**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 5 residents (CR#1) reviewed for CPR. CNA A and CNA M failed to initiate life-saving measures (CPR) when CR#1 who had a full code status (all resuscitation procedures provided if their heart stops beating or they stop breathing) immediately when he was found unresponsive on [DATE] around 1:30 AM. EMS was called around 1:40 AM, arrived at 1:45 AM, and began CPR. CR#1 was transported to the hospital via emergency services, where he died on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:35p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. These failures placed residents at risk of experiencing worsening of condition, pain and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings Included: Record review of facility census dated [DATE] revealed there were 74 residents. A review of Resident CR #1's face sheet, dated [DATE], revealed that he was a [AGE] year-old male admitted on [DATE], with a primary diagnosis of encephalopathy (a brain disease affecting cognitive function). Record review of Resident CR #1's care plan dated [DATE] and revised on [DATE] revealed the following care areas: CR#1 Full Code Status. Goal: Inform staff of code status, Full Code. Interventions: Monitor for decrease in change of condition Review of physician order, dated [DATE], revealed CR#1 was designated as full code status. Record review Phone interview attempt with Nurse M on [DATE] at 3:00pm, but surveyor was unsuccessful. Phone interview attempt with CNA M on [DATE] at 3:30pm, but surveyor was unsuccessful. Phone interview attempt with CNA A on [DATE] at 3:45pm, but surveyor was unsuccessful. In a phone interview on [DATE] at 8:49am with CNA M, she said when she returned to work if a lunch break on [DATE] around 1:30 AM, CNA A came to the unit stating that CR #1 was off the premises on the ground and unresponsive. She said CNA A left CR #1 where she found him outside, to notify other staff and call 911 at approximately 1:40am. She said CNA A and CNA M returned to the location of the resident but did not initiate CPR because everything was happening so fast. CNA M stated she and CNA A did not have the AED or crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). She said that when she and CNA A arrived at the location where CR #1 was found, CR #1 was unresponsive with blood coming from his mouth. She said no one knew how long CR #1 had been unresponsive. She stated that EMS arrived about 3-4 minutes after CNA A called 911. She stated that CPR was initiated by EMS staff upon arrival. CNA M could not explain why CPR was not initiated prior to EMS arrival around 1:45am on [DATE]. She stated the facility was notified that CR #1 was pronounced deceased at the hospital at 2:11am on [DATE]. CNA M stated she was not suspended was still allowed to work following the incident. CNA M stated that she was not CPR certified, and she had not received CPR training while employed at the facility. Phone interview attempt with CNA A on [DATE] at 9:30am, but surveyor was unsuccessful. In interviews on [DATE] at various times with five CNAs, (CNA E, CNA C, CNA K, CNA D, and CNA T) they said they were unfamiliar with CPR response times and how to work an AED machine. All stated the facility had not provided CPR training in the last year, and it was not a requirement for employment. In an interview on [DATE] at 3:00pm, The DON stated she could not explain the facility's expectations of the staff implementation of a Code Blue (an emergency code used in a healthcare facility where a patient's life is at immediate risk due to cardiac arrest or respiratory failure). The DON stated staff should not leave a resident alone if found unresponsive. The DON stated that the facility had not provided CNA A and CAN M with CPR training. She stated that the facility did not require the CNAs and Nurses to be CPR certified. She stated that she was not aware of any CPR trainings or in-services provided recently. She stated that CR#1 was a full code status and CPR should have been initiated if CR#1 was unresponsive. The DON stated that a CODE Blue was not called. The DON did not explain who was responsible for ensuring that all staff were trained on code status and when to implement CPR. She did not explain how similar incidents would be prevented in the future. The DON stated that CNA M and CNA A had not been suspended or reprimanded following the incident. Interview on [DATE] at 4:45pm, The Operations Manager stated he was notified of the incident at 5:30 a.m. on [DATE] by the Clinical Resources Nurse. CNA A left CR #1 on the sidewalk to call 911 from the facility. He stated that he was not aware of any staff training provided. The Operations Manager could not provide a timeline of the incident or identify the system failure. He did not explain how care staff would prevent future incidents from occurring. The Operations Manager stated he is responsible for managing the operations at the facility. He stated that the facility administrator was notified of the incident on [DATE] afternoon. Record review of CNA A and CNA M's employee files revealed no record of CPR training and certification for CNA A and CAN M. Record review of cardio-pulmonary resuscitation policy original date 11/2016 with Revision/Review Date(s) 01/2022 and 12/2023 stated in part: It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advance directives or a Do Not Resuscitate (DNR) order. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. The facility will have staff certified in CPR available 24 hours/day to provide basic life support and CPR prior to the arrival of emergency medical services (EMS) personnel . Staff will maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment . Record review of in-services revealed no documented CPR training provided in the one year look back period ([DATE] thru 10/11//2024). Record review of CNA job description read in part: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. There was not referenced information related to CPR education requirement for CNA staff. An IJ was identified on [DATE] at 8:35p.m. The IJ template was provided to the Operations Leader and DON via email on [DATE] at 8:35p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 2:38pm The Immediate Jeopardy findings were identified in the following area: F678 Cardio-Pulmonary Resuscitation: The facility failed to ensure that nursing staff provided CPR in accordance with professional standards, failed to provide on-going monitoring of a resident after a change in condition was identified and reported, failed to immediately and properly assess a resident after a change in condition was identified and reported, failed to document assessments performed after a change in condition was identified and reported, failed to immediately contact EMS when a resident was found unresponsive, and failed to thoroughly investigate an incident. The facility failed to immediately initiate life-saving measures (CPR) when CR#1 when was found unresponsive on [DATE] around 1:30 AM. EMS was called around 1:40 AM, arrived at 1:45 AM, and EMS began CPR on CR#1. CR#1 was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Immediate Actions 1. The Medical Director was notified of IJ on [DATE] at 8:46pm. 2. Review of licensed nursing staff personnel files was completed by Business Office Manager and Staffing Coordinator and validated by RN, Director of Nursing to ensure current licensed nurses held a current CPR card completed [DATE] and [DATE]. 3. CPR policy reviewed by DON, ED, Operations Manager, Clinical Resource, Clinical Market Leader, Medical Director and RT, Certified CPR Instructor [DATE]. No changes were made. 4. Education initiated with nursing staff [DATE] to provide basic life support, including CPR, and use of AED to any resident requiring such care, and alert EMS. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 5. All nursing staff will complete CPR competency [return demonstration and BLS posttest] conducted by RT, Certified CPR Instructor, initiated [DATE]. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 6. Education initiated with Therapy staff on [DATE] to provide basic life support, including CPR and the use of AED to any resident requiring such care and alert EMS. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 7. All staff will be offered the opportunity to become CPR certified. [DATE] Nursing and Therapy staff are receiving CPR certification training; all other non-licensed staff will be offered CPR training. Completion date [DATE]; training provided by RT, Certified CPR Instructor. Staff is trained prior to their next shift. Any staff unavailable will not be allowed to work until training is completed. 8. This training and competencies - CPR training will be completed in-person with staff prior to the start of their next shift. A member of management [ADONs or Staffing Coordinator] will be at the facility at each change of shift to ensure staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff members will not be allowed to work unless they have received their training and knowledge check. [DATE] 9. To maintain compliance, HR will monitor CPR certification with DON oversight. [DATE] CPR certification will be maintained in a binder and reviewed at least monthly and/ or upon hire of licensed nursing/ therapy staff. Ad hoc QAPI meetings regarding items in the IJ template completed [DATE]. Attendees included the Medical Director, Clinical Resource, Operations Manager, DON, ADON, Clinical Resources, and Clinical Market Leader, and included the plan of removal items and interventions. The Operations Manager and DON were reeducated on CPR process by RN, Clinical Resource on [DATE]. Monitoring of the plan of removal included the following: Record review of employee files who worked on [DATE] (6pm -6am), CNA M, CNA A, CNA E CNA C, Nurse T and LVN P revealed no record of staff being BLS certified, or CPR trained. Record review of education in-service training dated [DATE] and [DATE] revealed basic life support, including CPR competency and CPR in-services was provided to all staff scheduled on [DATE] and [DATE]. Record review of QAPI sign-in sheet date [DATE] reflected MD participated via telephone, operations Leader, DON, Wound Care Nurse, Social Services, HR, MDS coordinator, Therapy Services, Clinical Resource Staff were in attendance. Record review of nursing staff personnel files was completed and revealed CPR competency as [DATE] all staff scheduled on [DATE] and [DATE]. During the interview on [DATE] at 4:30am, Nurse T stated that she had worked at the facility for only a week and was not familiar with resident CR #1. Nurse T stated that she was the nurse assigned to CR#1 on [DATE] thur [DATE], at the time of te incident.She mentioned that she was unsure whether the resident had full code status or was an elopement risk. Throughout her shift, she only reviewed CR #1's MAR records and did not look at CR #1's care plan or orders regarding code status. She noted that this information could be found in the clinical record under physician orders, but she had not had the chance to review it. On the night of the prior to the incident ([DATE]), Nurse T recalled last seeing CR #1 at 11:00pm when she administered his medication. After this, CR #1 indicated he was going to bed, but Nurse T did not assist him in returning to his room or transferring from his wheelchair to his bed. She admitted she did not check on CR #1 between 11 PM and 1 AM and denied being asleep at any point during her 12-hour shift. Nurse T stated that she is currently CPR certified, but she was uncertain whether the facility had received documentation confirming this. During handoff report at the start of her shift, she was informed that CR #1 was independent and did not require assistance. At 1:00 AM on [DATE], CNA A informed her that CR #1 was missing from his room. Nurse T stated that she did not call an elopement code but could not explain why. During the interview on [DATE] at 4:15am, CNA A reported that on the night prior to the incident ([DATE]), she saw CR #1 a local barbecue bar near the facility during her 15-minute break at approximately 10:45pm. She noted that CR #1 frequently left the facility independently and did not notify anyone of his whereabouts. At 1:30am on [DATE], she found CR #1 on the ground behind the facility near a barbecue bar, out of his wheelchair, bleeding from the mouth and unresponsive. She immediately returned to the facility called 911 and notified Nurse T and another CAN M who was the assigned staff to CR #1. She stated that Nurse T appeared to be sleeping at the time. CNA A and CNA M then returned to CR #1's location but did not initiate CPR, although she did not specify why it was not started. CNA A stated that she and CNA M did not take AED to the location of CR #1 upon returning. CNA A stated that she was not BLS certified, and the facility had not provided CPR training since she's been employed at the facility. She stated that EMS arrived approximately 10 minutes after being called. She stated that upon EMS arrival, EMS initiated CPR and transported CR #1 to the hospital where he was later pronounced dead. Interviews on [DATE] - [DATE] with staff on both shifts (6am - 6 pm) and (6pm to 6am) for CNAs and 6 a.m.-6 p.m. included the DON and Operations Leader, Nurse T, LVN B, and LVN J all on night (6pm to 6am) shift were able to verify in-services and to validate their understanding basic life support, including CPR, and use of AED. They were able to identify what was neglect and provide examples of some signs and symptoms of respiratory distress, the code for emergency (code blue) used. CNAs were able to explain they were in-serviced on calling the nurse when there is an emergency. LVN's and CNAs were able to explain the importance of calling a code blue promptly in response to emergencies; and how to check the code status in the clinical record to ensure they were able to conduct CPR. Staff was able to return demonstrations related to the process for providing CPR and using the AED. Staff was able to verbalize and understanding of the facility's CPR policy related to CPR implementation. The Operations Leader was informed the Immediate Jeopardy was removed on [DATE] at 10:00 am. The facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision. The facility failed to provide sufficient supervision to CR#l on [DATE] at 1:30am, when he was found unresponsive behind the facility, with blood coming from his mouth. CR#l was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Multiple staff working the night shift (CNA E, CNA A, CNA M, CNA C and Nurse T), were unaware CR#1 was missing from the facility and an elopement code was not initiated. There was not an effective system in place to track residents entering and exiting the building. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization, or death. Findings included: Record Review of CR #1's face sheet, dated [DATE] revealed that he was a [AGE] year-old male admitted on [DATE], with a primary diagnosis of encephalopathy (a brain disease affecting cognitive function). Record Review of CR #1's MDS assessment dated [DATE] indicated that CR #1 had a BIMS score of 7 out of 15, reflecting severely impaired cognition. He had no behaviors, including wandering, and required substantial/maximal assistance with transfers from bed to chair. Record review of the elopement risk assessment for CR #1, dated [DATE], reflected the elopement risk assessment failed to reveal that CR #1 was a low risk for elopement. The comprehensive care plan initiated on [DATE] did not include a care plan for impaired cognition or address wandering or elopement. Record review Observation on [DATE], at 11:45am revealed upon the surveyor's arrival, no receptionist or staff member was present at the desk to monitor exit-seeking residents at the front door. On [DATE] starting at 12:55pm, in phone Interviews with two-night CNAs (CNA E and CNA C), they stated that they did not see CR #1 at all during their shift on [DATE] and [DATE] and did not know CR #1 was missing. They stated they would usually see CR #1 through their shift, but lately he had not been his usual self. Both stated they were in- serviced on elopement process on [DATE] following the incident. Neither could explain why an elopement code was not called on [DATE] in the morning. Observation on [DATE] starting at 12:30pm, revealed residents (later identified as Resident #2 and Resident #3) exiting without signing out or being accommodated by staff. It was unclear if residents were leaving to smoke or leaving to go out on pass. On [DATE] at 12:55pm, in an interview with receptionist, she stated that there was no desk coverage after 10:00 p.m., and all residents should be in after the last smoke break. The receptionist stated staff (activity director or receptionist) typically accompanied residents while in the smoking area, but there was no clear way to distinguish residents leaving for smoke breaks from those leaving for other reasons. The receptionist stated that there is no coverage at the receptionist desk when accompanying residents while they are smoking. In interviews on [DATE] starting at 1:10pm, Three CNAs (CNA K, CNA D and CNA T) and two nurses (LVN A and RN L) revealed staff had been recently in-serviced on resident sign-in/sign-out procedures. They conducted resident rounds every two hours and were required to call a Code 20 for elopements. However, staff were unfamiliar with the Resident Roster list, which identified residents needing assistance when exiting, and could not explain who was responsible for escorting these residents. In an interview on [DATE] at 2:00pm, The Operations Leader stated he was notified of the incident at 5:30 a.m. on [DATE] by the Clinical Resources Nurse. He reported that CNA A found CR #1 unresponsive on a nearby sidewalk at 1:30 a.m. CNA A, who was not assigned to Resident #1, discovered him while returning from lunch. She left him on the sidewalk to call 911 from the facility. Staff were unaware that CR #1 had left, as he had not signed out. He stated that CR #1 had a history of leaving without signing out. The Operations Leader stated nothing had been done to address CR #1 not signing out. The Operations Leader stated that the residents are responsible to sign-in/sign-out. The Operations Leader was not able to identify who was responsible for reviewing the sign in and out sheets. The Operations Leader was aware that there is no receptionist at the front desk after 10:00pm. He stated that he was not aware of any staff training provided to address what to do after 10:00pm when the receptionist leaves. The administrator stated he reviewed video surveillance on [DATE], which showed CR #1 leaving at 10:38pm on [DATE], but there was no footage of him returning. The administrator could not provide a timeline of the incident or identify the system failure. He stated the facility had implemented a Resident Roster list that will remain at the front desk with the receptionist, which identified residents needing assistance when exiting, but could not explain who was responsible for escorting these residents. He could not explain how care staff would be made of aware of the list and how the list prevented future incidents form occurring. In an interview on [DATE] at 4:00pm, The DON said she was informed of the incident at 1:47 a.m. on [DATE]. She stated that Nurse T had last seen CR #1 at 11:00pm on [DATE] during medication rounds, and CR #1 had said he was going to bed. The DON stated that Nurse T did not follow up to ensure CR #1 was in bed as she was new at the facility and was not familiar with CR #1. The DON stated that she was aware that CR #1 was not compliant with signing in and out. The DON did not reveal who was responsible for checking to ensure that the sign in and out sheet were being completed daily. The DON stated nothing had been done to address CR #1 not signing out. The DON was aware that there was no receptionist at the front desk after 10:00pm daily. She stated she had not provided staff trainings to address what to do after 10:00pm when the receptionist leaves. The DON stated there was no policy specifying how frequently staff should round on residents. She stated another resident previously eloped in [DATE], and the facility implemented a sign-out form, but no additional measures were taken. She stated the form was implemented by in servicing the residents and staff that residents are to sign out when leaving the facility on a leave pass. She could not explain how the implementation of the acknowledgment form had been reviewed for its effectiveness in keeping the residents safe and preventing future elopements. She could not explain the facility's expectations of the staff in the identified implementation. The DON stated that residents have the right to leave the facility when they like, but she could not identify the facility's role in ensuring the safety and account of residents leaving or returning. The DON could not explain how the facility ensured the daily accurate census if residents leave without signing out. The DON said an elopement code was not initiated during the incident as staff were unaware CR #1 had gone missing. The DON stated staff was trained on elopement code and process on [DATE], following the incident. She also noted that while a Resident Roster was created based on cognitive levels, staff had not been trained on its use. She stated the facility had implemented a Resident Roster list that will remain at the front desk with the receptionist, which identified residents needing assistance when exiting, but could not explain who was responsible for escorting these residents. She could not explain how care staff would be made aware of the list and how the list prevented future incidents from occurring. On [DATE] at 8:49am, in an interview with CNA M, who was assigned to CR #1 the night of the incident, CNA M stated she had last seen CR #1 around 6:00pm on [DATE], when she provided his dinner tray to him. She stated that the shifts started at 2:00pm on [DATE] and the resident was lying in bed at that time. She stated this was not unusual as the resident seemed to be depressed for the past two months, after losing his roommate. She stated that nursing staff was aware that he was not his usual self, but she was unaware if anything had been done to address the decline. She stated that at 12:30am on [DATE] (while on her lunch break) she noticed that CR #1's room light was on. She stated that that she had not check on CR #1 from 6:00pm on [DATE] and 12:30pm on [DATE] because CR #1 was independent and could communicate his needs. She stated that she noticed that CR #1 was not in his room, and she informed Nurse T. She stated that Nurse T stated that she had last seen him at 10:45pm when she gave him his nightly medication and he stated he was going to bed. CNA M stated the staff did not assist him in transferring from his chair to bed or ensure that CR #1 was in bed. CNA M stated she was not aware that CR #1 required assistance to bed. She also stated that Nurse T as new and was not familiar with CR #1. She stated that an elopement code was not called as she recalled everything happening so fast. She stated another staff, CNA A, who was not assigned to CR #1 came to the unit at 1:30am on [DATE] stating that CR #1 was off the premises on the ground and unresponsive. CNA A left CR #1 and called 911. CNA A and CNA M returned to the location of the resident. CNA M stated it is unknown how long CR #1 had been unresponsive. She stated the facility for notified that CR #1 was pronounced deceased at the hospital at 2:11am on [DATE]. CNA M stated the resident left the facility all the time without signing in and out and the facility administration was aware of it. She stated there is no keypad code required to exit the build afterhours, but a keypad code is required to re-enter. She stated that resident have the key code (a number code required to be entered in a keypad before entered the facility) and there is no system to account for residents. She stated there is no receptionist after the last scheduled smoke break at 10:00pm each day. She stated that CR #1 was a smoker. She stated that even when there is a receptionist there is no system to account for the residents. She stated that the care staff and receptionist did not communicate when a resident was leaving. She stated if the resident did not sign out there is no way for staff to know the resident whereabouts. CNA M stated the facility system is not designed to keep the residents safe. During the interview on [DATE] at 4:30am, Nurse T stated that she had worked at the facility for only a week and was not familiar with resident CR #1. Nurse T stated that she was the nurse assigned to CR#1 on [DATE] thur [DATE], at the time of te incident. She mentioned that she was unsure whether the resident had full code status or was an elopement risk. Throughout her shift, she only reviewed CR #1's MAR records and did not look at CR #1's care plan or orders regarding code status. She noted that this information could be found in the clinical record under physician orders, but she had not had the chance to review it. On the night of the prior to the incident ([DATE]), Nurse T recalled last seeing CR #1 at 11:00pm when she administered his medication. After this, CR #1 indicated he was going to bed, but Nurse T did not assist him in returning to his room or transferring from his wheelchair to his bed. She admitted she did not check on CR #1 between 11 PM and 1 AM and denied being asleep at any point during her 12-hour shift. Nurse T stated that she is currently CPR certified, but she was uncertain whether the facility had received documentation confirming this. During handoff report at the start of her shift, she was informed that CR #1 was independent and did not require assistance. At 1:00 AM on [DATE], CNA A informed her that CR #1 was missing from his room. Nurse T stated that she did not call an elopement code but could not explain why. During the interview on [DATE] at 4:15am, CNA A reported that on the night prior to the incident ([DATE]), she saw CR #1 a local barbecue bar near the facility during her 15-minute break at approximately 10:45pm. She noted that CR #1 frequently left the facility independently and did not notify anyone of his whereabouts. At 1:30am on [DATE], she found CR #1 on the ground behind the facility near a barbecue bar, out of his wheelchair, bleeding from the mouth and unresponsive. She immediately returned to the facility called 911 and notified Nurse T and another CAN M who was the assigned staff to CR #1. She stated that Nurse T appeared to be sleeping at the time. CNA A and CNA M then returned to CR #1's location but did not initiate CPR, although she did not specify why it was not started. CNA A stated that she and CNA M did not take AED to the location of CR #1 upon returning. CNA A stated that she was not BLS certified, and the facility had not provided CPR training since she's been employed at the facility. She stated that EMS arrived approximately 10 minutes after being called. She stated that upon EMS arrival, EMS initiated CPR and transported CR #1 to the hospital where he was later pronounced dead. Record review of review of CR #1 the sign out sheet revealed that there was no record of CR #1 signing out on [DATE] and [DATE]. Record review of nursing noted for [DATE] and [DATE] revealed no documentation of the timeline of the incident. An IJ was identified on [DATE] at 7:45pm The IJ template was provided to the Operations Leader and DON via email on [DATE] at 7:45pm. The facility's Plan of Removal was accepted on [DATE] at 3:46pm, and included the following interventions: The Immediate Jeopardy findings were identified in the following area: F 689 Quality of Care The facility failed to ensure adequate supervision to prevent accidents for 1 of 5 residents (CR#1) reviewed for supervision. The facility failed to provide sufficient supervision to CR#1 on [DATE] at 1:30am, when he was found unresponsive behind the facility, with blood coming from his mouth. CR#1 was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Immediate Actions 1. The Medical Director was notified of IJ on [DATE] at 8:06 PM. 2. Education initiated with all staff on [DATE] on Abuse: Prevention of and Prohibition Against to include Neglect with a post test. Reeducation initiated [DATE]. Completion date [DATE]. Training provided by DON/ designee. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 3. The Out-on-Pass policy was reviewed by the IDT and revised. The three strike rule will be implemented in cases of repeated non-compliance to this policy. Upon the third strike, the Business Office and Administrator may choose to initiate the process of issuing a 30-day discharge notice to the resident. An ad hoc QAPI was held. [DATE]. Policy was approved in the Ad hoc QAPI. 4. Education initiated with all staff on [DATE] on Out-on-Pass Policy and residents will be required to sign out to go out on pass; with a census of residents that identifies which residents are independent and which require supervision when out on pass. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training was conducted by DON/ designee and Staffing Coordinator. 5. 24/7 receptionist staffing initiated on [DATE]. Reeducation on receptionist protocol initiated on [DATE], including policy that if the receptionist needs to step away, another staff member will relieve the receptionist. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training provided by DON/ designee; Operations Manager and Staffing Coordinator. Sister facility DONs/ ED or Ops Manager will be scheduled to completed knowledge checks daily x 2 weeks, then weekly x 2 weeks to monitor effectiveness. DON/ designee will monitor effectiveness weekly in Systems Review. 6. Social Services and Medical Records will ensure that the Out-on-Pass acknowledgement is signed by residents, this will include a three strike rule for compliance. [DATE]. Social Services will be responsible for reviewing with the effectiveness of this protocol with oversight from the Operations Manager. This will be reviewed weekly during the Systems Review by the DON/ ADONs/ Social Services. 7. Education initiated with all staff on [DATE] on elopement policy and identifying residents at risk for elopement and when to initiate and elopement response. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. The training is being provided by the DON/ ADON/ Staffing Coordinator with a knowledge check. Elopement drills will be conducted at a minimum of monthly by the Maintenance Director and reviewed by the DON, effectiveness will be reviewed at the time of the drill. 8. Elopement assessments of all residents were reviewed to identify which residents are elopement risks on [DATE]. Binders were placed at each nurse station and the receptionist desk for identification purposes on [DATE]. Residents who scored high for elopement risk, currently reside in the secured units (2nd floor); no residents on 3rd floor were identified as at risk for elopement. 9. Elopement drills were held twice a day from [DATE]-14, and will continue three times a week x 4 weeks, then weekly x 4 weeksXXX[DATE] The DON/ ADONs/ Staffing Coordinator conducted the drills. An elopement drill form will be completed for each drill. The Elopement policy was reviewed by DON, Operations Manager, Clinical Resource, Clinical Market Leader and Medical Director [DATE]. No changes were made. Education initiated with all nursing staff on [DATE] regarding making rounds routinely. Approximately every 2 hours, dependent on resident needs and or preference. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. [DATE] Training provided by DON/ ADONs/ Staffing Coordinator. Charge nurses will perform census count every shift. [DATE] The shift census will be tracked utilizing a census sheet with the charge nurse signing off, indicating all residents are accounted for. Charge Nurses will report absent/ missing residents at the time of the census check to the DON/designee. ADONs/ designee will be responsible for collecting daily, when on duty and reviewing. These trainings and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Ad hoc meetings regarding items in the IJ template completed [DATE]. Attendees included the Medical Director, Operations Manager, DON, ADONs, Clinical Resources, and Clinical Market Leader, and included the plan of removal items and interventions. The ad hoc QAPI was acknowledged and the plan with the interventions were agreed upon. Monitoring: Observations on [DATE] at 12:30 pm and 2:30pm and on [DATE] at 4:00am and 12:00pm - 2:30pm revealed someone sat in the receptionist area, and coverage was provided when the receptionist was gone on break. Observations on [DATE] stating at 4:00am thru 6:00am and 8:00am thru 10:00am revealed were completing frequent rounding on by checking on the residents there in the units. Interviews on [DATE] - [DATE] with staff on both shifts (6am - 6 pm) and (6pm to 6am) for CNAs and 6 a.m.-6 p.m. included the DON and Operations Leader, Nurse T, LVN B, and LVN J all on night (6pm to 6am) shift and the receptionist were able to verify in-services elopement drills were provided. Nursing staff were able to appropriately define elopement risk, identify the location of the resident elopement book, provided the procedure for a resident found trying to leave the facility without supervision (report to the charge nurse). The Receptionists said they were to let nursing staff or administrative staff, if available, know when they were going on break. All the receptionists knew to check the census sheet who was able to verify resident who were able to leave out on pass. The receptionist said she was to let nursing staff know she was going on break so someone could relieve her to cover the front desk while on break. All interviewed nursing staff stated that they were aware that 24-hour coverage would be maintained at the receptionist desk. CNA stated that they were made aware that they would rotate the responsibility of relieving the receptionist for bathroom and lunch breaks. Nursing and CNA staff stated they were in-serviced on rounding at least every 2 hours. Interview on [DATE] at 10:30am with Social Services Staff, she stated that she had been in-serviced on the policy for residents going out on pass and three-strike rule for noncompliance. She stated that if residents were non-compliant with the going out on pass policy, a IDT meeting would be held to determine the next best step for the resident. Record review Reeducation on receptionist protocol initiated on [DATE], including policy. Record reviews revealed an Elopement Risk binder was located at the nursing station with the face sheets of all current residents and the elopement risk assessments for each resident. Record reviews of the charts were completed for Resident #s 2, 3, 4 and 5 and reflected elopement assessments. Resident care plans included their elopement status. Record review of training sign in sheet dated [DATE] thru [DATE] revealed that elopement in-services were completed with nursing staff who were scheduled to work on [DATE] thru [DATE]. Record review of census counts was verified on [DATE] and revealed that a census count was completed and sign off on by the charge nurse. Record review of trainings and in-services revealed that elopement drills were completed on [DATE] and [DATE] with nursing staff scheduled to work on [DATE] and [DATE]. Record review of trainings and in-services dated [DATE] revealed that social service staff had been in-serviced on the resident going out on pass and three strike rule for resident who were noncompliant. The Operations Leader was informed the Immediate Jeopardy was removed on [DATE] at 10:00 am The facility remained out of compliance with a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #37) of 3 residents reviewed for pressure ulcers. The facility failed to notify Resident #37's physician and modify his interventions when he refused to wear his protective boot on his left foot and when he refused to be repositioned in bed. The facility failed to accurately assess and modify interventions for Resident #37, whom the facility said prefers to lie on his abdomen, and he had a suprapubic catheter. Resident #37 developed a stage 4 pressure ulcer on his left medial foot and on left abdomen and right groin. An IJ was identified on 01/24/24. The IJ template was provided to the facility on [DATE] at 3:00 p.m. While the IJ was removed on 01/26/24 at 3:55 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on reporting and assessing for changes of condition. These failures placed residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of Resident #37's face sheet dated 01/03/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #37 had diagnoses which included cardiac arrest (heart suddenly stops pumping), muscle wasting and atrophy (a condition in which muscles begin to waste away due to disuse), paraplegia (inability to voluntarily move lower parts of the body), dependence on renal dialysis (removing of waste and excess fluid from the body with kidney failure) and peripheral vascular disease (a slow and progressive circulation disorder). Record review of Resident #37's quarterly MDS assessment, dated 11/20/2023, revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Further review of Resident #37's MDS revealed the resident developed a pressure ulcer after admission. The intervention for the pressure ulcer such as pressure reducing device for bed, turning, and/or repositioning program was not indicated. Record review of Resident #37's undated care plan revealed: Resident #37 developed a stage 4 pressure ulcer on left medial foot. Interventions: administer treatments as ordered and monitor for effectiveness, offload pressure as much as possible. Further review of Resident #37's care plan revealed Resident #37 had an actual impairment to skin integrity related to non - pressure wounds on: left abdomen, and right groin. Interventions: educate resident on the importance of turning and repositioning, treatment per MD orders. It also read the resident desires to lay on his stomach. Record review of Resident #37's admission/readmission skin evaluation dated 07/11/23 revealed Resident #37 did not have any skin issues on his left foot, or any skin issues on his abdomen or groin. Record review of Resident # 37's Braden scale dated 11/7/23 revealed resident was at high risk for a pressure ulcer and further review revealed the resident had very limited mobility: could make slight changes in body or extremity independently. Record review of Resident #37's weekly skin evaluations from 08/28/23, 09/05/23, and 09/11/23 did not reveal the resident had any skin issues on the left medial foot. Record review of Resident #37's weekly skin evaluation dated 9/19/23 revealed a stage 4 pressure ulcer was first observed on the resident's left medial foot and it measured 1.0 X 1.0 cm. Record review of Resident #37's weekly skin evaluation from 12/11/23 and 12/18/23 did not reveal the resident had any skin issues on the left abdomen or right groin area. Record review of Resident #37's wound evaluation and management summary report for the left medial foot by the wound care doctor dated 09/19/23 described the wound duration greater than 13 days, measured 1.0 X 1.0 cm at stage 4 with thick adherent devitalized necrotic tissue (this tissue cannot be savaged and must be removed to allow wound healing to take place). The wound was debrided. Record review of Resident #37's wound evaluation and management summary report for the right groin by the wound care doctor dated 12/26/23 described the wound duration greater than 1 day, measured 2.5 X 2.5 X 0.1 cm, light serous and 100 % granulation tissue (the stage for epithelial tissue to be laid on of a wound bed). Record review of Resident #37's wound evaluation and management summary report for the left abdomen by the wound care doctor dated 12/26/23 described the wound duration greater than 4 days, measured 2.0 X 2.0 cm depth was not measurable due to presence of nonviable tissue and necrosis. The non pressure wound was debrided. Record review of Resident #37's physician order date January 2024 revealed the following orders: cover suprapubic catheter port with an island border gauze every night shift on Sunday, offload wound as resident would allow, float heels in bed as the resident would allow, reposition as resident would allow was started on 01/04/24. Record review of Resident #37 physician order date January 2024 read pressure wound stage 4 of left foot medial, cleanse with NS/WC pat dry, apply collagen powder, and cover with an island border gauze. Record review of Resident #37's order summary report dated January 2024 revealed the following orders: cover suprapubic catheter port with an island border gauze every night shift on Sunday, offload wound as resident would allow float heels in bed as the resident would allow, and reposition as resident would allow was started on 01/04/24. Record review of Resident # 37's progress notes dated 12/22/23 revealed entry by the wound care nurse which read in part during routine wound care resident was observed to have an unstageable pressure wound to the left stomach related to pressure applied to the resident by laying on the catheter . Record review of Resident #37's progress notes from 12/05/23 to 01/04/24 did not reveal any documentation of Resident #37's refusal for turning and repositioning, physician notification of Resident # 37 refusal to wear the boot on his left foot, alternate intervention in place, or any education given to Resident #37. During an interview on 01/03/23 at 9:15 a.m., the Wound care nurse said Resident # 37 had a wound on the left medial foot because he refused to wear the boot on his foot. Resident #37 laid on his abdomen because that was the only way he could lay down. He had stage four pressure ulcer on both ischia and Resident#37 was admitted to the facility with two wounds. The wound care nurse said he had been lying on his abdomen since she became the wound care nurse about four months ago. The Wound care nurse said she found the wound on Resident #37's left abdomen on 12/22/23 when she made her usual wound rounds. The wound on the right groin was discovered when she made wound rounds with the wound care doctor and the wound care doctor said the non-pressure wound was from the catheter tubing. She said there was no intervention in place before and after the wound occurred. The wound care nurse said she did not call Resident #37's physician and told him that Resident #37 preferred to lay on his abdomen because this was on going before she became the wound care nurse. During an interview on 1/3/24 at 4:35 p.m., the DON said Resident #37 likes to lie on his abdomen. The DON said the staff tried encouraging him to lie on his sides and back, but he would not. The DON said she had to investigate his plan of care to find out if there was an intervention put in place since the resident had a suprapubic catheter and preferred to lie on his abdomen. The DON said she did not notify Resident #37's physician that the resident chose to lay on his stomach. She was not sure if any alternative intervention was put in place by the nurses before Resident #37 developed the two non -pressure wounds. The DON said the nurses do the weekly skin assessment, and the wound care nurse does the wound assessments. The DON said the wound care nurse and the nurse managers were responsible for putting interventions in place and education the nursing staff. The DON did not respond when she was asked what a negative outcome for Resident #37 could be when she was not turned and repositioned. During an interview on 1/4/23 at 8:30 a.m., the DON said that Resident #37 wanted to get up, and the wound care nurse was ready to provide the wound treatment. The state surveyor told the DON she was on her way to observe the wound care treatment. During an interview on 01/04/24 at 8:38 a.m., the DON said the ADON told her that Resident #37 did not want the state surveyor to observe his wound care. During an interview on 01/04/24 at 3:46 p.m., the Wound Care doctor said Resident #37 preferred to sleep on his abdomen and did document that on his notes. He communicated to the nursing staff about turning and repositioning Resident #37. The Wound care doctor said the two non-pressure wounds were caused by Resident #37 laying on the tube. He stated Resident#37 had an air mattress, and he was not aware if an alternate intervention was put in place to prevent the wounds. The wound care doctor said the unstageable wound could develop within four hours from the tubing, without showering, any sign of skin breakdown or discoloration, and he thinks the facility did all they could do for Resident #37. During an interview on 01/4/24 at 3:54 p.m., ADON L said Resident #37 laid on the suprapubic tube while he was lying on his abdomen, and it had been ongoing since she started to work in the facility. ADON L said the areas (left abdomen and right groin) developed non-pressure wounds. ADON L said the staff told her Resident #37 refused to turn, she did not call Resident #37's physician or educate the resident. The facility did not have any other intervention except for turning and repositioning in place before and after the wound developed. ADON L said after the wound care nurse talked to the state surveyor, they put in a new order to wrap the Suprapubic catheter tubing to prevent it from touching the resident's skin. ADON L said the nurse management monitors the nurses when they make random rounds and in - service on catheter. ADON L the Wound Care Nurse and nurse managers were responsible for modifying intervention and when asked while there was no intervention in place when the staff was aware Resident #37 preferred to lay on his, ADON L did not respond. During an interview on 01/04/24 at 3:58 p.m., the Wound care nurse said she initiated an order yesterday (01/03/24) to wrap the tubing weekly to prevent the tubing from coming in contact with Resident #37's skin. During an interview on 01/04/24 at 4:04 p.m., the wound care nurse said Resident #37 was supposed to wear a boot on his left foot, and he refused to wear the boot. The wound care nurse said there was no other intervention put in place since Resident #37 declined the boot. She stated this could have contributed to the development of the pressure ulcer because the foot may not have been relieved from pressure. The wound care nurse said she did not tell the DON or the resident physician that Resident # 37 refused to wear the boot on his foot or document the refusal. The wound care nurse said the wound on Resident #37's left medial foot started on September 19th, 2023. The wound care nurse said the nurse does the head-to-toe assessment, and she does the wound assessment. The wound care nurse said she did not notice any change in color on Resident # 37's left medial foot until she was made aware of the wound. The wound care nurse said she did not offer to float Resident #37's left foot on a pillow because there was no order to float his foot. During an interview on 01/04/24 at 4:09 p.m., the DON said the staff told her that Resident #37 refused to turn and preferred to lay on his abdomen. The DON said she did not educate Resident #37, but the nurses said they educated him. The DON said she did not call Resident #37's physician to inform him about the resident's refusal to turn and reposition and that he preferred to lie on his abdomen. The DON said she was the wound care nurse for the facility about two years ago. She used to prop Resident #37 legs on pillows and Resident #37 had no problem with it at that time. She was not aware he refused to wear the boot. The DON said she had told the nurses to use pillows to elevate Resident #37's leg, and she did not know why the nurses did not do it. The DON said she would research and see if the nurses documented that Resident #37 refused to elevate his legs even with a pillow and if Resident #37's physician was notified about his refusal before he developed the pressure ulcer and non - pressure Ulcer. The DON said she would research and see if the nurses documented that Resident #37 refused to turn and reposition and if the nurses notified Resident #37's physician about his refusal before he developed the non-pressure wounds. The DON said she was still determining if the facility implemented any intervention other than turning and repositioning. The DON said the areas could develop non-pressure wounds if pressure was not relieved. During an interview on 01/05/24 at 12:36 p.m., LVN M said Resident #37 refused to turn on his side, but he does turn for her. LVN M said she would go back to the resident's room about 30 minutes later, and he would go back to his abdomen. LVN M said she was unsure if any intervention was put in place since he preferred to lie on his stomach. LVN M said she would call the NP and ask if there was any intervention to prevent the tube from giving the resident wounds. She was not aware the wound on his abdomen was from the Suprapubic tubing. LVN M said she did not tell Resident #37's physician about the resident's refusal and she did not respond when she was asked why she did not notify the physician. LVN M said there was no alternative intervention in place to prevent the non-pressure wounds, and she did not inform the DON of the resident refusal or document any refusal. LVN M said Resident #37 gets up early in the morning and stays up throughout her shift (12 hours). LVN M said the nurse monitors the aides, and she had in-service and skills check-off on wound care and prevention. LVN M said the ADON monitored the nurse's when she made random rounds. During an interview on 01/05/23 at 1:46 p.m., CNA C said Resident #37 gets up in the morning at various times, and Resident #37 stays up through his shift. CNA C said he does not turn Resident #37 when he was in bed because Resident#37 turns himself and lies on a different side of his body. CNA C said Resident #37 wore a boot on his left foot, where he had a wound. CNA C could not remember if he started to wear the boot before or after Resident #37 developed a wound on his foot. CNA C said he provided incontinent care to Resident # 37 every two hours, and sometimes he showered the resident, and he did not notice any wound on his abdomen or groin area. CNA C said he came to work about two weeks ago and saw the patch(dressing) on the resident's abdomen. During an interview on 01/05/24 at 2:53 p.m., the DON said she could not find any refusal documentation for turning and repositioning Resident #37. The DON said there was no documentation that Resident #37's physician was notified of his refusal by the nurses. The DON stated there was no other intervention put in place to help prevent non-pressure and pressure ulcer wounds from developing, except Resident #37 had an air mattress. The DON said Resident #37 was started on zinc sulfate tablet 220 mg on 01/04/24 and other supplements. The DON said the facility does not do labs for Resident #37 because the dialysis center does his labs. She did not know what Resident #37's pre-albumin was. The DON said the dialysis should contact the facility if there were any issues with Resident #37's lab. The DON said she would contact the dialysis center and get back to the state surveyor. During an interview on 1/5/24 at 4:47 p.m., LVN H said she started working on the second floor in December 2023. The aides usually turned Resident #37 every two hours and Resident #37 was changed every two hours. LVN H said Resident #37 also turns himself. LVN H said Resident # 37 was up most of the day, and she worked 6 a.m. to 6 p.m. LVN H said the aides had not complained to her that the resident refused to wear the boot. LVN H said Resident #37 was on the B bed, and the nurse assessed his skin at night. LVN H said there was no intervention put in place that she could remember to prevent or relieve Resident #37 from developing a pressure ulcer. LVN H said she did not notify Resident #37's physician about any refusal because she did not see any need for it because Resident #37 did not refuse to wear the boot or turn and repositioned on her shift. Record review of the facility policy on skin and wound monitoring and management dated 03/2015, revisions: 12/2019, 1/2022 read in part the purpose of this policy is that the facility provides care and services to . #1 . promote interventions that prevent pressure injury development . procedure C . identify risk factors which relate to the possibility of skin breakdown and/ or the development of pressure injury which include, but are not limited to: resident refusal of some aspects of care and treatment . prevention . #3b . monitor impact of intervention and modify intervention as appropriate . #8 response to resident choices that differ from plan of care #8a if the resident is not able to or chooses not to participate in the care plan to prevention of skin breakdown, or treatment of exiting wound . the nursing staff shall communicate with the resident's physician to discuss an appropriate intervention or response . if the resident's physician is unavailable, the nursing staff shall contact the medical director . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16 p.m. The DON and Administrator were notified. The Administrator was provided with the IJ template on 01/24/24 at 3:00p.m. The following Plan of Removal submitted by the facility was accepted on 01/25/26 at 10:59 a.m.: The Medical Director was notified by the Executive Director on 01/24/2024 at 3:32 p.m. 1. The Attending Physician was notified by the Executive Director, of the IJ on 1/24/2024 at 3:32 p.m. 2. The Wound Care Specialist was notified by the Executive Director, of the IJ on 1/24/2024 at 3:53 p.m. 3. New Braden scales for the total census initiated 01/24/2024 and will be completed 01/24/2024 by Clinical Resources, Clinical Leaders MDS Nurse, ADON and DON. 4. Audit completed by DON on 01/24/2024 of all residents who are at risk for PU/PI, Care plans and care profiles were updated for all residents at high risk to include personalized/individualized interventions/prevention. This was also completed 01/24/2024. 5. Skin assessments were completed on all high risk Bradens 01/24/2024- no new areas were identified. These were conducted by the DON, ADON, MDS Nurse and Clinical Resource. 6. Education initiated 01/24/2024 by Clinical Resource with DON, ADON, Nurses, CMAs, and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, turning and repositioning notification of changes in wounds, interventions and preventions, as well as communication between Nursing staff and health care professionals; will be completed by 1/25/2024. Any staff unable to attend will not be allowed to work unless they have received their training and knowledge check. 7. All licensed nurses will complete competency on skin assessments started on 01/24/24 and will be completed 01/25/2024 by DON, ADON, and Clinical Resource 8. All CNA's will complete competency on skin check started on0l/24/2024 and will be completed on 01/25/2024 by DON, ADON, MDS Nurse, and Clinical Resource 9. MDS Coordinator will be reeducated on proper coding of MDS 01/24/2024 o··· completed by Clinical resource 01/24/2024. 10. This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 11. An ad hoc QAPI meeting regarding items in the IJ template will be completed on 01/24/2024. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 12. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the skin check competency checklists. 13. All residents with pressure ulcers be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and Wound Nurse. The DON and Administrator will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed. 14. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 15. Resident #37 was reevaluated by the Wound Care Specialist on 1/23/2024, he does not recommend applying any appliances to the suprapubic site as this will increase the pressure to the site; resident will be encouraged to turn side to side as he tolerates or will allow. Resident has a low air loss mattress; wheelchair cushion when up and heels are to be floated when he is in the bed as he will allow. RD and Therapy will reevaluate for any other interventions, completed by 1/25/2024. Psych evaluation to be scheduled, resident consented 1/25/2024. Surveyor monitored the plan of removal for effectiveness as follows: Record review of the plan of removal #15 read Resident #37 was reevaluated by the Wound Care Specialist on 1/23/2024, and he does not recommend applying any appliances to the suprapubic site as this will increase the pressure to the site; resident will be encouraged to turn side to side as he tolerates or will allow. Resident has a low air loss mattress, wheelchair cushion when up, and heels are to be floated when he is in the bed as he will allow. RD and Therapy will reevaluate for any other interventions completed by 1/25/2024. The psych evaluation is to be scheduled; the resident consented on 1/25/2024. Record review of in-service records dated 1/24/24 revealed the MDS Coordinator was trained on proper coding of MDS. Record review of in-service records dated 1/24/24 and 1/25/24 revealed Multiple nurse aides from multiple shifts completed competency checks on skin checks during care. They reported to the nurse if there were any skin issues and documented on-point click care. In service on prevention and interventions: turning and repositioning resident in the bed and wheelchair every two hours and report to the nurse if resident refused and document on point click care. Record review of in-service records dated 1/24/24 and 1/25/24 revealed. Multiple nurses from both shifts completed competency checks on the Braden scale: done on admission, weekly for four weeks, and whenever there was a change in skin condition. Skin assessment is started on admission and weekly by the charge nurse, who reports any change in skin condition to the resident's physician. In service on prevention of pressure ulcers, turning and repositioning and reporting any refusal to the physician and documenting on residents' progress notes, also reporting to nurse managers of any refused intervention, and the resident responsible party should be notified. The nurse managers would update the care plan. Record review of the Braden scale revealed that 15 Residents were documented as having a high or very high risk for developing pressure ulcers. Record review of skin assessments revealed that the DON, ADON, MDS Nurse, and Clinical Resource completed the evaluation on all high-risk Braden 01/24/2024, and no new areas were identified. Interviews on 01/25/24 with four nurses (2 LVN and 2 RN) between 12:44 p.m. and 2:38 p.m. on the above training: Braden scale should be done upon admission, weekly for 4 weeks, and quarterly, and when there was a change in any skin condition. They were also in service on weekly skin assessments, notifying resident physicians about any change in a resident's skin condition or refusal of skin intervention, and documenting in the resident progress note. They said the nurse should notify nurse management of any refusal and any change or modification of intervention so that it would be updated in the care plan. Interviews on 01/25/24 between 2:00 pm and 2:19 pm, two-day staff (CNAs) were interviewed, and they said they were in serviced and trained on skin check: they should check the resident's skin during all care and notify the charge nurse if there was any skin impairment and document on point click care. They also said they were trained on measures to prevent pressure ulcers: turning and repositioning every two hours, floating heels on the pillow, reporting to the nurse if any resident refused, and documenting the refusal on point clock care. All interviewed staff expressed understanding of the training provided above. Interview on 01/25/24 at 1:24 p.m., ADON E said she was retrained and had in service on the facility's Braden scale, skin assessment, resident physician notification for refusal, intervention modification, and updating care plan. She expressed understanding of the plan of removal training provided to her. Interview on 1/25/24 between 7:29 p.m. and 7:50 p.m., two nurses (LVNs night shift) were interviewed on the facilities in service and training on skin assessment, intervention, and reporting to a resident physician about change in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/25/24 between 8:00 p.m. and 8:33 p.m., five-night staff (CNAs) were interviewed on the facility in-service and training on skin assessment, intervention, and reporting to a resident physician about change in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/26/24 between 10:14 a.m. and 10:30 a.m., two nurses (LVNs) were interviewed on the above training: Braden scale should be done upon admission, weekly for 4 weeks, and quarterly, and when there was a change in any skin condition. They were also in-service on weekly skin assessments, notifying resident physicians about any change in a resident's skin condition or any refusal of skin intervention, and documenting on the resident progress note. They said the nurse should notify nurse management of any refusal and any change or modification of intervention so that it would be updated in the care plan. All staff interviewed expressed adequate understanding of the removal training plan provided to them. Interview on 1/26/24 between 10:35 a.m. and 10:50 a.m., two - staff (CNAs) were interviewed on the facility's in-service and training on skin assessment, intervention, and reporting to the resident nurse about changes in skin condition, refusal of intervention, and documentation. All staff interviewed expressed adequate understanding of the plan of removal training provided to them. Interview on 1/26/24 at 11:10 a.m., ADON L was interviewed on the facility in-service training on skin assessment, intervention, and reporting to a resident physician about changes in skin condition, refusal of intervention, and documentation, and updating the care plan. ADN L expressed adequate understanding of plan of removal trainings provided to them. Interview on 01/26/24 at 11:37 a.m., the MDS coordinator said she had training on Thursday on correctly coding interventions, and she also trained on pressure ulcers on Relias yesterday. The MDS said she uses UDA (user-defined assessment) and shows if the resident has a pressure ulcer. Then, she would interview the wound care nurse and the floor nurse about the resident's wound treatment and interventions. The MDS coordinator said she would also review the wound care doctors' notes and assess the resident. The MDS coordinator said these would determine how she would code for the resident after the assessment, interview, and record review. She said the care intervention is done as a team during IDT (interdisciplinary team} and morning meetings. The MDS coordinator said she was also told to consult with DON during the retraining when unsure of any intervention. Interview on 01/26/24 at 12:00 p.m., the DON said all the staff were retrained and in service on the Braden scale, skin assessment, reporting to the physician for any skin impairment, refusal of intervention and care, reporting to nurse managers and the managers with come up with a different or modified intervention and care plan it. She said the nurses and the aides were in service on documentation and notifying the resident responsible party. Interview on 01/26/22 at 12:10 p.m., the Administrator said all staff were in-serviced on the removal plan and the facility's new system. The DON will monitor as mentioned in the removal plan. The Administrator said he would oversee the plan of removal completion and implementation. On 01/26/24 at 3:55 p.m., the Administrator and the DON were notified the Immediate jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum 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.