrived at the hospital and Resident #5 was unresponsive and had one wound on her heel and a bad one on her bottom. Resident #5's family member said she was never notified by the facility that Resident #5 had a wound on her heel or bottom. The family member stated she was told by the facility Resident #5 had a diaper rash. Resident #5's family member said she was told by the hospital the wound on her bottom was black, and the hospital was checking to see if the infection went to her bone. During an interview with Hospital RN Z on 09/14/2024 at 3:20 p.m., Hospital RN Z said Resident #5 admitted with a diagnosis of metabolic encephalopathy (alteration in consciousness) and sepsis. Hospital RN Z said Resident #5 had a DTI to her left heel and she had a very bad sacrum wound and was now on a wound vac. Hospital RN Z stated the hospital took pictures of the wounds upon admission. During an interview with LVN A on 09/15/2024 at 10:56 a.m., LVN A stated she was the charge nurse for Resident #5 on the 2 p.m. -10 p.m. shift on 09/08/2024. LVN A stated she observed Resident #5's wound around 9 p.m. on 09/08/2024 when she provided wound care. LVN A stated she provided wound care to Resident #5, 2-3 times a day. LVN A stated treatments were documented on the resident treatment administration record. LVN A stated it was not documented on the TAR for 09/08/2024 and said she did not know why it was not documented. LVN A stated Resident #5 had PRN orders for wound care and said, well it was done, and I do it daily. LVN A said, on 09/08/2024 around 9pm, Resident #5's wound appeared red with greyish area and larger than quarter size and it was deep. LVN A said she would instruct staff to rotate Resident #5 when in the bed and said Resident #5 was not up and in her wheelchair long at all on her shifts but she did not work on Resident #5's dialysis days. During an interview with CNA A on 09/15/2024 at 11:21 a.m., CNA A said the last time she provided care for Resident #5 was approximately 2 weeks ago. CNA A stated Resident #5 had a quarter size red area on her bottom and said she was not aware of any other wounds. During an interview with CNA B on 09/15/2024 at 11:32 a.m., CNA B stated she had not worked in the last 2-3 weeks. CNA B stated when she observed Resident #5's wound about 3 weeks ago, it was small and I think it hurt her, maybe quarter size. She complained that it hurt every time we changed her. CNA B said she would reposition Resident #5 during the shift and said she thought Resident #5 was scheduled for baths three times a week but didn't know often she was getting them. During an interview with LVN C on 09/15/2024 at 12:28 p.m., LVN C stated she worked for a staffing agency and was the charge nurse on 6 a.m. - 2p.m. shift on 09/09/2024. LVN C said she did not assess Resident #5 prior to her leaving for dialysis on the morning of 09/09/2024. LVN C said she received a call from the dialysis clinic around noon and the nurse said Resident #5 was sent to [hospital name] ER because she had altered mental status after the dialysis procedure. During an interview with the facility Treatment Nurse on 09/15/2024 at 12:54 p.m., the treatment nurse revealed she began doing treatments at the facility at the beginning of August 2024. She stated her role as the treatment nurse was to assess skin, round with the wound care physician, take orders, notify the doctors and family of changes with the wound and provide wound care daily. The treatment nurse stated wound treatments were documented on the resident TAR and she was notified of changes in the resident skin by the direct care staff and also received copies of the resident shower sheets. The treatment nurse stated she performed skin assessments weekly and the last time she completed a skin assessment for Resident #5 was on the morning of 09/09/2024 around 5am-6am prior to Resident #5 going to dialysis. The treatment nurse described Resident #5's wound on the morning of 09/09/2024 as pink with scant amount of drainage and close to her sacrum. She said Resident #5 had no eschar and the skin was pink and moist. The Treatment Nurse said she did not look at Resident #5's heels that morning and was not aware of Resident #5 having a wound on her left heel. The Treatment Nurse stated she did a treatment on Resident #5 on the morning of 09/09/2024 and said she did not know why it was not documented on Resident #5's TAR as being completed. The Treatment Nurse revealed the Wound Care Physician rounded at the facility weekly and should have seen Resident #5 weekly but stated the Wound Care Physician often rounded while Resident #5 was at dialysis. The Treatment Nurse stated she thought it had been a couple of weeks since the wound care physician had assessed Resident #5's wound. The Treatment Nurse described the wound as MASD and the wound was around 2.0 x1.0 x0.4cm. During an interview with the facility Treatment Nurse on 09/15/2024 at 2:30 p.m., the treatment nurse stated when the wound care physician missed observations of Resident #5 each week she, just told her it was the same each time and she said if it gets worse to send her a picture. During an interview with the DON on 09/15/2024 at 2:50 p.m., the DON revealed the facility had not spoken to Resident #5's family since Resident #5 went to the hospital on [DATE] and had not received any updates or medical records from the hospital since Resident #5's admission to the hospital on [DATE]. During an interview at Resident #5's dialysis clinic with the Clinical Manager and Social Worker on 09/16/2024 at 9:15 a.m., the Social Worker revealed Resident #5 was arriving at dialysis with an altered mental status for about a month but significantly improved once she was dialyzed. The Social Worker said Resident #5 received treatment at the clinic since 08/15/2023 and usually arrived at dialysis around 7 a.m. and left around 2 p.m. to return to the facility. The Clinical Manager said on 09/09/2024, Resident #5 became unresponsive to stimuli and very lethargic toward the end of her dialysis treatment, the nurse notified the physician, and the physician gave an order for Resident #5 to be sent to the ER. The Clinical Manager said Resident #5 had a foot check on 09/06/2024 and was observed to have a dressing to her left heel. The Clinical Manager stated it was not facility proctive to remove the dressing to look at the wound and Resident #5 arrived dressed to her treatments each week and clinic staff would not have observed a sacrum wound. The Clinical Manager stated Resident #5 arrived on 09/09/2024 around 7:30 a.m. and was picked up by EMS at 11:23 a.m. to be transported to the ER. During an interview with the facility Wound Care Physician on 09/16/2024 at 11:39 a.m., the physician stated she began assessing residents at the facility at the beginning of August 2024 and the facility would request the consult and the resident would get added to her list of residents to assess each week. The Wound Care Physician stated she observed Resident #5 sacrum wound on 08/12/2024 and said the wound measured 1.5 x 0.4 x 0.1cm and looked like dermis and classified as MASD. We do not assign a stage to MASD and cannot really measure a depth less than .1. It was superficial and looked like irritation. The Wound Care Physician stated she was supposed to assess Resident #5 weekly but Resident #5 was always gone to dialysis when she would come by to make rounds. She stated she relied on the treatment nurse to guide her to tell her which patients needed to be seen, if they were not at the facility from her previous visit, then she tried to make accommodations to see the resident. The Wound Care Physician stated she received updates on resident progress if she did not see them she communicated very closely with [treatment nurse name]. We also have an option to do a telemedicine visit, because I am new, I have not mastered that, but it is something we can do in the future. The Wound Care Physician said there was a discussion about changing Resident #5's dialysis treatment days because I go to multiple facilities and my schedule is not flexible. The Wound Care Physician stated the Treatment Nurse mentioned she noticed some changes on Resident #5's wound on 09/09/2024 but did not say what type of changes. The Wound Care Physician stated she was not notified of the slough and eschar tissue documented on the treatment nurse assessment on 09/09/2024 and said if she was notified of she would have known the wound needed a debridement. The Wound Care Physician said I would have expected to be notified immediately that there is necrotic tissue and slough, that is a big change. I was just notified by [treatment nurse name] that she wanted me to come by and look at the wound sometime that week and we were talking about me coming on 09/11/2024. She did not tell me the current status of the wound. The Wound Care Physician stated she would have changed the treatment order if she was notified about the slough and eschar development on the wound and stated my suspicion is there is tissue that needed to be removed. That is not optimal that it was not removed. Without seeing the wound, I can only say that I think that the non-viable tissue needed to be removed. The Wound Care Physician stated she would have expected to be notified about the change in the wound and she said the facility treatment nurse did not notify her of necrotic tissue The wound care physician was shown a photo of Resident #5's sacrum wound taken at the hospital on [DATE] at 10 p.m. and said that is very different than what I have seen or been notified of. I had no idea it looked like that. Oh geez, that is bad. If I knew it looked like that, I would have come in on a Saturday. I am a surgeon by training, I can smell the wound, I know how it is supposed to look and not look. We do have patients that are more complicated. If I knew it looked even 10% of that I would have debrided it. The Wound Care Physician also stated The honey and alginate did not make it worse; it just would not have done anything to heal it. It needed further treatment. The Wound Care Physician was asked how long it could take a wound to get to that stage and she said It could not happen in 8 hours. People on dialysis and diabetic progress pretty quickly. It could have been a week or 3 weeks but would not develop like that. Yeah, given her diagnosis, I would say a week to 2 weeks. During an interview with the facility Treatment Nurse on 09/16/2024 at 1:00 PM, the Treatment Nurse stated Resident #5 did not have necrotic tissue on her sacrum when the treatment nurse assessed her. The Treatment Nurse was shown her assessment from 09/09/2024 which reflected the Treatment Nurse had documented Resident #5 had 10% necrotic tissue and 20% slough and she said Yes, there may have been some eschar in there, I told the wound care physician it had gotten larger. The Wound Care Physician knew there was slough, I don't know if I mentioned the eschar. The Treatment Nurse stated she did not have any documentation to support her notification but knew she called The Wound Care Physician r and told her the wound was bigger and said she should have told her about the eschar. The Treatment Nurse was asked if she notified the wound care physician about Resident #5's wound changes and slough from her 09/04/2024 assessment and she said I text her all the time, we just haven't been able to get together. I guess we could have gotten together and did a video chat. No, I don't have anything documented that I notified her, just verbally and I know I should have documented it. The Treatment Nurse said it was important to notify the physician of changes so we can change something and go in a different direction. Just the size was concerning, and I know she sits up a lot, but we could have changed the order, frequency or done something different. The Treatment Nurse stated she should have notified Resident #5's primary physician if the wound was changing and Resident #5 was not being assessed by the Wound Care Physician. She stated I could have notified him too. The Treatment Nurse stated the sheets were completed by the direct care staff who provided the shower and then turned into the Charge Nurse and to the Treatment Nurse to review. The Treatment Nurse stated she assumed that N/A marked on the shower sheets meant Resident #5 did not get a shower. The Treatment Nurse was asked about Resident #5 having N/A on the majority of her shower sheets in August and September and the treatment nurse said we just implemented the sheets in August. If someone refuses, we should be documenting refusals on it so those must be on her dialysis days so they should have been changed and given to her before she leaves for dialysis or on the opposite days. During an interview with Resident #5's primary facility physician on 09/16/2024 at 2:12 p.m., the Physician stated he last observed Resident #5 approximately two weeks prior to 09/16/2024. The Physician stated he did not see the sacrum wound and a wound care physician followed Resident #5. The Physician stated the Wound Care Physician should be notified of changes in wounds so the treatment orders could have been changed to address the changes in the wound and said I would hope the wound care physician would know about it because it is their responsibility. The physician stated he was not notified of Resident #5's wound having slough or eschar and stated I would expect the wound care doctor to be notified of that. I would be notified if the patient needs other things like antibiotics. If there was no wound care doctor I would want to be notified. The Physician was asked if he was notified of any change in condition with the resident and he said lethargy and altered mental status was not new for Resident #5 and she was declining for the last few months. The Physician was asked what should have been done if the Wound Care Physician was not able to see Resident #5 weekly and he said That is a question for the facility, what do they do when a provider doesn't come? I don't see the patient wounds because the wound care nurse should be following orders from the wound care doctor. During an interview with the facility DON on 09/16/2024 at 4:07 p.m., the DON said the facility had a treatment nurse Monday - Friday and charge nurses were responsible for wound care on the weekends if the treatment nurse was not there. The DON said the facility had a clinical meeting daily and the charge nurses went to the meeting and gave report on the residents and the facility had a weight and skin meeting weekly on Wednesdays. The DON stated wound care was validated and monitored for wound healing through communication between the D[TRUNCATED]