**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure resident received adequate supervision to prevent accidents for 3 (Residents 1, 2, and 3) of 6 residents reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on March 26, 2022, February 1, 2025, and again on June 21, 2025. On June 21, 2025, resident #1 was seen on the corner of the facility near a stop sign of an unbusy street. The facility was unsure how the resident eloped. A root cause analysis was not completed to determine how the resident eloped. There were two other residents at the facility (Resident #2 and #3) who were at a high risk for elopement with no interventions to prevent the elopement. Intervention's not put in place include but are not limited to: Redirecting, placing on a one on one once staff has seen a behavior change until assist, and or talking to. This failure resulted in an identification of an (IJ) Immediate Jeopardy on July 22, 2025, at 08:25pm. The IJ Immediate Jeopardy template was provided to the ADM on July 22, 202 at 08:25pm. While the (IJ) Immediate Jeopardy was removed on July 23, 2025, at 3:45pm, the facility remained out of compliance at a scope of isolate and severity level scope of isolate and severity level of no actual harm because all staff had not been trained on elopement.This deficient practice could place residents at risk of elopements that could result in serious injury and death.Findings included: Resident #1A record review of Resident #1's face-sheet updated, reflected that he was a [AGE] year-old man admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1 was admitted with diagnosis of Unspecified Dementia, Nontraumatic Intracerebral Hemorrhage, Unsteadiness on feet, Bradycardia, Heart Failure, Allergic Rhinitis, Cerebral Infraction, Vitamin D Deficiency, Benign Neoplasm of colon and Anima. A record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 6 which indicated severe cognitive impairment. Review of section GG- functional abilities indicated Resident #1 required moderate assistance for personal hygiene and was dependent for lower and upper body dressing, showering and toileting. Resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sit. Resident 1 required moderate assistance to sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. A record review of Resident #1's care plan from March,21,2025 reflected Resident #1 was an elopement risk. The goal was the resident's safety would be maintained through the review date. The Interventions were for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. All CAN's will document wandering behavior and attempted diversional interventions in behavior log. All CNA's will Monitor resident for elopement attempts and for verbalizations of wanting to go home. A record review of Residents #1's Progress Notes reflected Resident #1 was an elopement risk and had over 21 wandering risk scale assessments completed throughout his stay at the facility. Resident 1 had eloped on March 2, 2022, February 2,2025 and June 21, 2025, while at the facility. A record review, of Residents #1's progress notes dated March 2, 2022, at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location. A record review conducted on July 22, 2025, of residents #1'a progress notes dated June 21, 2025, entered by LVN A, resident #1 will discharged from the current facility and placed at a sister facility with a secure unit. A record review of Resident #1 progress notes dated June 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuries.noted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE], at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in February, there was no health concerns were found. CN A stated that during the morning meeting's staff discuss residents who are high wonder risk. She said that in the resident's care plans is where staff will find how long a one on one should be. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025, and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract Resident #2 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. *Resident #2 was dependent on staff for meeting emotional, intellectual, physical, and social needs. *Resident #had an ADL self-care performance deficit due to a left femur fracture. *Resident #2 had an impaired cognitive function and dementia.No other interventions were put into place such as 2-hour check or 15 minutes if needed. In an attempted interview with Resident #2 on July 23,2025 at 3:23pm. Resident #2 refused to be interviewed. A record review of Resident #2 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 13, indicating that she a high risk to wander. Resident #3A record review of Resident #3's factsheet undated, reflected that she was a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Resident #3's was admitted with diagnosis of cerebral palsy, aphasia, COVID-19, epilepsy, cognitive communication, quadriplegia, and a conduct disorder. A record review of Residents #3's quarterly MDS assessment dated [DATE], reflected Residents #3's BIMS score was unable to be completed, due to server cognitive impairment. Furter record review of section GG on the MDS reflected the resident had an impairment on both sides of her body and required a wheelchair to get around. The resident required total assistance with bathing, dressing, personal hygiene transfers. A record review of Residents #3's care plan dated June 23, 2025, reflected she was a wanderer without exit seeking behaviors. The goal of the facility was to maintain Resident #3 safety throughout her next review date. The interventions in place are to monitor her behavior for exit seeking behaviors every shift and to distract Resident #3 from wandering by offering pleasant diversions, structure activities, food, conversation, television or a book. As well as maintain visual checks every two hours. The care plan reflected that Resident #3 has impaired cognitive function/dementia or impaired thought processes. No other interventions were put into place such as 2-hour check or 15 minutes if needed. A record review of Resident #3 Wander Risk Scale-V3 dated June 23, 2025, 1:23pm, reflected that her score is a 11, indicating that she a high risk to wander. An interview conducted on July 22, 2025, at 03:49pm with the DON reflected her expectations of staff were to call her when a resident eloped. She said since she arrived on June 30, 2025, her practice has been that once a new resident enters the facility, she personally completes a Wander Risk Assessment. The DON stated if a resident was a high risk of elopement, but showing no behaviors, then she has them on two-hour checks. She stated if the resident's behavior become evident of higher risk of elopement, then the resident was placed on a one on one- or 15-min check. The DON reported currently Resident #2, and Resident #3 were on high risk of elopement. Interventions are currently in place. The interventions include behavior monitoring on every shift for exit seeking behaviors, and distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, or what the residents prefers. DON A stated at this time Resident #3 was labeled as discharged in electronic medical record due to her being out of the facility on a family pass since July 20, 2025. The DON stated she received an in-service on July 22,2025, for wandering. Facility's Wandering and Elopement policy dated March 2022, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An (IJ) Immediate Jeopardy was identified on July 22, 2025at 08:25pm., due to the above failures. The ADM was notified on July 22, 2025. The ADM was provided with the (IJ) Immediate Jeopardy template on July 22, 2025, at 08:30pm, and a Plan of Removal (POR) was requested.A plan of removal was first submitted by the Regional Nurse on July 22, 2025. The plan of removal was accepted on July 23, 2025, at 03:25pm.Plan of Removal Date Initiated: July 22, 2025The faculty must ensure that each resident received adequate supervision to prevent accidents. The facility failed to ensure Resident #1 did not elope from the facility in February 2025 and again on June 21, 2025. With a change in condition the facility could have prevented elopement.Residents at risk for elopement could be affected by this deficient practice. Action: An Inservice was provided to the DON and Administrator by the Regional Director of Clinical Services regarding missing resident/elopement procedures, resident identification binder, and hourly rounding on those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be monitored via an Inservice signature log.Person(s) Responsible: RDCSDate: July 22, 2025 Action: An Inservice was provided to direct care staff regarding missing resident/elopement procedures and residents in the elopement identification binder prior to the beginning of their shift. Comprehension will be verified by return verbal summary and attendance will be monitored via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift.Person(s) Responsible: DON/DesigneeDate: July 23, 2025 Action: Residents identified to be at high risk will be placed in an elopement identification binder placed at the nursing stations and front desk. The elopement identification binder will contain the resident profile and a picture. Person(s) Responsible: Maintenance Director/DesigneeDate July 22, 2025Action: All licensed nursing staff will be educated prior to the beginning of the next scheduled shift regarding conducting hourly rounds for those residents identified as high risk. Comprehension will be verified by return verbal summary of the education presented and attendance will be documented via an Inservice signature log. Those staff who are PRN or on PTO, LOA, or FMLA will receive the education prior to their next scheduled shift. Person(s) Responsible: Charge NurseDate: July 22, 2025Action: Wandering Risk Assessments will be conducted upon admission, quarterly, or with new wandering behavior. Those identified as high risk will have applicable interventions initiated. Person(s) Responsible: DON/DesigneeDate: July 22, 2025Action: All residents at high risk and listed in the elopement identification binder will be reviewed daily in the morning meeting process and in the weekly We Care Meeting to review for exit seeking behaviors.Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: All residents identified as high risk will have all applicable interventions documented on their care plan. Person(s) Responsible: DON/DesigneeDate: July 22, 2025 Action: Signage has been placed on public access door prompting Please check with staff before letting any resident out of the building alone.Person(s) Responsible: ADMDate: July 22, 2025 Action: The RDCS will audit the missing entries report once weekly x 8 weeks to ensure compliance with hourly visual and behavior monitoring checks. The RDCS will randomly select three staff members weekly to ensure compliance within servicing x 8 weeks. The RDCS will attend one weekly We Care Meeting to ensure compliance with weekly monitoring. Person(s) Responsible: RCDSDate: July 22, 2025 Action: A root cause analysis was conducted by the Ad Hoc Committee members. It was determined that the root cause was as follows: Multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviors. Person(s) Responsible: IDT Date: July 22, 2025Action: An Ad Hoc QAPI was conducted to complete a root cause analysis and review the plan of removal with IDT team and Medical Director. Person(s) Responsible: AdministratorDate: July 22, 2025 Monitoring on July 23, 2025, included the following:Observation made on July 23, 2025, at 09:50am of sign on front for out and inside of facility asking that all visitors and staff check with staff at desk before letting any resident out of the facility alone. Observation made on July 23, 2025, at 10:05am of alarm on 12 exit doors. All alarms functioning properly. Interview and record review on July 23rd, 2025, at 10:23am with ADM revealed he observed maintenance completing emergency door checks that morning. ADM stated the code to the front door changes when it needs to be. ADM Provided a log of signed log's indicating that a member of maintenance had in fact conducted door checks every morning for the last six months. Interviews conducted from July 22, 2025, through July 23, 2025, between 11:30am and 2pm, with LVN B, CNA A, CNA B and ADON B, reflected they had all been in-serviced on July 22, 2025, on wandering. They stated there was a red binder at every nurse's station and in front at the receptionist desk with the high risk of elopement residents. They said they have all been informed that when a resident was at high risk of elopement, they need to have eye's laid on them every hour. LVN B, CNA A, CNA B and ADON B stated that they have no concerns regarding the facility and the supervision of the residents. Interview on July 23, 2025, at 12:07 with CNA C reveled her last in-service was July 23, 2025, on wandering. She said during the in-service she was reminded the binder with high risk for wandering binder was red and was placed at every nurse's station. She said she learned new ways to stop a resident from elopement such as talking to them, making sure someone always has an eye on them or keeping them busy when wandering behavior was evident. Interview on July 23, 2025, at 02:46m ADON B reveled she received her last in-service on wandering July 23, 2025. She said that her definition of eloping was when a resident was attempting to try to get out of the facility. ADON B stated when she sees a resident attempting to elope, she plans to stay with the resident for one and one and do a one. She stated she will then contact the DON and receive further instructions. ADON B said there was a high-risk monitoring binder with the high-risk wanders in the book that was kept at each of the nurse station and the front desk. ADON said some signs of wandering behavior she will look for will include a resident stating that they want to go home over and over, staying near the door, and or appearing anxious.Interview on July 23, 2025, at 02:55pm with RN A reveled she had in serviced all staff on wandering and how to detect wandering behavior in residents. She stated a resident must present signs of elopement once before she expected staff to let her, or the DON know so the resident's behavior can be assessed. Record review on July 23, 2025, at 03:01pm reflected the updated care plan of Resident 2 and Resident 3 and been updated to reflect being checked on every hour as opposed to every two hours. Record review on July 23, 2025, at 3:05pm of QAPI reflected the root cause for residents' elopement was due to multiple leadership changes have resulted in educational deficiencies for a high turnover staff population regarding the elopement policies, appropriate interventions for those with wander/exit seeking behaviors, and notification of the Admin/DON regarding wandering/exit seeing behaviorsThe facility will ensure that residents who exhibit wandering behavior and /or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.On July 23, 2025, at 03:45pm, the ADM was informed the (IJ)immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on July 23,2025 the facility remained out of compliance at a scope of isolate and severity level of no actual harm because all staff had not been trained on elopement.Findings included:This was an abbreviated /extended survey, and the sample was increased. Resident #1A record review of Resident #1's face-sheet updated, reflected that he was a [AGE] year-old man admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1 was admitted with diagnosis of Unspecified Dementia, Nontraumatic Intracerebral Hemorrhage, Unsteadiness on feet, Bradycardia, Heart Failure, Allergic Rhinitis, Cerebral Infraction, Vitamin D Deficiency, Benign Neoplasm of colon and Anima. A record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 6 which indicated severe cognitive impairment. Review of section GG- functional abilities indicated Resident #1 required moderate assistance for personal hygiene and was dependent for lower and upper body dressing, showering and toileting. Resident #1 required supervision or touching assistance to roll left and right, sit to lying, and lying to sit. Resident 1 required moderate assistance to sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. A record review of Resident #1's care plan from March,21,2025 reflected Resident #1 was an elopement risk. The goal was the resident's safety would be maintained through the review date. The Interventions were for staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. All CAN's will document wandering behavior and attempted diversional interventions in behavior log. All CNA's will Monitor resident for elopement attempts and for verbalizations of wanting to go home. A record review of Residents #1's Progress Notes reflected Resident #1 was an elopement risk and had over 21 wandering risk scale assessments completed throughout his stay at the facility. Resident 1 had eloped on March 2, 2022, February 2,2025 and June 21, 2025 while at the facility. A record review, of Residents #1's progress notes dated March 2, 2022 at 02:21pm entered by CNA B stated Appears that pt was let out of the building by someone entering as the door was locked but it was reported to this nurse that resident was outside in the parking lot. Initially he was not seen but he was near the end of the parking lot, looking out over the street. Asked if he was simply enjoying the sunshine he responded, No I'm trying to go home! Brought inside. Vitals assessed. ADON aware. Administrator aware. Phoned and spoke with [Residents #1's] [family member] who will come up to visit although I did make clear there were no injuries. Monitoring will be completed with resident location.A record review of Resident #1 progress notes dated July 22, 2025 at 02:21pm CNA B, reflected that Resident #1 was outside down the street at a stop sign by passerby who called facility to notify staff and also a residents family member from the North side notified staff of resident being outside. Resident brought back into facility by staff and assessed with no injuriesnoted and vitals are 124/64,67,18,98.1. When asked where he was going, he stated to my brother's house. Resident taken to his room and placed into bed. 15-minute checks implemented at this time. DON, Administrator, and RP notified of incident. Plans in place to move resident to secure unit once consent from his daughter. Record review of the Wander Risk Scale assessment dated [DATE] at 06:31am reflected that Resident #1 score was a 9 indicating that Resident #1 is at a high risk to Wander. A telephone interview conducted on July 22,2025 at 3pm with LVN A reflected during shift change she received a call from a community member who had been passing by. A community member told her there was a man out by the stop sign sitting in a wheelchair with the facilities name on it. LVN A stated as she was talking to the community member on the phone, the TD A was approaching her pushing Resident #1. LVN A said she thanked the community member and disconnected the call. LVN A said TD A told her she was leaving from the facility when someone told her a resident was sitting in front of the facility near the stop sign. LVN A stated she asked Resident #1 where he was going and he responded, I was going to my [family member] house. LVN A said she completed a head-to-toe assessment and found no injuries or heat exhaustion. She said she then called RN A to inform her on what happened. LVN A said she also called Resident #1's family member, however she did not answer. LVN A was advised by RN A to put Resident #1 on 15min checks. LVN A said she was given an elopement and abuse and neglect in-service. LVN A stated Resident #1 could have received life threatening injuries from being unsupervised during his elopement. An interview conducted on July 22, 2025, at 03:36pm, with TD A reflected she was leaving for the day when she was told by a resident that a man was in a wheelchair was seen near the stop sign. She said she located the resident and seen that it was Resident #1. TD A said she then approached him and returned him to the south side, which was where his room was located. TD A said she took Resident #1 to LVN A who took Resident #1 to complete a head-to-toe assessment. She said that she has never seen Resident #1 elope before. TD A said she received an in-service the next day about elopement and what to do. She said the facility handled the situation in a timely matter and she had no concerns. An interview and observation on July 22,2025 at 11:57am with CN A reflected LVN A got a call from a community member saying they saw someone in a wheelchair with the facility's name on it. TD A and LVN A went to get the resident and completed assessment and found no injuries, his temperature was fine, and he was not over heated. She said that she instructed LVN A to place Resident # 1 on a one-on-one observation, until he was discharged to a sister facility, the next day around 1pm on June 24, 2025. CN A said LVN A informed her she notified the family. CN A said while she was reviewing residents #1's progress notes she noticed resident #1 has eloped before in February. CN A said she believed the resident was found under the awning in front of the building and brought back inside. She stated she did not know why he was not transferred out of the facility at that time. CN A said she was unable to discuss this with the ADM on site at that time because he was no longer the ADM at the facility. CN A said according to the notes she read after the elopement in February, there was no health concerns were found. She said the building was not equipped with a wonder guard or alarm system due to cost. CN A said the front door had a code that must be entered to exit and enter the building. She said both incidents took place after hours and at that time there was no one monitoring the doors. CN A stated thought Resident #1 may have eloped by a family member(visitor) letting him out. CN A revealed the facility gave all new residents a Wandering Assessment scale risk, and they are all considered to be a high elopement risk if they are ambulatory or diagnosed with Alzheimer's or dementia. An interview in on July 22, 2025, at 03:19pm with ADON A, reflected she was not present when the incident took place. She stated when she was informed of it, she offered to sit with Resident #1 and provide one on one supervision. She arrived at the facility at 12am on June 22, 2025 and relieved a fellow employee who she did not remember the name of the employee. ADON A said she had never known of Resident #1 to elope prior to this situation. She said when she asked Resident #1 why he left the facility, he would not say how he got out of the door. ADON A said when a resident was at high risk of elopement, they are placed on a two-hour check, if their behavior was persistent, they are placed on a one on one or 15min check. ADON A said there was a binder kept at every nurse's station with the residents who are at risk of elopement. She said there was a receptionist at the front of the building from 8:30am to 5pm on the weekdays and a MOD that worked the front for four hours on the weekend. She reported the door has a lock code to enter and exit that was on 24hours a day. Resident #2A record review, of Residents 2's face sheet undated, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was admitted with diagnosis of wedge compression fracture of second lumbar vertebra, Type 2 diabetes, muscle weakness, displaced fracture of base of neck of left femur, vascular dementia and weakness. A record review of Resident #2's quarterly MDS assessment dated [DATE]th, 2025, reflected she had a BIMS score of 4 which indicated severe cognitive impairment. Review of section G revealed Resident #2 required extensive assistance with bed mobility, transfers, eating and toilet use. A record review of Resident #2's care plan dated June 23, 2025, reflected the following focus areas:*Resident #2 was a wander risk without exit seeking behaviors. The goal of the facility was to maintain Resident's #2 safety throughout her next review date. The interventions were to monitor her behavior for exit seeking behaviors every shift and to distract R

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #66) of 1 resident reviewed for significant medication errors. The facility failed to ensure Resident #66 received the prescribed anti-convulsant medication on 6/9/2025 and 6/10/2025. Resident #66 had seizure-like activity, was transferred to the ED, and remained admitted at the hospital for diagnosis of seizure. An Immediate Jeopardy (IJ) situation was identified on 6/12/2025. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of serious harm, up to and including death. Findings Include: A record review of Resident #66's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #66 had diagnoses which included cerebral infarction (a condition where brain tissue dies due to lack of blood supply), seizures (temporary disruptions of brain activity, convulsions, loss of consciousness), and nontraumatic intracerebral hemorrhage in brain stem (a serious type of stroke caused by bleeding in the brain stem). A record review of Resident's #66's MDS, dated [DATE], reflected no BIMS score for Resident #66. A record review of Resident #66's Medication Administration Records dated 6/9/2025 and 6/10/2025 reflected Resident #66 missed the scheduled doses of Lacosamide 150 mg tablet on 6/9/2025 at 5:00 PM and 6/10/2024 at 8:00 AM. A record review of Resident #66's facility progress note, dated 6/11/2025 at 5:55 PM, reflected Resident #66 was observed with twitching in her face and jaws and had turned her head to the left. The NP was notified and ordered the transfer to the ED. On 06/13/2025 at 2:40PM a Record Review of the hospital History and Physical signed on 06/13/2025 at 3:24AM was conducted. Diagnoses were listed as Acute on Chronic hypercapnic (too much carbon dioxide in the bloodstream) and hypoxemic (a condition where there is low oxygen in the blood) respiratory failure, Acute metabolic encephalopathy (a brain disorder caused by chemical imbalances in the blood, often stemming from underlying medical conditions or organ dysfunction), Seizure Disorder. Record Review of an additional History and Physical dated 06/12/2025 revealed a reason for admission as Acute Hypercapnic Respiratory Failure. Record review of the anticonvulsant therapy read as follows: Patient has been so far treated for seizure with Keppra and Vimpat (loaded with 1.5g Keppra initially the started on 500mg twice daily (then further loaded with an additional 3.5g Keppra). Keppra was increased to 1.5g twice daily and Vimpat to 200mg twice daily and was placed on EEG (a test that measures and records the electrical activity of the brain. Upon MICU evaluation patient was very somnolent, only grimaced to sternal rub so she was brought to the ICU for acute hypercapnic respiratory failure and encephalopathy due to multiple reasons. Plan from Neurology read as follows: #Metabolic encephalopathy worsening Multifactorial Ongoing seizures, post-ictal state, and seizure medications Hypercapnia No seizure of EEG per Neuro tonight Likely worsened by hypercapnia Continue EEG and AEDs Continue AVAPS for now During an interview on 6/12/2025 at 11:30 AM, the Regional Director of Clinical Services stated Resident #66 was transferred to the ED on 6/11/2025 at 6:30 PM for suspected seizure activity. Upon further investigation, she discovered Resident #66 missed two consecutive doses of Lacosamide 150 mg tablet, an anti-convulsant medication. The first missed dose was 6/9/2025 at 5:00 PM and the second missed dose was on 6/10/2025 at 8:00 AM. During a phone interview on 6/12/2025 at 2:16 PM, RN D stated LVN I processed the original readmission orders for Lacosamide tablets which the facility did not have on hand. The agency nurse entered the wrong medication administration times in the system, and the resident missed the evening dose on Monday. RN D stated on the morning of 6/10/2025 he discovered the tablet form was ordered as opposed to the liquid form of the medication, called the NP to report the discrepancy and asked if the order should be changed to the liquid form. RN D stated the NP returned his call around lunchtime which was too late to administer the morning dose of medication. During an interview on 6/12/2025 at 2:30 PM with RN E, she stated she readmitted the resident on 6/09/2025, upon Resident #66's return from the hospital. RN E stated she entered the first two pages of medication orders and LVN I entered the last two pages of the medications order. Resident #66 should have received the evening dose of Lacosamide on 6/9/2025. The hospital discharge document stated the resident received the last dose of Lacosamide on the morning of 6/9/2025. During an interview on 6/12/2025 at 3:15 PM, the Medical Director stated the missed doses of Lacosamide for Resident #66 could have contributed to Resident #66's seizure like activity. A record review of Resident #66's physicians' order entry for 6/09/2025 reflected an order for Lacosamide Oral Tablet 150 mg one tablet twice daily for seizures entered by LVN A. A record review of Resident #66's hospital Discharge summary, dated [DATE], reflected an order for Lacosamide 150 mg tab by g-tube route two times a day, morning, and bedtime. A record review of the facility's, undated, policy named, 9.3 Medication Administration reflected: Facility staff should take all measures required by Facility Policy, Applicable Law, and the State Operations Manual when administering medications. Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. This was determined to be an Immediate Jeopardy (IJ) on 6/12/2025 at 5:25 PM. The ADM and RDCL were notified. The ADM was provided with the IJ template on 6/12/2025 at 5:51 PM. The following Plan of Removal submitted by the facility was accepted on 6/13/2025 at 12:15 PM. Summary of Details which lead to outcomes: On 6/10/25 an annual re-certification survey was initiated at [NAME] Inn Nursing and Rehabilitation. On 6/12/25 at 6:41 PM the surveyor provided an immediate Jeopardy template notification that Regulatory Service has determined that the condition at the facility constitutes an immediate threat to the residents' health and safety. F760 - The facility failed to keep the residents free from significant medication errors. The facility failed to ensure Resident #1 received the prescribed anti-convulsant medication on 6/9/25 and 6/10/25. Identify residents who could be affected: A total of eleven residents who receive anticonvulsant medications for seizure disorders have the potential to be affected. Identify responsible staff/ what action taken: Start date: 06/12/2025 Completion date: 06/12/2025 Responsible: Regional Director of Clinical Services Action: The Regional Director of Clinical Services provided education to the Assistant Director of Nursing and the Administrator regarding the completion of the admission checklist during the morning meeting process. Beginning on 6/11/25, medication orders will be entered into the EMAR system for all new admissions and readmissions by a member of the nursing leadership team within 4 hours of the resident's arrival from this date forward. During an interview with the ADON on 06/13/2025 at 2:32PM the ADON stated she was trained on the task of needing to enter the admission orders within 4 hours of the resident's arrival for admission to the facility. Start date: 06/11/2025 Completion date: Initial in servicing completed on 6/12/25 and ongoing. Responsible: Assistant Director of Nursing/Designee Action: In-service training provided to all licensed nurses and certified medication aides regarding the process for unavailable seizure medications. If an anticonvulsant medication is unavailable and not in the Stat safe, the nurse is to notify the pharmacy and nursing administration. If a certified medication aide finds an anticonvulsant medication to be unavailable, they are to notify the charge nurse. If a dose is missed, the nurse is to notify the provider. All PRN staff, and those on PTO, LOA, or FMLA, will receive in-service training prior to their next scheduled shift. This training will be provided as part of the new employee orientation for all licensed nurses and certified medication aides. Start date: 6/11/25 Completion Date: 6/12/25 Responsible: Regional Director of Clinical Services Action: An audit was completed for all residents prescribed anticonvulsants for seizure disorders to ensure that medications were available for administration and orders were accurate. No further unavailable medications or transcription errors were found. During record review and interview with the RDCS on 06/13/2025 at 2:07PM, each resident on anticonvulsants was included on the audit list. The RDCS verbally affirmed this audit was completed. Start date: 6/12/25 Completion Date: 6/12/25 Responsible: Regional Director of Clinical Services Action: An audit was completed for residents receiving prescribed anticonvulsants for seizure disorders to ensure there were no additional doses missed. The clinical documentation for the two residents identified in the audit was reviewed, with no documentation of seizure activity noted. During record review and interview with the RDCS on 06/13/2025 at 2:07PM, each resident on anticonvulsants was included on the audit list. The RDCS verbally affirmed this audit was completed. Start Date: 6/12/25 Completion Date: Initiated on 6/12/25 and ongoing. Responsible: Regional Director of Clinical Services/Designee Action: The RDCS/Designee will review the medication administration history for those receiving anticonvulsant medications for seizure disorders three times weekly to ensure no additional missed doses and efficacy of education provided. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Pharmacy Consultant Action: A full MAR to Cart audit has been scheduled for 6/13/25 to ensure medication orders have been transcribed and are correct. Pharmacist observed auditing carts on the afternoon of 06/13/2025. During an interview, the Pharmacist confirmed he had conducted the audts. Start Date: 6/13/25 Completion Date: Initiated on 6/13/25 and ongoing. Responsible: Regional Director of Clinical Services/Designee Action: All new orders will be reviewed during the morning clinical process to ensure accurate transcription and medication availability. Start date: 06/11/25 Completion date: 06/12/25 Responsible: Regional Director of Clinical Services Action: The Medical Director was notified of the medication errors on 6/11/25. The Medical Director was notified that an IJ had been issued on 6/12/25. The Medical Director did not wish to take additional action. Start Date: 06/12/25 Completion Date: 06/12/25 Responsible: Administrator Action: An Ad Hoc QAPI was held to review the plan for the medication error that occurred on 6/11/25. Record Review of the agenda and sign in sheet from the QAPI meeting that was held on 06/11/2025 was conducted. The topic of the missed medications was listed on the agenda. The sign in sheet for the meeting included the signatures of the required attendees. Monitoring of the POR included the following: A record review on 6/13/2025 at 2:46 PM of the in-service sign in sheets reflected 100% of the nurse and CMA employees signatures. In-service training was provided to all licensed nurses and certified medication aides regarding the process for unavailable seizure medications. If an anticonvulsant medication is unavailable and not in the Stat safe, the nurse is to notify the pharmacy and nursing administration. If a certified medication aide finds an anticonvulsant medication to be unavailable, they are to notify the charge nurse. If a dose is missed, the nurse is to notify the provider. All PRN staff, and those on PTO, LOA, or FMLA, will receive inservice training prior to their next scheduled shift. This training will be provided as part of the new employee orientation for all licensed nurses and certified medication aides. During an interview on 6/13/2025 at 2:30 PM, the ADM stated the RDCS completed staff training for the review of the Admissions Checklist during morning meetings. The admission Checklist included a prompt to audit for new orders for anticonvulsant medication orders. During an interview on 6/13/2025 at 2:32 PM, the ADON stated she was trained by the RDCS regarding the review of the Admissions Checklist during daily morning meetings. The Admissions Checklist includes a prompt to audit for new orders for anticonvulsant medication orders. During an interview on 6/13/2025 at 2:36, RN D stated she received training on steps to take when a resident missed a dose of anticonvulsant medication. She stated to whom she would have contacted and what action would have been taken. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. During an interview on 6/13/2025 at 3:11 PM, LVN F stated she received training from the RDCS on the steps staff should have taken when the anticonvulsant medications were not available. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. An interview attempt was made on 6/13/2025 at 3:19 PM with LVN G. There was no answer and no ability to leave voicemail. During an interview on 6/13/2025 at 4:05 PM, RN E stated he received training from the RDCS on the steps staff should have taken when the anticonvulsant medications were not available. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. An interview attempt was made on 6/13/2025 at 4:32 PM with LVN L. A message was left, and a call back was requested. An interview on 6/13/2025 on 4:54, LVN I stated she received training from the RDCS on the process for missed doses of medication. She stated she would contact the provider to notify of the missed dose and request orders to hold the dose or go ahead and give the medications. The ADM and RDCS were informed the Immediate Jeopardy was removed on 6/13/2025 at 6:15 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents 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 2 (Resident # 1 and Resident #9) of 5 Residents reviewed for pressure ulcers. 1. The facility failed to perform wound care to Resident #9's Stage 3 pressure ulcer to right buttock, as ordered, on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/14/25, 01/20/25, 1/21/25 and 1/22/25 . Resident #9's wound was infected on 01/16/2025 and got worse from a stage 3 to a stage 4. 2. The facility failed to perform wound care on Resident #9's sacral wound per orders for Resident #9 dated 1/16/2025 until 1/23/2025. Resident #9's wound was infected on 01/16/2025 and got worse from a stage 3 to a stage 4. An Immediate Jeopardy (IJ) was identified on 02/11/25. The template was provided to the facility on 2/11/25 at 2:30 PM. While the IJ was removed on 02/12/25 at 3:36 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis ( a serious condition in which the body responds improperly to an infection, causing the organs to work poorly), reduced mobility, and a lower quality of life. 3. The facility failed to change a wound vac dressing to Resident #1's Stage 4 pressure ulcer, as ordered, on 01/12/25 and 01/17/25. Findings included: Review of Resident #9's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Cerebral infarction (also known as ischemic stroke, occurs as a disruption of blood floor to the brain due to problems with blood vessels that supply it), non-traumatic intracerebral hemorrhage in the brain stem (focal bleeding from a blood vessel in the brain) Review of Resident #9's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section GG (Functional Abilities) reflected she was dependent on bed mobility and transfers. Section I (Active Diagnoses) reflected diagnoses including aphasia (difficulty using or comprehending language), cardiovascular accident (stroke), chronic lung disease, and other tracheotomy (surgically created hole, also called a stoma in your windpipe) complications. Section M (Skin Conditions) reflected she was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries and no venous or arterial ulcers. Review of Resident #9's Comprehensive Care Plan, initiated 12/28/24 and revised on 01/28/25 reflected it did not address the pressure injury/ulcer ., meaning, Resident #9 was not admitted with pressure injury. Review of Resident #9's skin assessment dated [DATE] reflected the resident had excoriation (wear of the skin often caused by scratching, rubbing, or friction against the skin surface) at right buttock measuring 3 x 6 cm. Review of Resident #9's TAR reflected: Wound Care Consult as indicated, one time only for skin breakdown for 7 Days -Start Date- 12/29/2024. Review of Resident #9's NP's progress notes dated 01/03/2025 reflected: Chief Complaint/Reason for this Visit - wound. New wound to buttocks presents today, stage 3. Wound care referral provided. Stage 3 pressure ulcer: Wound care referral, continue wound care as prescribed. Review of Resident #9's Physician orders dated 01/03/2025 reflected a referral to be seen by wound care doctor. Clean stage 3 to right buttock with normal saline, apply hydrocolloid dressing daily one time a day Supplementary. Key: Drainage: Saturated/Moist/Dry General Appearance: Red/Yellow/Pink/Black/Green/Whit e/Tan/Purple/Brown/Gray Surrounding Skin: Macerated/Reddened/Firm/Normal -Start Date- 01/04/2025 Review of Resident #9's January 2025 MAR/TAR reflected an order dated 01/04/25 and discontinued on 01/20/25, Clean stage 3 to right buttock with normal saline, apply hydrocolloid dressing daily. The dressing change was not documented on 01/06/25, 01/09/25, 01/11/25, 01/12/25, 01/14/25 , and 01/20/25 . It was also reflected there was no wound care order in place for 01/21/25 and 01/22/2025. Review of Resident #9's skin assessment dated [DATE] reflected pressure at right buttocks. Review of Resident #9's clinical records reflected Resident #9 was not seen by the Wound Doctor until 1/16/2025 since the referrals were made on 12/29/2024 and 1/03/2025. Review of Resident #9's Wound Doctor's notes dated 1/16/2025 reflected: LOCATION: Sacro coccyx Extending to Bilateral Buttocks ETIOLOGY: Pressure Injury/Ulcer - Wound Stage: 4 - Pressure Injury PREOPERATIVE INDICATIONS: Necrotic tissue, infected tissue, slough , and drainage SIGNS OF INFECTION: Pain, foul odor, erythema (redness to the skin), and purulent(pus) drainage WOUND DESCRIPTION: UNDERMINING: 2 cm at 12 o'clock EXUDATE: Copious, purulent, and sanguineous PERIWOUND: Erythematous ( redness to the skin due to the accumulation of blood in dilated capillaries) WOUND EDGE: Friable (thin skin) DRESSING USED: Calcium Alginate and Bordered Gauze Review of Resident #9's MAR/TAR for January 2025 reflected Resident #9 was treated with the following antibiotics for wound infection: Doxycycline Hyclate Tablet 100 MG Give 1 tablet via PEG-Tube (a medical device use to provide nutrition and hydration directly to the stomach, also known as G-tube) two times a day for wound infection for 14 Days -Start Date- 01/16/2025 -D/C Date- 01/22/2025. Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet via G-Tube two times a day for wound infection for 7 Days -Start Date- 01/22/2025. Clindamycin HCl Oral Capsule 300 MG (Clindamycin HCl) Give 2 capsule via G-Tube every 8 hours for wound infection for 7 Days -Start Date- 01/22/2025. Review of Resident #9's TAR reflected orders from Wound Doctor's visit from 01/16/2025 for Resident #9's wounds were not implemented until 1/23/2025. Review of Resident #9's clinical physician orders reflected an order dated 01/22/25 , Clean stage 4 to sacrum with normal saline, apply calcium alginate, then foam adhesive dressing daily. During an observation and interview on 01/27/25 at 10:30 AM, Resident #1 was lying in bed with the head of the bed elevated. The wound vac machine was observed hanging at the bedside. She stated she had a bed sore and was supposed to get wound care on Mondays, Wednesdays, and Fridays but they did not always change the wound vac dressing when they were supposed to. She stated the nurse had just changed the wound vac dressing a short time ago. During an observation and interview on 01/27/25 at 10:41 AM, Resident #9 was observed lying in bed with the head of the bed elevated. Resident was unable to verbalize but family member at bedside confirmed that the resident had a pressure sore on her back side and was dependent on staff for repositioning. The family member stated she had not seen the wound and did not know if it was worsening. During a telephone interview on 01/27/25 at 3:36 PM, the Medical Director stated the nurses should, follow up on wound care. He stated he was familiar with NPWT, usually the settings come from the hospital or wound care doctor. He expected orders to be followed. During an interview on 01/27/25 at 4:00 PM, the DON stated she expected wound vacs to be maintained, and she expected that staff had been trained. She stated she was not sure if there were any competencies for the wound vacs. The DON stated she had been in the building for only 6 days and was not yet familiar with everything. She stated she did not know if agency nurses had been trained on the wound vac. She stated she expected wound care to be completed as ordered and documented. She stated not performing wound care as ordered could lead to infection or delay healing. During an interview on 01/28/25 at 12:04 PM the ADON stated she had observed RN B change a wound vac dressing but she had not received hands-on training on actual wound vac device. She stated it was her expectation that wound care was provided as ordered. If it was not documented, it did not happen. She stated it did not meet her expectations that dressing changes were missed. She stated she had talked with Resident #1's wound care doctor about one missed dressing change. During an interview on 01/30/25 at 12:09 PM, the MDS Nurse stated it was her expectation that all treatments were documented when given. She stated if it was not documented, it did not happen. She stated everything had to be documented to give a picture of what is going on with the resident. She stated documentation was important because the doctor needed to know, if it went to court you needed to know, so you had to document everything. During an interview on 01/30/25 at 12:50 PM, the ADON stated it was her expectation that residents were assessed, and it was documented. She stated regarding wound care, she expected the old dressing was assessed, the wound was assessed, and the resident's response to the treatment was assessed and all of that was documented. She stated wounds should be measured and wound vac settings documented. She stated there needed to be a paper trail to inform the doctor and the insurance of the resident's status. She stated not providing wound care could cause wounds to worsen. During an interview on 01/30/25 at 3:07 PM, LVN E stated it was important to follow the physician orders, such as wound care. She stated treatments were ordered for a reason. She stated wound care was documented when the care was provided. Not providing wound care could cause worsening or more wounds. During an interview on 02/11/2025 at 10:11 am the Wound Doctor stated that he has been seeing Resident #9 for wound care to the sacral wound. He stated he first saw Resident #9 on 1/16/2025, at which point he described the wound as a fairly large sacral wound that was fairly necrotic and draining pus, unstageable ( a pressure ulcer that is cover with necrotic tissue or eschar making it hard to stage or treat), necrotic, once the necrotic tissue was removed over the wound bed, it was immediately a Stage IV pressure ulcer due to the depth of the wound. The Wound Doctor stated, following his assessment of the wound, he started Resident #9 on antibiotics (Doxycycline) for the infection, initially, which was later changed by the primary doctor. The wound Doctor stated, missing wound care can cause problems, like worsening of the wound. The Wound Doctor stated it was his expectation that wound care be done daily as ordered, unless otherwise specified. The Wound Doctor stated Resident #9's comorbidities that might affect wound healing were right hemiparesis, weakness, less mobility, and offloading was a big deal with her wound, less able to feel pain. He also stated nutritional wise, Resident #9 was good. During interview on 2/11/25 at 11:38 am, RN B stated she was ADON for the period in question from 12/28 2024 through 1/23/2025 and made rounds with the Wound Doctor on his visits. She stated the ADON was responsible for monitoring wound progress. She stated it was the expectation that wound care orders be put in the Resident's chart right after the wound Doctor's visit. She stated she did not know why the Wound Doctor was not notified between 1/3/25 to 1/16/25 of the wound consultation for Resident #9. She stated she did not know why the new wound care orders for Resident #9 from the Wound Doctor visit on 1/16/25 were not updated in Resident #9's chart until 1/23/25. She stated that if wound care consult was not given to the Wound Doctor when he was in the building, they would have to wait until the following week as they did not have a way to contact the Wound Doctor between visits. RN B stated if the residents were not seen by the wound doctor timely and the wound care orders were not implement as ordered, the resident's wounds would get worse. RN B stated Resident #9 was not able to move herself from side to side without assistance from staff. RN B stated she worked with Resident #9 on 1/22/2025 but could not state why wound care for Resident #9 was not done on 01/22/2025. Attempts made on 02/11/2025 at 12:37 PM to contact LVN M, the nurse assigned to Resident # 9 on 1/9/2025 but to no avail , a voice message was left. During a phone interview on 02/11/2025 at 12:39 PM, LVN N, the nurse assigned to Resident #9 on 1/21/2025, stated she worked with an agency and only worked 1 shift at the facility. LVN N stated she could not remember Resident #9, but she did a couple of wound cares on the day that she worked at the facility. LVN N stated if she didn't sign or document on the MAR/TAR that means the treatment was not done. During a phone interview on 2/11/2025 at 01:37 PM, LVN A, the nurse assigned to Resident #9 on 01/06/2025, 1/11/2025, 1/12/2025, 01/14/2025 and 1/20/2025, stated she worked with Resident #9, and Resident #9 required daily wound care and the need to be repositioned every two hours. LVN A stated she was responsible for wound care on her shift as a nurse. LVN A stated she performed wound care on Resident #9 on the days she worked with the Resident except for when the Wound Doctor was making his rounds but was unable to recall the dates, she worked with Resident #9 or the dates wound care was completed for the resident. LVN A stated that without documentation of care, it wound suggest the wound care was not done. LVN A stated that providing necessary care to residents and documenting their care was part of quality nursing care and could be neglect if it was not done. Resident #9 was not seen by the Wound Doctor until 1/16/2025 and the Wound Doctor did not visit the facility on 1/20/2025. During an interview on 02/11/2025 at 3:20 PM the Nurse Consultant stated the DON was out sick and she was in place of the DON. she stated that her expectations for physician orders were that they would be implemented and followed. The Nurse Consultant stated wound care orders should be implemented as soon as possible, at the latest, the following morning to enable the resident to receive care ordered by the following morning. The Nurse Consultant stated the Residents could have a negative outcome, such as worsening of a wound, if new orders were not implemented timely. The Nurse Consultant stated that Residents could have negative outcome, such as worsening of a wound, if wound care was not performed as ordered. The Nurse Consultant stated that if a nurse does not document care, then it was not done. Review of the facility's Charting and Documentation policy, revised July 2017, reflected in part, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: 2. The following information is to be documented in the resident medical record: 2. a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided, b. The name and title of the individual(s) who provided the care, c. The assessment data and/or any unusual findings obtained during the procedure/treatment, d. How the resident tolerated the procedure/treatment, e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April 2018, reflected in part, Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. The policy did not address providing wound care as ordered. The Administrator was notified on 02/11/2025 at 2:30 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 02/12/2025 at 12:41 PM: Plan of Removal Immediate Jeopardy On 01/27/2025 an abbreviated survey was initiated at the facility. On 02/11/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Date Initiated: 02/11/2025. The notification of Immediate Jeopardy states as follows: F686 - The facility failed to ensure residents 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. Statement of Deficient Practice: All residents who require wound care could be at risk for potential negative effects. 1. Upon learning the facility failed to ensure residents with pressure ulcers received necessary treatment and services facility had wound physician complete rounds on resident who have consented. All other wound treatments not ref erred or consented to wound care physician will be directed by primary care until otherwise directed by primary physician. Nurse Consultant and Director of Clinical Services have conducted an audit to ensure all wounds identified have a current treatment in place. Responsible Party: DON/ADON, Target date: 2/11/2025 Follow up: Monitor for completion through morning meeting process. 2. Nurse Consultant and Director of Clinical Services provided in- service education to all nursing staff currently on shift regarding following physician ordered wound care and documentation of wound care. Responsible Party: DON/ADON, Target date: 2/11/2025 Follow up: Provide ongoing education to all new hires, agency, prn leave of absence prior to first shift worked and Follow WE CARE meeting process to ensure compliance. 3. All nursing staff will be provided with in-service following physician ordered wound care and documentation of wound care prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff. Responsible Party: DON/ADON or Designee Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 4. Identify any new wounds through orders, weekly skin assessments and admission assessments review completed during clinical morning meeting will be referred to primary care physician and wound care physician if ordered by primary care physician. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 5. Wound care physician will be notified via telephone by DON or designee when wound care consultation is ordered. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Follow WE CARE meeting process to ensure compliance. 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance. Responsible Party: IDT Team Target date: 2/11/2025 and ongoing Follow-up: Review any compliance issues in QAPI meeting for 3 months 7. Medical Director notified of alleged deficient practice. Responsible Party: Administrator Target date: 2/11/2025 The investigator monitored the Plan of Removal on 02/12/2025 as follows: During interviews conducted on 02/12/2025 between 12:00 noon through 3:30 PM, LVN F, LVN K, RN B, LVN A, LVN L, the MDS Nurse stated they were in-serviced by the ADON and the Administrator on 2/11/2025 and 2/12/2025 prior to their shifts. They stated they were in-serviced on wound care policy, notifying the DON of new wound care orders, implementing new wound care orders immediately after the Wound Doctor's visit. They stated they knew where to find the Wound Doctor's contact number at the nurse's station and in the Resident's chart in Point click Care, the system the facility use to document electronically. They stated they were in-serviced on documenting that treatments were done. They also stated, for new admission current residents, they were in-serviced to ensure skin assessments were done, if there were skin issues, document the color, size, odor and notify the primary care physician, DON and all parties. They stated they were told to follow up with referrals. During an interview on 2/12/2025 at 2:23 PM, the ADON stated she was in-serviced by the Nurse Consultant on 02/11/2025 on the process of new and current residents with wounds, skin assessments weekly as indicated. The ADON stated she was told to get a complete description of the wound, and notify the NP, transcribe orders immediately, communicate with the Wound Doctor if there were referrals, carry out orders from the Wound Doctor immediately. The ADON stated all Residents seen by the wound Doctor had his number in their chart where the nurses can look to contact him. The ADON stated she was to ensure the floor nurses are putting in orders immediately, completing wound care orders as ordered, following up with referrals. The ADON stated she was trained by the Administrator on 2/12/2025 on how to monitor PCC dashboard for missed treatment and follow up with the nurses why the treatments were missed. The ADON stated, she was to ensure after the wound Doctor's visits that all new orders were put in the Resident's charts. She stated the Nurse Consultant rechecked the Wound Doctor's orders from 02/11/2025 to ensure all orders from the Wound Doctor's visit were in the resident's charts. During an interview on 02/12/2025 at 2:54 PM the Administrator stated she was in-serviced by the Nurse Consultant on 02/12/2025 and she was in-servicing nurses at the beginning of their shifts on treatment orders, what to do if they identify new wounds. The Administrator stated the facility already identified all the wounds in the facility, they made sure the new wounds identified by the facility staff were seen by the Wound Doctor on 2/11/2025, made sure there were treatments in place and accurate, was verified by the Nurse Consultant and the Regional Director. The Administrator stated the facility would monitor through their daily morning meeting and the weekly WE Care meeting . The DON stated part of the morning meeting process, they would check the clinical dashboard to make sure treatment had been completed. The Administrator stated the Wound Doctor's contact was in PCC in the Resident's chart. The Administrator stated the DON was responsible to ensure treatments were done and she would designate someone in her absence of the DON. Review of Wound Doctor's visit orders dated 2/11/2025 reflected all new orders were in the Residents charts. Review of facility's in-services reflected in-services were initiated on 02/11/2025 at 5:35 PM with attached documents of: Medication orders, Pressure Ulcers/Skin breakdown-clinical Protocols: Receiving and Transcribing physician orders-Treatment Orders Physician Referrals-Wound assessment and Management Wound treatment documentation-Complete documentation and monitoring Review of facility's Quality Assurance Performance Improvement Committee document reflected QAPI had a meeting on 02/11/2025 to discuss IJ regarding wound care treatment orders. The Administrator was notified on 02/12/2025 at 3:36 PM that the IJ had been removed. While the IJ was removed on 02/12/25 at 3:36 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. 3. Review of Resident #1's face sheet printed on 01/28/25 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] after an overnight stay in the emergency room. Her diagnoses included pressure ulcer of sacral region (between the buttocks) - stage 4, chronic pain, neuromuscular dysfunction of bladder (lack of bladder control due to a nerve problem), paraplegia (paralysis), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected she required substantial/maximal assistance with bed mobility. Section M (Skin Conditions) reflected she had an unhealed stage 4 pressure ulcer. Review of Resident #1's current clinical physician orders reflected an order dated 07/29/24, Change wound vac dressing every MWF and as needed. After removing dressing, apply [cleanser] soaked gauze for 3 minutes, apply topical iodine over wound bed, apply adaptic dressing to wound bed then apply wound vac foam at 150mmHg continuous. Apply Eakin ring around peri wound to prevent stool into wound. Use skin prep to protect skin from dressing. Another order dated 07/29/24 reflected, If wound vac is unable to hold a seal or turned off for 2 hours, remove entire dressing and replace with alginate packing. Review of Resident #1's January 2025 MAR and TAR reflected the wound vac dressing was not changed on 01/13/25 and 01/17/25 . Review of Resident #1's comprehensive care plan reflected in part: Problem - Last revised 10/18/24 - The resident has a pressure ulcer stage four to buttocks. NPWT wound vac is in place (continuous 150mm Hg) to promote healing process. Goal - The residents pressure ulcer will show signs of healing and remain free from infection. Interventions - Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. The care plan was not revised to reflect the current order for 125mmHg. Review of Resident #1's Wound Care Progress note, from the wound clinic physician, dated 01/22/25, reflected in part, Resident #1 stated that her wound vac had been changed once weekly. I contacted the ADON at the facility. Resident had a wound vac change that was not done on Friday 01/18/25 but otherwise had her dressing changed 3x/week . Initial sacral wound began April 2022 .She was off NPWT from 06/13/24-07/26/24 . Continue NPWT 125mmHg. During a brief interview on 01/27/25 at 3:30 PM with the ADM, a policy for wound vacs and nursing competencies for wound vacs were requested. A policy for wound vacs was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #5) of six residents reviewed for pain. The facility failed to provide effective pain management for Resident #5 while she resided at the facility from 01/17/25 - 01/27/25. She had a recently acquired amputation that caused her to be in excruciating pain. The facility did not adjust her pain medication or notify her NP. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/29/25 at 4:04 PM and an IJ template was given. While the IJ was removed on 01/30/25 at 6:15 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, major depressive disorder, chronic pain, and acquired absence of left leg above the knee. Review of Resident #5's EMR, on 01/29/25, reflected her admission MDS assessment had not been completed. Review of Resident #5's admission care plan, dated 01/17/25, reflected she had acute pain related to left AKA and sacroiliitis (a painful condition which affects both sacral joints ) with an intervention of monitoring/documenting for side effects of pain medication and notifying the physician if interventions were unsuccessful. Review of Resident #5's physician order, dated 01/17/25, reflected Hydrocodone-Acetaminophen Oral Tablet-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #5's MAR , dated January 2025, reflected she was administered the medication (Hydrocodone-Acetaminophen) on the following days with the pain level (numerical) and effectiveness documented (pain level from 1-10): 01/17/25 at 10:36 PM - Pain Level 7 - Ineffective 01/18/25 at 4:30 AM - Pain Level 6 - Effective 01/18/25 at 10:03 PM - Pain Level 10 - Unknown if effective 01/19/25 at 8:40 AM - Pain Level 8 - Ineffective 01/19/25 at 4:40 PM - Pain Level 10 - Effective 01/20/25 at 10:50 PM - Pain Level 7 - Effective 01/21/25 at 11:25 AM - Pain Level 8 - Effective 01/22/25 at 10:15 AM - Pain Level 6 - Effective 01/26/25 at 3:47 AM - Pain Level 8 - Effective 01/26/25 at 5:55 PM - Pain Level 9 - Effective Review of Resident #5's physician order, dated 01/17/25, reflected Tylenol Oral Tablet - 325 MG - Give 2 tablets by mouth every 6 hours as needed for pain. Review of Resident #5's MAR, dated January 2025, reflected she was administered the medication (Tylenol) on the following days with the pain level (numerical) and effectiveness documented: 01/19/25 at 7:18 PM - Pain Level 8 - Effective 01/20/25 at 7:48 AM - Pain Level 4 - Effective 01/21/25 at 2:07 PM - Pain Level 3 - Effective Review of Resident #5's physician order, dated 01/18/25, reflected Buprenorphine Transdermal Patch Weekly 10 MCG/HR - Apply 1 patch transdermally one time a day every 7 day(s) for pain. Review of Resident #5's MAR, dated January 2025, reflected she only received the patch on 01/18/25. Review of an intake reported to HHSC, dated 01/24/25, reflected the following regarding Resident #5: RP and [Resident #5] report that at night when the CNAs [CNA G and CNA H] come in to provide care that they are rough with her and when she tells them she is hurting they will say we are not hurting you. Review of Resident #5's ER paperwork, dated 01/27/25, reflected the following: Reason for admission: s/p Lt AKA pain . Left AKA stump wrapped, [Resident #5] intolerable of pain and refused exam on leg . . On exam, [Resident #5] has intractable pain . Patient uncomfortable and histrionic on exam per documentation. Left AKA stump with purulent drainage, mild skin necrosis . . [Resident #5] was discharged on the 17th to a skilled nursing facility and had increasing pain in her AKA site. [Resident #5] gets dialyzed Monday Wednesday Friday but apparently missed Friday's dialysis due to the pain . During a telephone interview on 01/29/25 at 1:12 PM, CNA G stated if a resident was complaining of pain, she would tell the nurse. She stated she remembered providing care to Resident #5 (on 01/23/25) and knew she had a fresh amputation so she understood she would be in pain. She stated she was swinging at us (she and CNA H) because of the pain she was in during peri care . She stated RN J knew how much pain she was in because she had gone in and out of the room. She stated she was not sure if RN J gave her medication or what medication could have been given because she was just a CNA and did not know about medications. She stated it took CNA H and herself at least 30 minutes to provide the care due to the amount of pain Resident #5 was in. She stated they were not purposely trying to hurt her but had to get her clean. Review of Resident #5's progress notes, on 01/29/25, reflected no documentation regarding the pain during peri care on 01/23/25 . Pain medication was not administered to Resident #5 until 01/26/25. During a telephone interview on 01/29/25 at 1:34 PM, Resident #5's NP stated she had never expressed pain to her. She stated she would expect nursing staff to notify her if pain was not being managed or if pain medications were not effective. She stated she could have done something about it. She stated Buprenorphine patch orders should be followed. She stated if the order was for every seven days, it should be changed every seven days as it would no longer be effective. She stated a negative outcome of being in uncontrolled pain could be high blood pressure, heavy breathing, or anxiety. She stated Resident #5 was always anxious. During a telephone interview on 01/29/25 at 2:46 PM, Resident #5's RP stated he believed the staff agreed the pain medication was not sufficient while she was at the facility, but they were just following the orders given. He stated her severe pain never subsided the whole time she was at the facility. He stated she recently (01/28/25) had to have a procedure where they put a tube in her wound (incision site) to drain it due to an infection. He stated the infection had been causing her even more pain. An attempt was made to interview RN J on 01/29/25 at 3:04 PM. A returned call was not received prior to exiting. Review of the facility's Pain Policy, Revised October 2022, reflected the following: . The staff will assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain. . If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. The ADM was notified on 01/29/25 at 4:04 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/30/25 at 10:47 AM: The notification of Immediate Jeopardy states as follows: F697 The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Statement of Deficient Practice: The facility failed to provide effective pain interventions for Resident #5. CORRECTIVE ACTION: 1. Upon learning of the deficient practice the Regional Director of Clinical Services and Nurse Consultant began a review of residents charts for pain assessment orders . RESPONSIBLE PARTY: RDCS TARGET DATE: 1/29/25 FOLLOW-UP: Monitor for completion through morning meeting process. CORRECTIVE ACTION: 2. DON began inservice education for all nurses currently on shift regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place and how to conduct a pain assessment properly. Nursing Administration will complete a second pain assessment on 5 residents twice weekly for 3 months to ensure proper assessment of resident pain and level of nurse proficiency. Regional Director of Clinical Services and Nurse Consultant have conducted a pain assessment on each resident currently in the facility and residents will be continued to be assessed q shift ongoing. No residents have been identified at this time for uncontrolled pain. RESPONSIBLE PARTY: DON TARGET DATE: 1/29/25 FOLLOW-UP: Provide ongoing education to all new hires, agency, prn, leave of absence prior to first shift worked. CORRECTIVE ACTION: 3. All licensed nursing staff will be provided with in-service education on regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff. RESPONSIBLE PARTY: DON/ADON or Designee. TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Review daily staffing to ensure compliance. CORRECTIVE ACTION: 4. Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions or new complaints RESPONSIBLE PARTY: DON/ADON or Designee TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Follow morning meeting process to ensure compliance CORRECTIVE ACTION: 5. Review all residents currently identified for increased or change in pain weekly during WE CARE clinical meeting to confirm ongoing interventions and physician notification. RESPONSIBLE PARTY: IDT Team TARGET DATE: 1/29/25 and ongoing. FOLLOW-UP: Follow WE CARE meeting process to ensure compliance. CORRECTIVE ACTION: 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance. RESPONSIBLE PARTY: IDT Team TARGET DATE: 1/29/25 FOLLOW-UP: Review any compliance issues in QAPI meetings for 3 months CORRECTIVE ACTION: 7. Medical Director notified of alleged deficient practice. RESPONSIBLE PARTY: Administrator TARGET DATE: 1/29/25 The Investigator monitored the Plan of Removal on 01/30/25 as followed: During interviews conducted on 01/30/25 between 11:13 AM and 6:06 PM, 3 rehab therapists, 2 RNs, 6 LVNs, and 11 CNAs from both shifts stated they were in-serviced on pain. They all stated that if any resident complained of pain during care, they would stop immediately. The CNAs and therapists said they would notify the nurse immediately. The CNAs said they would tell the nurse and give the nurse a written note as a reminder. The nurses stated they would assess the resident every shift and with every complaint of pain. The nurses stated they would provide pain medication and follow up to ensure effectiveness. They stated if the medication was not effective, they would notify the doctor or nurse practitioner. Review of the facility's QAPI agenda, dated 01/29/25, reflected the MD, ADM, DON, ADON , MDS Nurse, SW, and Licensed Nursing Staff were in attendance. Review of an in-serviced entitled Pain, dated 01/29/25, reflected all nursing staff were in-serviced on their pain policy and the following: Monitor for pain every shift. Document pain/pain levels. Complete pain assessment if resident has pain. Provide medication if needed. If resident does not have pain meds notify MD/NP and document in EMR. CNA and Nurse will stop ADL, wound care, etc. and resident must be assessed and medication for pain. Activity resume with medication. Review of the WE CARE documentation form, revised 04/2023, reflected the form identified the procedure for conducting the meeting and the information to be reviewed. The information included pain and how the ADON or designee would review PRN pain medication documentation in [EMR system] for residents taking pain medications consistently. The facility had not had their weekly WE CARE meeting prior to exit. The ADM was notified the IJ was lowered on 01/30/25 at 6:15 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from Neglect for 1of 5 residents (Resident #1) reviewed. The facility failed to ensure that Resident # 1's G Tube and JP drains were cleaned and flushed according to physician's orders, causing the G tube and JP drains not to function properly. The facility failed to ensure Resident # 1 who had a G tube and JP drains received appropriate care and treatment timely. The tubes and drain were found to be dirty and clogged with mold, gnats, flies, maggots, and fly larvae. As a result, the resident was sent to a local hospital for evaluation and treatment The facility failed to follow the NP order to send the resident to the hospital on 6/5/2023 for interventions and was not sent out until 6/9/2023. This failure placed all residents at risk for Neglect An IJ was identified on 6/12/2023. The IL template was provided to the facility on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023 at 5:00PM, the facility remained out of compliance at the scope of actual harm with the potential for more than minimal harm that is not immediate because all staff had not been rained on all corrective systems. Findings included: Review of Resident #1 face sheet reflected that she was a 54- year- old woman, admitted to the facility on [DATE] with a diagnosis of Gastroenteritis ( an internal infection marked by diarrhea, cramping, nausea, vomiting and fever) and Colitis (inflammation in the colon) due to radiation, Gastroparesis, D Urinary Incontinence (Unintentional passing or urine), Hypertensive Retinopathy (retinal vascular damage caused by hypertension), Bilateral Hydroureter ( dilation of the renal pelvis, calyces and ureter), Hydronephrosis (excess fluid in the kidney due to a backup of urine) with ureteral structure, and Acute embolism ( blockage of a pulmonary lung artery) and Thrombosis (serious condition where one or more blood clots form in your blood vessels or heart). Resident # 1 admitted to the facility with 2 JP (Jackson Pratt surgical drains, a closed suction device that collects fluids) drains and bulbs and a G tube (Gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident # 1 admission MDS dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 has the cognitive ability to make her wants and needs known. Section G functional status of the MDS reflected Resident # 1 was totally dependent on assistance with bathing, and personal hygiene. Resident # 1 required extensive assistance with brushing teeth, combing hair, and washing face. Resident # 1 required two- person assist with transfers. Review of Resident # 1's care plan dated 5/17/2023, did not reflect or address the care for the G- Tube or JP drains. Observation on 6/9/2023 at 6:10pm of Resident #1's G-Tube and 2 JP drains at hospital. The G-Tube was observed to be clogged and very dirty with fluid, it did not appear to have not been flushed according to the order. Observation of 2 JP drains and bulbs revealed they were clogged with fluid and dirty. The bulbs were observed on a plastic bag with a foul odor coming from the bag. The bulbs had fluid gathered that was a brownish color, there was a towel wrapped around the bulbs in the bag that was soaked in fluid from the drainage. Record review of hospital records dated 6/9/2023, reflected Resident # 1 was admitted due to concerns with tubes. The report reflected Resident # 1 had feculent material from JP drains. Mold growing on G Tube as well as fruit flies, maggots noted. The record indicated the resident stated this had been going on for some time and that she complained of nausea, abdominal pain for the past two weeks. Records reflected Resident # 1 G-tube and JP drains appeared to have been neglected due to the condition. The records indicated Resident #1 's health conditions were described as having the drains in a bag where it was draining and had a very foul odor. The 2 JP drains and G Tube had not been flushed and cleaned properly over a period. Record Review of the physician's orders: 4/29/2023 - Empty surgical drain to right upper abdomen every shift for wound 4/29/2023- Empty surgical drain to right lower abdomen 5/1/2023- Flush PEG tube with 100ml of H20 once per shift two times a day for G tube 5/31/2023 Flush Each Drains with 5ml of H2O Q-shift evening shift 6/5/2023 Send to hospital IR for replacement of G tube. Review of progress note dated 6/4/2023 by LVN B, reflected Unable to flush due to inability to flush. ADON notified. Resident eating and drinking orally. Record review of progress note dated 6/5/2023 by LVN C, reflected Mold noted to G-tube and dr. notified for further instruction Record review of progress note dated 6/7/2023 by LVN D, reflected G tube, tagged off due to the appearance of mold in G-tube appointment for tomorrow to evaluate. Record review of progress note dated 6/9/2023 by LVN A, reflected Resident # 1 had 2 JP drains to Right lower quadrant of abdomen. Upon entering room to flush JP drain as ordered q shift, drains found in a bag with mold, flies, and fly larva inside. Strong prudent and foul odor. Drains were not flushed due to condition they were found in. Copious (abundant) amounts of prudent drainage. Resident # 1 requested to be sent to ER (emergency room). 911 notified and Resident # 1 was sent to the hospital. Recordd review of TAR (treatment adminsitration record) dated 6/1/2023 -6/9/2023, reflected for the order to Flush the PEG tube with 100ml once per shift reflected the tube was not flushed on 6/3/2023, 6/6/2023, and 6/9/2023 Empty surgical drain to upper right abdomen and lower right abdomen every shift reflected not dumped 6/3/2023, 6/6/2023, and 6/9/2023, and Flush each drain with 5ml of H2O Qshift in evening- not completed 6/3, 6/9 Review of admission record to facility dated 5/2/2023, reflected Resident # 1 admitted to the facility with G tube and JP drains in place, Facility Physical exam dated 5/2/2023, reflected Gastrointestinal: Abdomen soft , Non-tender, Normative BS, Drain x 2 abdomen, G tube L abdomen, no concerns noted with G tube or JP drains upon admission to facility. During an interview on 6/9/2023 at 6:10pm with Resident # 1 at the hospital, revealed she felt like the facility was killing her. She stated her G -Tube and JP drains had been in that condition for weeks, she stated when she would tell the staff that they would say they were going to come back and flush her tubes and dump her drains, but they never came back, and it continued to get worse. She stated the smell was bad, so she stopped going to therapy the last three days due to not wanting others to smell her bag. Resident # 1 stated she would ask the facility for bags for the JP drains. She stated she wrapped the towel around the drains, but the towel got soaked from the drainage and was smelling also. Resident # 1 stated she felt sick to her stomach and that she had pain in her abdomen area. During an interview on 6/12/2023 at 8:10am LVN A stated she worked at the facility on 6/8/2023 the 6pm to 6am shift. She stated when she came on shift, the nurse going off advised her that Resident # 1 had a G-Tube and 2 JP drains. She stated when she assessed Resident # 1 and entered the room there was a very foul odor. She stated the two JP drains were in a transparent plastic bag, filled with flies/Larva, and discharge from the drains. She stated the G-Tube was clogged and filled with fluid and had appeared to have not been flushed over a period of time. LVN A stated she immediately knew the resident needed to be sent out to the hospital, she stated she could not risk flushing the G Tube line and those fluids get flushed into the resident's system. LVN A stated Resident # 1 reported that she had been telling the facility for about two weeks. She stated the JP drains and G tube had been in that condition for about two weeks. She stated Resident # 1 stated she was relieved that she was sending her to the hospital. During an interview on 6/10/2023 at 3:06pm with the DON, revealed that she was made aware Resident # 1 was sent to the ER the morning of 6/9/2023. The DON stated LVN A advised her that there were maggots, flies, and mold on the G- tube and JP drains for Resident # 1. The DON stated she never assessed Resident # 1's condition or saw the condition of the G- tube or JP drains. The DON stated they had problems with the odor since the resident admitted to the facility stated it was a rotten smell and it continued to get worse. The DON stated they had frequently discussed the issue in their morning meetings. The DON stated the nurse's job was for them to monitor the G tube and JP drains and clean them as needed according to the physician's orders. She stated the JP drains were draining dying flesh (caused from cancer) from the Resident # 1's body causing the odor. The DON stated they were working on trying to get Resident # 1 a referral to the hospital. During an interview on 6/10/ 2023 at 3:13pm with LVN B, revealed she advised the ADON on 6/4/2023 of the condition of the G- Tube and JP drains of Resident # 1. She stated she observed the G Tube to be clogged and dirty with fluid, she stated she was not able to flush the G-Tube at the time due to the condition. LVN B stated the ADON advised her that they were trying to get a consult with the NP. During an interview on 6/10/2023 at 3:35pm with the ADON, revealed LVN C advised her on 6/2/2023 of the condition of Resident # 1's G -Tube and JP drains. She stated she was also advised on 6/4/2023 by LVN B of the condition of Resident #1's G-Tube and JP drains. The ADON stated to her understanding the G Tube and drains were flushed and dumped. She stated once she was notified, they were trying to get Resident # 1 a consult with the NP. The ADON stated the NP assessed Resident # 1 on 6/5/2023 and stated she completed an order for Resident # 1 to be sent out to the hospital (IR) intervention radiology to have the G -Tube and JP drains replaced. The ADON stated she never saw or assessed the condition of Resident # 1's G Tube or JP drains herself. The ADON stated she sent the referral to the hospital on 6/7/2023. The ADON stated Resident # 1 could have gotten a bacterial, fungal infection or sepsis. Interview on 6/12/2023 at 12:30pm with the ADM, stated he was not aware that a resident had been sent out until 6/9/2023 in their morning meeting. He stated he never received a call about anyone being sent out to the hospital. He stated with Resident # 1 they were waiting for the hospital to get the right tubes and bulbs that fit so they could send her to back to the hospital to have them replaced. The ADM stated until they were able to get Resident # 1 an appointment scheduled the nursing staff were expected to follow the orders that were in place for the care of the G- tube and JP drains. Interview on 6/12/2023 at 2:12pm the NP, stated she assessed Resident # 1 on 6/5/2023. She stated she only assessed the G- tube because that's what staff reported was a problem. She observed the G -tube to have some residue around the entry site and it was clogged. She stated there did not appear to be mold when she observed the G tube, however she felt that it needed to be removed or changed since Resident # 1 was not using it at the time. She stated after she assessed Resident # 1, she completed an order for Resident # 1 to go to hospital (IR) to have the G -tube replaced, she stated usually they can get them in the next day. She stated the facility did not call and tell her that they had a problem getting Resident # 1 sent to the hospital, because if that was the case Resident # 1 needed to be sent to the emergency room. She stated she expected Resident # 1 to have been seen the next day at the hospital. The NP stated the Resident # 1 should have gone to the hospital before Friday 6/9/2023 with the condition of the G tube. The NP stated the facility never reached out to her or any of their on-call staff to indicate that there were any issues getting the Resident #1 seen at the hospital. She stated she believed that someone dropped the ball along the way and that is why it took that long for Resident # 1 to be sent out to the hospital. The resident could have developed an irritation, infection, and other bacterial diseases. Record review of facility Policies: JP (Jackson Pratt) Drains policy dated March 2019 reflected the following: Empty the bulb every 8 to 12 hours or when half full If a large amount of fluid leaks from around the drain site, use soap and water to clean the area The skin around the drain may become infected. Signs and symptoms of infection include: Cloudy, foul-smelling drainage Abuse/Neglect policy dated Dec. 2016 reflected the following: Residents have the right to be free from abuse/neglect The ADM was notified on 6/12/2023 at 5:55PM that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 6/12/2023 at 5:55PM. A Plan of Removal was first submitted by the ADM on 6/12/2023 at 8:15PM. The Plan of removal accepted on 6/13/2023 at 4:33PM. Plan of Removal F600- The facility failed to ensure that the resident was free from Neglect. Impact Statement All residents could be at risk of developing infections and other bacterial diseases such as sepsis and or death from being neglected. 1. Action Item: Current Director of Nursing and Assistant Director of Nursing will be terminated effective 06/13/23. 2. Action Item: Interim DON/Regional Director Clinical Services assessed all residents with JP drains or feeding tubes by 6/13/2023. Orders and care plans reviewed by 6/13/2023. 3. Action Item: Interim DON/Regional Director Clinical Services will in-service licensed nurses on proper assessment, care and monitoring of JP Drains and feeding tubes prior to beginning of next scheduled shift. 4. Action Item: The JP drains and feeding tubes will be identified by nursing during review of pre-admit clinical documentation and new admission review. Orders will be reviewed during morning meeting to ensure assessment measures are included. 5. Action Item: Orders dictating proper assessment care and monitoring of JP Drains and feeding tubes will be obtained from the physician and entered in the resident's chart in Point Click Care. 6. Action Item: Care Plans for all residents with JP drains of feeding tubes have been updated on 7. Action Item: Resident who are admitted with JP drains and or feeding tubes will be assessed and monitored upon admission by interim DON. 8. Action Item: Licensed nursing staff will be educated prior to the beginning of their next shift about conducting weekly skin assessments. 9. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about documenting on the resident treatment record. 10. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about proper documentation and notification of residents change of condition. 11. Action Item: All staff will be educated on identifying changes of condition and notification of change of condition utilizing the Interact Stop, Watch, and Change of Condition form prior to the beginning of their next shift. 12. Action Item: All staff will be educated on identifying and prevention of resident neglect prior to the beginning of their next shift. Observation made on 6/14/2023 at 3:00pm of G Tube flush by LVN D, observed using appropriate hand hygiene, staff used gloves in the process. LVN D talked with resident prior to providing the care, Resident was in a pleasant mood, LVN D reviewed the order to ensure the right person and the right amount of fluid was being used to flush the G tube. Observation of the flushing reflected no concerns, no clogs noted during the process LVN D assessed the residents G tube entry site no concerns noted. No redness or irritation observed. Observation made on 6/14/2023 at 3:10PM of PCC documentation by, LVN D observed documenting in PCC the completed task of flushing the residents G tube according to the order and documenting any concerns noted. During an interview on 6/14/2023 at 3:15PM with Resident # 2, stated she was doing fine. Stated staff always check and clean her G tube, she stated she had no concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 3:25PM with Resident # 3, stated he was doing fine, Resident # 3 thanked surveyor for checking on him. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. Resident # 3 G tube appeared to be functioning properly and flowing. During an interview on 6/14/2023 at 3:35PM with Resident # 4, stated she was doing fine. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged, appeared to be flowing properly. During an interview on 6/14/2023 at 3:40PM with Resident # 5, stated she was doing fine. Stated staff check on him all the time. Resident # 5 stated he did not have any concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 2:30PM with LVN D, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. She was able to discuss the procedures when flushing the G tube and the monitoring of the G tube. LVN D stated a G tube and JP drains should be monitored according to the order but believed that it should be monitored more so that any a change in condition or concerns can be noted quickly. LVN D was able to discuss the procedure when reporting suspected abuse/neglect and reported that the Administrator was the abuse/ neglect coordinator. During an interview on 6/14/2023 at 2:40PM with LVN C, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN C was able to discuss when assessing a resident that they should be documenting the output, soiled dressing from either G tube or JP drains, and irritation or infection around the entry site of the tube. LVN C discussed if they G tube is clogged and unable to flush to immediately notify the provider and advise that they are sending the resident to the hospital. LVN C reported the administrator is the abuse/neglect coordinator and stated they contact him immediately if they see or suspect abuse/ neglect. During a phone interview on 6/14/203 at 4:34PM with LVN E revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN E stated when assessing residents with G tubes and JP drains, she goes by the orders. She stated they are assessing for signs of infection, irritation around the entry site, they are assessing the condition of the tubes and if they are functioning properly, they are assessing any changes in the resident's condition. LVN E stated any changes in any of these areas they are documenting in the PCC system and contacting the provider for further instructions. She stated if a resident had to be sent out to the ER, they are notifying the DON, Admin, and the family. LVN E stated the Admin. was the abuse/neglect coordinator and they reported any signs of suspected abuse/neglect immediately. During a phone interview on 6/14/203 at 4:45PM with LVN F revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN F reported they are checking for any changes in the resident's condition. She stated they are checking to ensure that G tube and JP drains are functioning and that they can be flushed and dumped as required according to the orders. LVN F stated any changes in these areas they are documenting in the PCC system and notifying the provider of the changes or concerns noted. She stated the Admin. was the abuse/ neglect coordinator and they are to report any signs of abuse/neglect immediately. During an interview on 6/14/2023 at 5:00PM with Admin. revealed he expected staff to follow the orders that were in place. If there is an emergency the nursing staff was able to contact the provider (NP) on-call line if needed Medline for guidance or should have sent the resident out to the hospital in an emergency. He stated all staff were trained on abuse/ neglect and the protocol if they see or suspect abuse or neglect, stated all contact numbers were located at each nurse's station. During an interview on 6/14/2023 at 3:15PM with interim DON, revealed the facility had no other residents with JP drains and bulbs. She stated there are four residents who have G-tubes, and all residents were assessed, orders and care reviewed. Record review on 6/14/2023 of in-services on Care, Assessment and Monitoring of JP drains and Enteral Feeding Devices reflected 10 nursing staff in-serviced. Record review on 6/14/2023 of PCC regarding resident assessment, orders and care plan reviewed, reflected the four residents identified as having G tubes were reviewed in PCC system. Each resident's care plan had been updated to reflect the care needs for the resident and the G tube, the orders were reviewed for each resident verified to be current and in the PCC system indicating the cleaning needs and frequency of the G tubes. Each resident was assessed and documentation in the PCC system reflected the residents current care needs. Record review of personnel file for DON, reflected the DON was terminated effective 6/13/2023. Record review of personnel file for ADON, reflected the ADON was terminated effective 6/13/2023 6/14/2023- Review of orders residents who currently have G-tube Resident's # 2, # 3, # 4, and #5. All orders have been entered into the Point Click Care system 6/14/2023 review of care plans reflected the care plans were updated 6/14/2023 to care and assessment needs for the following Residents # 2, #3, # 4, and # 5. 6/13/2023 to include proper assessment, care, and monitoring. All new admission residents will have an initial care plan updated to include proper assessment, care, and monitoring. 6/14/2023 Record review reflect the MDS coordinator was in-serviced on comprehensive care plans for residents with JP drains and G tubes 6/14/2023 record review reflect in-service with nursing staff on completion of interim care plans for residents, 8 nursing staff completed this in-service No new admissions at this time, Resident # 2 was admitted on [DATE] and documentation reflected he was assessed for his G tube care and needs. Record review of in-service dated 6/14/2023, reflected 10 nursing staff had been in-serviced on weekly skin assessments for residents. Record review on 6/14/2023 of skin assessments completed for Resident's # 2, # 3, # 4, and #5. Record review of in-service on electronic documentation of treatment provided dated 6/14/2023, reflected 10 nursing staff had completed this training. Record review of in-service of Change in Condition dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Change in Condition documentation utilizing the Stop, Watch, and Change in Condition form dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Abuse/Neglect dated 6/14/2023 reflected all staff had completed this training. An IJ was identified on 6/12/2023. The IJ template was provided to the facility administrator on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023, the facility remained out of compliance at a scope of isolated and a severity level actual harm because all staff had not been trained on effectiveness of corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care that included but not limited to assessing, evaluating, and responding to resident's care needs. The facility failed to assess Resident # 1's G tube and JP drains and provide care needed. This failure placed residents at risk of not getting their care needs assessed and provided by competent nursing staff. An IJ was identified on 6/12/2023. The IL template was provided to the facility on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023 at 5:00PM, the facility remained out of compliance at the scope of actual harm with the potential for more than minimal harm that is not immediate because all staff had not been rained on all corrective systems. Findings included: Review of Resident #1 face sheet reflected that she was a 54- year- old woman, admitted to the facility on [DATE] with a diagnosis of Gastroenteritis ( an internal infection marked by diarrhea, cramping, nausea, vomiting and fever) and Colitis (inflammation in the colon) due to radiation, Gastroparesis, D Urinary Incontinence (Unintentional passing or urine), Hypertensive Retinopathy (retinal vascular damage caused by hypertension), Bilateral Hydroureter ( dilation of the renal pelvis, calyces and ureter), Hydronephrosis (excess fluid in the kidney due to a backup of urine) with ureteral structure, and Acute embolism ( blockage of a pulmonary lung artery) and Thrombosis (serious condition where one or more blood clots form in your blood vessels or heart). Resident # 1 admitted to the facility with 2 JP (Jackson Pratt surgical drains, a closed suction device that collects fluids) drains and bulbs and a G tube (Gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident # 1 admission MDS dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 has the cognitive ability to make her wants and needs known. Section G functional status of the MDS reflected Resident # 1 was totally dependent on assistance with bathing, and personal hygiene. Resident # 1 required extensive assistance with brushing teeth, combing hair, and washing face. Resident # 1 required two- person assist with transfers. Review of Resident # 1's care plan dated 5/17/2023, did not reflect or address the care for the G- Tube or JP drains. During an interview on 6/9/2023 at 6:10pm with Resident # 1 at local hospital, revealed she felt like the facility was killing her. She stated her G -Tube and JP drains had been in that condition for weeks, she stated when she would tell the staff that they would say they were going to come back and flush her tubes and dump her drains, but they never came back, and it continued to get worse During an interview on 6/10/ 2023 at 3:13pm with LVN B, revealed she advised the ADON on 6/4/2023 of the condition of the G- Tube and JP drains of Resident # 1. She stated she observed the G Tube to be clogged and dirty with fluid, she stated she was not able to flush the G-Tube at the time due to the condition. During an interview on 6/10/2023 at 3:35pm with the ADON, revealed LVN C advised her on 6/2/2023 of the condition of Resident # 1's G -Tube and JP drains, she stated she was also advised on 6/4/2023 by LVN B of the condition of Resident #1's G-Tube and JP drains. The ADON stated she never saw or assessed the condition of Resident # 1's G Tube or JP drains herself. The ADON stated she sent the referral to the hospital on 6/7/2023. The ADON stated Resident # 1 could have gotten a bacterial, fungal infection or sepsis. In an interview on 6/10/2023 at 3:15PM the DON, stated LVN A advised her that there were maggots, flies, and mold on the G- tube and JP drains for Resident # 1. The DON stated she never assessed Resident # 1's condition or saw the condition of the G- tube or JP drains. The DON stated they had frequently discussed the issue in their morning meetings. The DON stated the nurse's job was for them to monitor the G tube and JP drains and clean them as needed according to the physician's orders. The [NAME] stated this could have caused the resident to get an infection and other bacterial diseases causing more health issues. Record review of hospital records dated 6/9/2023, reflected Resident # 1 was admitted due to concerns with tubes. The report reflected Resident # 1 had feculent material from JP drains. Mold growing on G Tube as well as fruit flies, maggots noted. Stated the resident that this had been going on for some time and that she complained of nausea, abdominal pain for the past two weeks. Records reflected Resident # 1 G-tube and JP drains appeared to have been neglected due to the condition. The record indicated Resident #1 's health conditions were described as having the drains in a bag where it was draining and had a very foul odor. The 2 JP drains and G Tube had not been flushed and cleaned properly over a period. Record Review of the physician's orders: 4/29/2023 - Empty surgical drain to right upper abdomen every shift for wound 4/29/2023- Empty surgical drain to right lower abdomen 5/1/2023- Flush PEG tube with 100ml of H20 once per shift two times a day for G tube 5/31/2023 Flush Each Drains with 5ml of H2O Q-shift evening shift 6/5/2023 Send to hospital IR for replacement of G tube. Review of progress note dated 6/4/2023 by LVN B, reflected Unable to flush due to inability to flush. ADON notified. Resident eating and drinking orally. Record review of progress note dated 6/5/2023 by LVN C, reflected Mold noted to G-tube and dr. notified for further instruction Record review of progress note dated 6/7/2023 by LVN D, reflected G tube, tagged off due to the appearance of mold in G-tube appointment for tomorrow to evaluate. Record review of progress note dated 6/9/2023 by LVN A, reflected Resident # 1 had 2 JP drains to Right lower quadrant of abdomen. Upon entering room to flush JP drain as ordered q shift, drains found in a bag with mold, flies, and fly larva inside. Strong prudent and foul odor. Drains were not flushed due to condition they were found in. Copious (abundant) amounts of prudent drainage. Resident # 1 requested to be sent to ER (emergency room). 911 notified and Resident # 1 was sent to the hospital. Record review of facility Policies: JP (Jackson Pratt) Drains policy dated March 2019 reflected the following: Empty the bulb every 8 to 12 hours or when half full If a large amount of fluid leaks from around the drain site, use soap and water to clean the area The skin around the drain may become infected. Signs and symptoms of infection include: Cloudy, foul-smelling drainage Abuse/Neglect policy dated Dec. 2016 reflected the following: All residents have the right to be free from abuse/neglect The ADM was notified on 6/12/2023 at 5:55PM that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 6/12/2023 at 5:55PM. A Plan of Removal was first submitted by the ADM on 6/12/2023 at 8:15PM. The Plan of removal accepted on 6/13/2023 at 4:33PM. Plan of Removal F600- The facility failed to ensure that the resident was free from Neglect. Impact Statement All residents could be at risk of developing infections and other bacterial diseases such as sepsis and or death from being neglected. 1. Action Item: Current Director of Nursing and Assistant Director of Nursing will be terminated effective 06/13/23. 2. Action Item: Interim DON/Regional Director Clinical Services assessed all residents with JP drains or feeding tubes by 6/13/2023. Orders and care plans reviewed by 6/13/2023. 3. Action Item: Interim DON/Regional Director Clinical Services will in-service licensed nurses on proper assessment, care and monitoring of JP Drains and feeding tubes prior to beginning of next scheduled shift. 4. Action Item: The JP drains and feeding tubes will be identified by nursing during review of pre-admit clinical documentation and new admission review. Orders will be reviewed during morning meeting to ensure assessment measures are included. 5. Action Item: Orders dictating proper assessment care and monitoring of JP Drains and feeding tubes will be obtained from the physician and entered in the resident's chart in Point Click Care. 6. Action Item: Care Plans for all residents with JP drains of feeding tubes have been updated on 7. Action Item: Resident who are admitted with JP drains and or feeding tubes will be assessed and monitored upon admission by interim DON. 8. Action Item: Licensed nursing staff will be educated prior to the beginning of their next shift about conducting weekly skin assessments. 9. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about documenting on the resident treatment record. 10. Action item: Licensed nursing staff will be educated prior to the beginning of their next shift about proper documentation and notification of residents change of condition. 11. Action Item: All staff will be educated on identifying changes of condition and notification of change of condition utilizing the Interact Stop, Watch, and Change of Condition form prior to the beginning of their next shift. 12. Action Item: All staff will be educated on identifying and prevention of resident neglect prior to the beginning of their next shift. Observation made on 6/14/2023 at 3:00pm of G Tube flush by LVN D, observed using appropriate hand hygiene, staff used gloves in the process. LVN D talked with resident prior to providing the care, Resident was in a pleasant mood, LVN D reviewed the order to ensure the right person and the right amount of fluid was being used to flush the G tube. Observation of the flushing reflected no concerns, no clogs noted during the process LVN D assessed the residents G tube entry site no concerns noted. No redness or irritation observed. Observation made on 6/14/2023 at 3:10PM of PCC documentation by, LVN D observed documenting in PCC the completed task of flushing the residents G tube according to the order and documenting any concerns noted. During an interview on 6/14/2023 at 3:15PM with Resident # 2, stated she was doing fine. Stated staff always check and clean her G tube, she stated she had no concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 3:25PM with Resident # 3, stated he was doing fine, Resident # 3 thanked surveyor for checking on him. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. Resident # 3 G tube appeared to be functioning properly and flowing. During an interview on 6/14/2023 at 3:35PM with Resident # 4, stated she was doing fine. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged, appeared to be flowing properly. During an interview on 6/14/2023 at 3:40PM with Resident # 5, stated she was doing fine. Stated staff check on him all the time. Resident # 5 stated he did not have any concerns at this time. Observation of G Tube showed no signs of infection or irritation around the entry site, tube appeared to be clean, did not appear to be dirty or clogged. During an interview on 6/14/2023 at 2:30PM with LVN D, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. She was able to discuss the procedures when flushing the G tube and the monitoring of the G tube. LVN D stated a G tube and JP drains should be monitored according to the order but believed that it should be monitored more so that any a change in condition or concerns can be noted quickly. LVN D was able to discuss the procedure when reporting suspected abuse/neglect and reported that the Administrator was the abuse/ neglect coordinator. During an interview on 6/14/2023 at 2:40PM with LVN C, revealed she worked the 6AM-6PM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN C was able to discuss when assessing a resident that they should be documenting the output, soiled dressing from either G tube or JP drains, and irritation or infection around the entry site of the tube. LVN C discussed if they G tube is clogged and unable to flush to immediately notify the provider and advise that they are sending the resident to the hospital. LVN C reported the administrator is the abuse/neglect coordinator and stated they contact him immediately if they see or suspect abuse/ neglect. During a phone interview on 6/14/203 at 4:34PM with LVN E revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN E stated when assessing residents with G tubes and JP drains, she goes by the orders. She stated they are assessing for signs of infection, irritation around the entry site, they are assessing the condition of the tubes and if they are functioning properly, they are assessing any changes in the resident's condition. LVN E stated any changes in any of these areas they are documenting in the PCC system and contacting the provider for further instructions. She stated if a resident had to be sent out to the ER, they are notifying the DON, Admin, and the family. LVN E stated the Admin. was the abuse/neglect coordinator and they reported any signs of suspected abuse/neglect immediately. During a phone interview on 6/14/203 at 4:45PM with LVN F revealed, she worked the 6PM-6AM shift and was in-serviced on G tube and JP drains care, Abuse/Neglect, documenting in PCC system, Change in Condition, and the use of the Change in Condition form in the PCC system. LVN F reported they are checking for any changes in the resident's condition. She stated they are checking to ensure that G tube and JP drains are functioning and that they can be flushed and dumped as required according to the orders. LVN F stated any changes in these areas they are documenting in the PCC system and notifying the provider of the changes or concerns noted. She stated the Admin. was the abuse/ neglect coordinator and they are to report any signs of abuse/neglect immediately. During an interview on 6/14/2023 at 5:00PM with Admin. revealed he expected staff to follow the orders that were in place. If there is an emergency the nursing staff was able to contact the provider (NP) on-call line if needed Medline for guidance or should have sent the resident out to the hospital in an emergency. He stated all staff were trained on abuse/ neglect and the protocol if they see or suspect abuse or neglect, stated all contact numbers were located at each nurse's station. During an interview on 6/14/2023 at 3:15PM with interim DON, revealed the facility had no other residents with JP drains and bulbs. She stated there are four residents who have G-tubes, and all residents were assessed, orders and care reviewed. Record review on 6/14/2023 of in-services on Care, Assessment and Monitoring of JP drains and Enteral Feeding Devices reflected 10 nursing staff in-serviced. Record review on 6/14/2023 of PCC regarding resident assessment, orders and care plan reviewed, reflected the four residents identified as having G tubes were reviewed in PCC system. Each resident's care plan had been updated to reflect the care needs for the resident and the G tube, the orders were reviewed for each resident verified to be current and in the PCC system indicating the cleaning needs and frequency of the G tubes. Each resident was assessed and documentation in the PCC system reflected the residents current care needs. Record review of personnel file for DON, reflected the DON was terminated effective 6/13/2023. Record review of personnel file for ADON, reflected the ADON was terminated effective 6/13/2023 6/14/2023- Review of orders residents who currently have G-tube Resident's # 2, # 3, # 4, and #5. All orders have been entered into the Point Click Care system 6/14/2023 review of care plans reflected the care plans were updated 6/14/2023 to care and assessment needs for the following Residents # 2, #3, # 4, and # 5. 6/13/2023 to include proper assessment, care, and monitoring. All new admission residents will have an initial care plan updated to include proper assessment, care, and monitoring. 6/14/2023 Record review reflect the MDS coordinator was in-serviced on comprehensive care plans for residents with JP drains and G tubes 6/14/2023 record review reflect in-service with nursing staff on completion of interim care plans for residents, 8 nursing staff completed this in-service No new admissions at this time, Resident # 2 was admitted on [DATE] and documentation reflected he was assessed for his G tube care and needs. Record review of in-service dated 6/14/2023, reflected 10 nursing staff had been in-serviced on weekly skin assessments for residents. Record review on 6/14/2023 of skin assessments completed for Resident's # 2, # 3, # 4, and #5. Record review of in-service on electronic documentation of treatment provided dated 6/14/2023, reflected 10 nursing staff had completed this training. Record review of in-service of Change in Condition dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Change in Condition documentation utilizing the Stop, Watch, and Change in Condition form dated 6/14/2023 reflected 8 licensed nursing staff and 9 CNA/CMAs had completed this training. Record review of in-service of Abuse/Neglect dated 6/14/2023 reflected all staff had completed this training. An IJ was identified on 6/12/2023. The IJ template was provided to the facility administrator on 6/12/2023 at 5:55PM. While the IJ was removed on 6/14/2023, the facility remained out of compliance at a scope of isolated and a severity level actual harm because all staff had not been trained on effectiveness of corrective systems.