**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide supervision for, one of two residents in the survey sample, Resident #2, that resulted in harm to the resident. The resident left the building at 2:50 a.m. on 7/13/2023 and fell while outside the building. The resident was treated for a lacerations over his left eye and back of left side of head. In the days following the fall it was discovered the resident also had suffered a broken clavicle and a broken femur since the fall of 7/13/2023 with no other falls after 7/13/2023. The findings include: For Resident #2 (R2), the resident eloped out of the facility on 7/13/2023 at 2:50 a.m., with a fall requiring medical attention. On 7/19/2023 the resident was discovered to have a fractured clavicle and on 7/27/2023 the resident complained of pain in his right leg, an x-ray was ordered and the resident was found to have an acute fracture of his right femoral neck with slight shortening and abduction of the femoral head. The resident, age [AGE], was admitted on [DATE] with diagnoses that included but were not limited to: encephalopathy, diabetes, pancreatitis, anxiety disorder, recent right hip fracture without replacement, gastroesophageal reflux disease, alcohol abuse, history of falls, insomnia and wandering. On the MDS (minimum data set) assessment, prior to the fall, with an assessment reference date of 7/14/2023, an admission assessment, the resident was coded as having both short and long memory difficulties and being severely cognitively impaired for making daily decisions. In Section E - Behaviors, the resident was coded as having inattention and disorganized thinking. In Section E, it further coded the resident as having physical and verbal behavioral symptoms towards others on one to three days of the lookback period. R2 was coded as resisting care on four to six days but less than daily of the lookback period. The resident was coded as wandering behaviors that occurred four to six days of the look back period. R2 was coded, does the wandering place the resident at significant risk of getting to a potentially dangerous place, it was coded, yes. In Section G - Functional Status, the resident was coded as requiring supervision on one staff member for transfers, walking in the room or corridor, and eating. R2 was coded as requiring extensive assistance of one staff member for toileting and personal hygiene. Section G0300 - Balance During Transition and Walking, coded the resident in walking that he was not steady but able to stabilize without staff assistance. Observation was made of Resident #2 on 8/16/2023 at 11:40 a.m. R2 was in a wheelchair with his head on the table in the day room. Unable to see where Code Alert band was. A second observation was made of R2 on 8/17/2023 at approximately 9:30 a.m., the resident was in bed sleeping. Code Alert bracelet noted on left wrist. The Safety - Resident Evaluation dated, 7/8/2023, documented in part, Elopement Risk Evaluation: Mental Status - Alert with cognitive impairment (confusion, cognitive deficits, disorientation, poor decision making skills, decreased safety awareness, disturbances in judgement). Mobility: ambulatory. Predisposing Diagnosis: Does the resident have a diagnosis of dementia, organic brain syndrome, Alzheimer's disease, delusions, hallucinations, Bipolar disorder, Schizophrenia, anxiety disorder and/or depression? The resident was coded as having one or more predisposing diagnoses present. Facility Adjustment: the resident was coded as being no verbal expressions to leave facility. Elopement history: Does the resident have a history elopement attempts (at home, other facility, or current facility) in the past 6 months? The resident was coded as, no. Does the resident have a history of wandering? R2 was coded as, yes. Has the family/ responsible party voiced concerns that would indicate the resident may try to leave? The resident was coded as, no. Elopement Risk Determination: Recommendations: Based on the above evaluation, determination is as follows: the resident was coded as being at risk for elopement. WAs a wander bracelet placed on the resident? it was documented as, yes. Location of wander guard? LUE (left upper extremity). The nurse's note dated, 7/8/2023 at 3:46 a.m. documented, Res(resident) kept wandering all through the night despite several attempts to redirect him to bed. He enters into other resident rooms and attempts to pick their stuff to eat. The nurse's note dated, 7/9/2023 at 10:45 a.m. documented, Resident notes to be wandering the hallways this shift. Resident went out to he courtyard to walk, ground noted to be damp, staff attempted to have resident put his slippers on. He began yelling at staff and became combative, striking staff. Staff allowed the resident to calm down and offered him a snack. Resident sitting calmly now in the courtyard. Will continue with increased supervision r/t (related to) behaviors. The nurse's note dated, 7/9/2023 at 2:22 p.m. documented in part, Resident noted to have a witnessed fall in the courtyard at 1130 (11:30 a.m.) Resident stood when his family walked into the courtyard and lost his footing, falling onto his buttocks and hitting his head on a chair. Head to toe assessment completed. No injuries or skin issues noted. ROM (range of motion) WNL (within normal limits) .Resident noted to have grippy socks. Resident had refused per staff to not put his slippers on. Resident's mother brought a pair of tennis shoes in and assisted to putting them on. The nurse's note dated, 7/9/2023 at 4:32 p.m. documented, Resident urinated in courtyard, staff attempted to redirect and resident refused. The nurse's note dated, 7/10/2023 at 12:15 p.m. documented in part, IDT (interdisciplinary team) met to review falls. Resident had stood up from a chair and lost his footing causing him to fall. No injuries were noted after the incident. Neuro (neurological) checks were started, and resident's mother brought the resident a pair of shoes. The nurse's note dated, 7/10/2023 at 7:03 p.m. documented, Resident wondering (sic) around unit and outside, staff attempted to redirect resident, resident refused. The nurse's note dated, 7/12/2023 at 1:51 p.m. documented, Resident wandering around unit exit seeking. Redirected by staff x2. Resident was easily redirected with offering a second meal tray for lunch. The nurse's note dated, 7/12/2023 at 7:42 p.m. documented, Resident is wandering during this shift and was able to open side door. Alarm sounded and staff were able to redirect resident. All safety measures in place, call bell and fluids within reach. The nurse's note dated, 7/13/2023 at 3:42 a.m. documented, At approximately 0250 (2:50 a.m.) Resident was found outside in parking lot by staff member. This write was alerted and observed resident sitting on the floor (ground) with blood noted on face and head. Resident had grippy socks on. Unable to give a description of how he fell. Resident with two persons assisted back to his feet and redirected back in the building for further assessment. Head to toe assessment completed. Rom (range of motion) wnl (within normal limits), pupil perrla (pupil equal reactive to light). VS (vital signs) obtained wnl. Injuries noted to top of scalp, and deep laceration above lt (left) eyebrow. 911 called d/t deep laceration noted above lt eyebrow. Resident picked up by squad at around 0315 (3:15 a.m.) and transported to (initial of hospital), UM (unit manager), NP (nurse practitioner), RP (responsible party) made aware. The nurse's note dated, 7/13/2023 at 3:53 a.m. documented, Res (resident) was constantly wandering around, and trying to go out through the stair door. Was resisting every form of redirection. All efforts to get him sit down or be on his bed proved abortive. He enters into other residents' room, and each time he will be redirected to the hallway and to his room and most times to the dining room. The nurse's note dated 7/13/2023 at 8:15 a.m. documented, Resident returned from (name of hospital) ER (emergency room), 3 sutures to left eyebrow, one staple back of head left side. Multiple abrasions to bilateral arms, neuro checks continuing. Provider aware of sutures and staples. The nurse's note dated, 7/13/2023 at 2:10 p.m. documented, I notified residents mother about residents' behaviors of refusing care and wandering today. I asked mother is there were other family living close that could come see resident. She stated she would speak to family members to see if they could come visit resident more often. The physician note dated, 7/17/2023 documented in part, Chief complaint: right hand swelling and discomfort History of Present Illness: [AGE] year old recently admitted male for long-term care services was seen today after staff reported his right hand being swollen with accompanying slight discomfort. Of note the resident speaks very little and it is very difficult to engage in meaningful conversation. He continues to wander in the hallways and on the Courtyard but is reported by the staff as 'less aggressive' and directable compared to last week. He also had a fall last week after which he was sent to the emergency room and received a staple on his scalp laceration and 3 sutures on the left eyebrow laceration .Ordered x-ray of the write complete review along with x-ray of hand. The activities note dated, 7/17/2023 at 3:02 p.m. documented, Resident walks the halls and, in the courtyard, shows no interest in offered activities. Spoke very little during initial assessment and very difficult to engage in conversation. The nurse's note dated, 7/19/2023 at 6:03 a.m. documented, Res was awake and pacing in the hallway all through the night, and was un redirectable. The nurses' note dated, 7/19/2023 at 5:49 p.m. documented in part, X-ray results received for the left shoulder, humerus, and forearm. Results showed unremarkable left shoulder, normal humerus, and unremarkable left forearm. X-Ray results received for the right shoulder, humerus and forearm. Results showed unremarkable forearm, no osseous abnormality seen involving the right humerus. An acute looking distal clavicular fracture with caudad angulation, NP (nurse practitioner) made aware of the result and gave new orders for a sling to right extremity every s shift for 2 weeks as resident allows, non-weight bearing to right extremity every shift for 6 weeks as resident allows, a repeat X-ray of the right shoulder to be completed in 2 weeks, and a ortho (orthopedic) referral. The acute looking distal clavicular fracture with caudad angulation is r/t the resident's last fall. The nurse's note dated, 7/24/2023 at 5:52 a.m. documented, Res maintained a calm shift. Slept almost throughout the night. Paced the hallway at the early part of the night shift. The nurse practitioner's note dated, 7/26/2023 at 10:37 a.m. documented in part, Today I am seeing the resident for follow-up as he was recently diagnoses with right clavicular fracture. His right arm is in a sling currently. Nursing reports he was up all night and did not fall asleep until this morning. He reports pain all throughout the night. His mother is also visiting and reports that his left leg seems more swelled than usual. He does have slightly worsened edema to the left instead of right. He does endorse calf pain with dorsiflexion. The nurse's note dated, 7/26/2023 at 12:47 p.m. documented, Resident was sitting in dining room. Resident put himself on floor and laid down with sheet. Resident was assisted back to chair denied any c/o (complaints of) pain. Resident requested to lay down in bed due to being tired. Resident was assisted back to bed. Nurse from previous shift had passed along in report resident had not been to bed all night. all safety measures in place, call bell and fluids within reach. The nurse's note dated, 7/26/2023 at 12:50 p.m. documented, This nurse called and scheduled a venous doppler US (ultrasound) for LLE (left lower extremity) r/t pain and edema. ETA (estimated time of arrival) was not provided. All safety measures in place, call bell and fluids within reach. The physician note dated, 7/27/2023 at 11:11 a.m. documented, Chief Complaint: c/o pain. Reports on this [AGE] years old male resident being in pain in LLE after which a venous doppler was requested which is pending at the moment. This morning during stand - up it was brought to my attention that the resident's mom is requesting to x-ray his hips as he is having pain and having difficulty standing and walking. the resident himself is a poor historian d/t encephalopathy .ordered bilateral hip x-rays complete views. The nurse's note dated, 7/28/2023 at 9:08 a.m. documented in part, Resident and RP/mother notified of x-ray results showing right hip fx (fracture). MD/UM (medical doctor/unit manager) aware, new order to send resident to (initials of hospital) ER [NAME] Priority transport. The nurse's note dated, 7/28/2023 at 10:10 a.m. documented, Resident admitted to (initials of hospital) r/t right hip fracture. The physician order dated, 7/7/2023, documented, Wander Bracelet, check function daily every night shift. The TAR (treatment administration record) for July 2023 documented the above order. It was documented as having been checked each night shift. The comprehensive care plan dated, 7/7/2023, documented in part, Focus (R2) has a behavior problem of wandering, yelling out and being combative with staff, urinating in inappropriate places, defecating in public places, refusing meds, treatments and care, placing self on floor. The Interventions documented, 7/7/2023 - Administer medications as ordered. Monitor/document for side effect s and effectiveness. 7/12/2023 - Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. 7/7/2023 - If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 7/7/2023 - Intervene as necessary to protect the right and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. 7/20/2023 - offer coloring supplies. 7/12/2023 - offer snacks. 7/12/2023 - Praise any indication of the resident's progress, improvement in behavior. An interview was conducted with ASM (administrative staff member) #3, R2's physician, on 8/16/2023 at 2:09 p.m. When asked to speak of R2, ASM #2 stated, the resident came to the facility after having surgery to his neck and repair of a fractured right hip. She stated she saw R2 on 7/10/2023, he was ambulating on the unit. He had had a fall on 7/13/2023 requiring staples to the back of his head and stitches to his left eyebrow. She said the documentation indicated the resident was a nocturnal wanderer, and he was observed to be defecating and urinating on the floors and outside. She stated that on 7/17/2023 the resident had right hand swelling and discomfort, she stated the resident doesn't speak much but staff told me about it. He continues to wander. She stated she ordered an x-ray of his right hand, in light of his fall on 7/13/2023. ASM #3 stated the nurse practitioner saw the resident on 7/17/2023 for an abrasion and swelling now to the entire arm. An x-ray of the entire arm and shoulder was ordered. ASM #3 stated she saw the resident on 7/18/2023 for the left elbow abrasion and now the swelling was to the entire arm. She ordered an x-ray of the entire arm and shoulder. On 7/20/2023 the record indicated the resident had a right clavicular fracture. ASM #3 stated they sent him to the ER, and he came back with a sling to his arm and to follow up with the orthopedist. ASM #3 further reviewed the clinical record and stated, on 7/26/2023, he was seen by the nurse practitioner for increased pain, his pain medications were increased. There was noted slightly increase in his edema to his left lower extremity. A venous doppler was ordered. ASM #3 stated she saw the resident on 7/27/2023 for the left lower extremity pain and edema, the doppler results were still pending. She ordered x-rays of bilateral hips. The results of the x-rays indicated the resident had an acute fracture to his right hip. We sent him to the ER. When asked if the resident had a diagnosis of osteoporosis or osteopenia, ASM #3 reviewed the x-ray results and stated the radiologist did not mention anything regarding the bone density. When asked if the fracture of the hip was related to his fall on 7/13/2023, stated, yes. When asked why, in her professional opinion, did the resident not exhibit any symptoms of the clavicular or hip fracture prior to the dates they were discovered, ASM #3 stated the resident was on scheduled Tylenol and Oxycontin after the fall and that could have masked the symptoms of the other fractures. On 8/16/2023 at 3:13 p.m. OSM #1, the maintenance director, and this writer observed all doors in the facility. All outside doors were outfitted with the 15 second delay as per the fire code. The stairwell, in which the resident went down, had the 15 second delay to the door. R2 had to go down 10 steps to get to the outside door. This outside door, at the time of the elopement, did not have the 15 second delay lock on it. OSM #1 stated that door had the old Wander Guard system attached to it but it was not connected. The outside steps were observed. There were 11 steps to the first landing, 14 steps to the second landing, 10 steps to the next landing, seven steps to the next landing and five steps to the sidewalk. The resident went down 10 steps inside the building and 47 steps outside the building. All doors off the units had a keypad system to unlock the doors in addition to the 15 second requirement for Fire Safety Code. Every time OSM #1 triggered the alarm on all of the doors, a staff member came to check why the alarm was going off. An interview was conducted with ASM #1, the administrator and ASM #4, the regional director of operations, on 8/16/2023 at 3:40 p.m. When asked how R2 was able to get down the steps, ASM #1 stated the resident was able to push the door open as it releases after the 15 second delay for fire code. ASM #1 stated R2 was a walker. He had been in an assisted living facility prior and wandering had been a challenge for them. She stated they had hoped they could provide a safer environment. It happened the first week he was here she stated, they were getting to know him. When asked if the doors or wander guard misfunctioned, ASM #1 stated as she could recall, he was on the unit and was able to push the door. He went into the stairwell. There are a few options off that stairwell to go to the stairway to the outside and to enter the lower lever of the building. ASM #1 stated the resident went outside and down the steps to the employee parking lot. She stated the doors he got through worked the way they were supposed to. The first door he went through did not take him to the outside. They looked at all doors. They realized that we had two systems in place that were not communicating with each other. They had a Wander Guard system and a Code Alert System. They got the companies involved and got the Code Alert system to be the only system in use. ASM #1 and ASM #4 were made aware of the concern for harm for R2 on 8/16/2023 at 4:00 p.m. An interview was conducted with LPN (licensed practical nurse) #1, on 8/17/2023 at 7:17 a.m. When asked to explain what he observed on 7/13/2023 regarding R2, LPN #1 stated he was working on the other floor. The nurse assigned to the other floor was on lunch break as they tell each other when they leave the floor. A CNA (certified nursing assistant) (CNA #2) called me on the phone and told me R2 was outside in the parking lot. He stated he went down there, it was dark, R2 was sitting on the ground. He asked him (R2) to stand up. R2 stood up. When R2 stood up, LPN #1 noted the blood on him. (CNA #2) and LPN #1 assisted the resident into the building. LPN #1 stated he brought him to the nurse's station on the second floor and he did an assessment of the resident. That's when he found the laceration on the back of the head and above the eyebrow. LPN #1 stated he called 911 because the laceration above the eye looked deep. LPN #1 and this writer toured the stairwell and the outside steps. LPN #1 stated he found R2 across the parking lot sitting on a storm drain cover. An interview was conducted with CNA #1 on 8/17/2023 at 7:37 a.m. When asked if she worked the floor, R2 was on, the night he went outside, CNA #1 stated yes she did work that night but she was not his assigned aide. CNA #1 was asked if she saw R2 that night, CNA #1 stated she had seen him up and walking the unit. She further stated that when he is up walking, someone walks with him. When asked why someone was not with him when he got outside, CNA #1 stated she had gone to help another aide provide care for a resident that needed two people to care for them. CNA #1 further stated the other aide and herself were at the opposite end of the unit from where R2 went out the door, they didn't hear the alarm as they were in another resident's room, providing care. When asked if R2 is easily redirectable, CNA #1 stated she didn't know about with other people, but she and R2 get along well. She asks him to sit down with her, watch TV with her, he liked to listen to music on her phone. CNA #1 was asked if the resident had a Code Alert/wander guard on that night, CNA #1 stated, yes, he had one and believed it was on his wrist, but really can't recall. When asked if R2 was alert and oriented, CNA #1 stated he was alert, but he can be a little hard to understand at times. Description of the unit. The unit is on the second floor. It is in the shape of a 90-degree angle with the nurse's station being at the point of the angle where the two halls meet. R2 resided in a room near the exit door where he had exited from near the end of the one angle of the hallway. An interview was conducted with CNA #2, the CNA that found the resident in the parking lot, on 8/17/2023 at 9:03 a.m. When asked to describe what happened the night she came to work and found R2 in the parking lot, CNA #2 stated she comes to work at 3:00 a.m. for a 12-hour shift. She stated it was 2:50 a.m. when she pulled into the parking lot and her lights flashed on him (R2) sitting on the ground. CNA #2 parked her car and went immediately over to the resident to make sure he was okay. She called into the facility and (name of LPN #1) came outside. She stated they stood the resident up and they redirected him back into the building. When asked if the resident said anything, CNA #2 stated they had asked if he was okay, and he said yes. She stated, they asked him how he got out in the parking lot, he never answered that question. An interview was conducted with RN (registered nurse) #2, the nurse assigned to R2 the night he exited the building, on 8/17/2023 at 9:06 a.m. When asked to describe the night R2 exited the building, RN #2 stated she had two CNAs that night and all of them were on their feet all night. He (R2) was busy moving, never went to bed. She stated they tried to redirect him, and he would attempt to slap us. They took turns watching him. R2 made several attempts to open the door (door to the stairwell). RN #2 stated the CNAs, and she were doing their every two-hour checks on the residents. She went on her lunch break. RN #2 stated she last saw R2 at 2:45 a.m. She stated when she got back from her break, they told her what had happened. RN #2 further stated the CNAs were attending to another resident. When asked if R2 could move quickly, RN #2 stated, R2 moves very fast, if you blink, he's gone. RN #2 stated they track him every 15 minutes. [NAME] can keep an eye on him all the time. He is one of 20 residents on the floor. An interview was conducted with LPN #2 on 8/17/2023 at 9:43 a.m., a nurse who has cared for R2. When asked to describe R2, LPN #2 stated he is incontinent of both bowel and bladder. He is extensive assistance for all his care. She stated she hasn't had any issues with him with taking him medications or insulin. R2 does require a lot of being with him. LPN #2 stated they switch out throughout the day; someone needs to be always with him. She stated, That little man is quick. LPN #2 stated before he fell outside, he was walking everywhere, and they followed him around. They attempted to redirect him. She stated he now is dependent on the wheelchair, but he still can stand up. LPN #2 stated he can still be hostile with staff and scream into your face. He can be short tempered at times, but he can be very sweet too. She stated when he is ready to go, he's ready to go now. The facility policy, Elopement/Unsafe Wandering Risk Evaluations, documented in part, Policy: The organization is committed to ensuring that all reasonable measures are in place to ensure that each resident receives adequate supervision and assistance devices to prevent accidents, including elopement and unsafe wandering .Wandering and Elopement: Wandering is random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless .This goal directed wandering should also require staff supervision and a facility response to address safety issues. Specific Procedures/Guidance; 1. The Elopement Risk evaluation in PCC be completed by a licensed nurse/designee on admission, re-admission, and quarterly and as needed for a change in resident status. 2. If the resident is determined to be at risk for elopement or unsafe wandering, the staff will notify the resident's attending physician/practitioner and the resident' representative of the risk. 3. If the resident is determined to be at risk for elopement or unsafe wandering, preventive interventions will be implemented. a. Interventions may include but are not limited to: i. 1:1 supervision or frequent visual checks on the resident. ii. Use of 'alert' system device. iii. Placement on a secured unit/neighborhood. iv. Re-direction and diversional activities. 4. The resident's care plan will be reflective of identified risk and include person-centered interventions. 5. The medical record will document the resident's behavior including attempts and actual events of elopement or unsafe wandering and preventive interventions being implemented. The facility presented the following plan of correction: 1. (R2) exited the facility unattended 7/13/2023. (R2) was located within approximately 5 minutes. (R2) was transferred to the local hospital and treated for a laceration prior to returning to the facility. (R2) remains a resident at (Name of Facility). 2. All residents on the facility can be affected. A check of all doors was performed by the administrator, DON (director of nursing) & Maintenance. The exit door the resident used was equipped with a motion-activated camera system which alerts leadership staff when someone is near the door. A vendor was onsite 7/17/2023 and 7/18/2023 to assess door alarm functioning and plan for installation of additional alarms or updates as indicated. A keypad lock was installed on the Terrace egress door (door R2 exited building from) on 8/11/2023. 3. Maintenance staff were educated on checking exterior doors daily to ensure proper functioning of alarm systems to include wander alert systems on 8/11/2023. 4. The Medical Director was notified of the incident on 7/13/2023. 5. The facility conducted an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting reviewing the abatement plan on 7/14/2023 and updated the team on 8/11/2023. 6. Date of Compliance: 8/11/2023. All the credible evidence was reviewed. Verification of above was made through observation, resident interview, and staff interviews. Past Non-Compliance

Based on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure a resident's room was free of an accident hazard for one of 25 residents, resulting in harm at past noncompliance. Resident #210 received a second degree burn from a heating element with a missing heat guard. The Findings Include: Diagnoses for Resident #210 included: Dementia, anemia, brain injury, and seizure disorder. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 9/28/22. Resident #210 was assessed with moderate cognitive impairment. On 6/12/23 review of a facility synopsis dated 11/27/22 was reviewed and read in part that Resident #210 had 4 seizures back-to-back on 11/26/22 and during the seizures Resident #210's arm had flailed, causing the arm to drop over the side of the bed, landing on a baseboard heating system resulting in a burn. It was also noted that corrective action had taken place by repositioning the bed and placing a cover guard over the baseboard heater. Review of Resident #210's closed record documented via nursing progress notes that Resident #210 had several seizures on 11/26/23, 911 was called, and Resident #210 was sent to the emergency department due to the multiple seizures. The nursing notes did not describe Resident #210's burn to right arm. Review of Resident #210's hospital records documented that Resident #210 had a Right forearm, second degree burn with partial thick skin loss and surrounding blisters. Small amount of serous drainage. Three individual statements (two nurses and one certified nursing assistant) were reviewed from the staff taking care of Resident #210 at the time of the incident. All statements indicated that Resident #210 received a burn and was being cared for but did not document condition of the baseboard heater. Only one of the staff members taking care of Resident #210 at the time of the incident, was currently working at the facility. On 6/13/23 at 8:30 AM, license practical nurse (LPN #3, unit manager) was interviewed. LPN #3 said that although not working at the time of the incident and unable to speak to exactly what happened, but did say that as a result an inservice was done about uncovered baseboard heaters and all beds were moved away from the heating units and turned so that the bed is no longer parallel to the heating system. On 6/13/23 at 10:00 AM, the regional maintenance director (other staff, OS #8) was interviewed. OS #8 said that the heating guard was tore off and voiced uncertainty of how the guard had gotten torn off. Questioned further, OS #8 verbalized that Resident #210 had behaviors and could have torn the guard off or that the bed was against the heating system and the guard could have possibly been torn off while moving the bed. When asked if there was a repair order for the missing guard, OS #8 verbalized that there probably wasn't, as that would be something that would be repaired as soon as seen and reported. Questioned further, OS #8 expressed doubt that the guard had been off for very long, stating that the staff and maintenance review and observe rooms daily. OS #8 was asked the purpose off a heating guard. OS #8 verbalized the guard is in place to prevent direct access to the heating element to prevent possible burns. On 6/13/23 at 10:10 AM, LPN #4 was interviewed. Confirming being present in the room during Resident #210's seizure activity, LPN #4 stated that Resident #210's right arm fell between the bed and wall, landing on the baseboard heater, burning Resident #210's arm. LPN #4 stated that the burn wound was cleaned, dressed, and ice applied, before sending Resident #210 to the hospital due to the multiple seizures. When asked about the guard to the baseboard heater, LPN #4 verbalized that the guard was neither seen on the heater or in the room. LPN #4 verbalized that since this incident all baseboard heaters have been reinforced with bigger guards and the beds have all been repositioned away from the heating system. On 6/13/23 at 4:35 PM, the above information was presented to the administrator and director of nursing. The administrator verbalized that although the incident happened prior to her employment and while under another company's ownership, the incident was somewhat familiar and agreed that it happened. The administrator stated that corrections had been put in place at the time and that employees were in-serviced about bed positioning, along with the baseboard guards, and that the incident continues to be part of the facility's quality assurance program and plan. On 6/14/23, a summary of the plan of correction, along with supporting evidence that the plan of correction was carried out was presented. The plan of correction included: - Facility wide audit of heaters completed to ensure bed is appropriate distance from heater. - Cover placed over Resident #210's heater. - maintenance staff, environmental staff and clinical staff to be educated on ensuring appropriate distance between bed and heater. - Skin sweeps to be completed on everyone to ensure no burns to skin in rooms with baseboard heaters. - IDT will complete quality review weekly on bed/heater spacing and will address any issues immediately. - the plan of correction date of completion was 11/28/22. Observations of bed placement in regards to appropriate distance to baseboard heaters were completed by the survey team. Also, interviews of staff evidenced knowledge of appropriate distance from heaters, along with placement of the bed not being parallel with the heating systems. Review of Resident records, along with accident logs and interviews, did not evidence other residents with concerns regarding burns from baseboard heaters. On 6/14/23 at 10:45 AM, a maintenance staff person (OS #12) accompanied this surveyor to Resident #210's former room and explained the updated heating guards. The baseboard heaters were affixed to the wall at ground level and extended approximately 6 to 8 inches up the wall. The new guards surrounded the baseboard heaters completely. Resident rooms throughout the facility were also observed and had the same new guards placed. The plan of correction was accepted. This deficiency was cited as past non-compliance. No current deficiencies were cited under the concerned regulation during the survey. No other information was presented prior to exit conference on 6/14/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #112 was admitted to the facility on [DATE] with a readmission of 2/7/20. Diagnoses for Resident #112 included; Pneumonia, septicemia, UTI, quadriplegia, stage four pressure ulcer to buttocks. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/13/20. Resident #112 was assessed with a cognitive score of 15 indicating cognitively intact. On 02/10/20 at 9:10 AM, Resident #112's dressing changes wre observed with three license practical nurses identified as LPN #4 (unit manager), LPN #5, LPN #6. Resident #112 was turned, then LPN #5 washed hands, put on gloves, removed a dressing to the buttocks, then applied wound cleanser to all three wounds using the same gauze. LPN #5 then removed gloves, and put on new gloves without washing hands between glove changes. LPN #5 then applied Dakin's solution and sure prep to the outer buttock wound, and applied Hydrogel Collegen mixture to the outer wound. LPN #5 then applied sure prep to middle and inner wound, applied Collogen powder to the middle and inner wound using the same applicator, then applied a cover dressing to all three wounds. LPN #5 then moved to the left foot wounds without changing gloves or washing hands. LPN #5 removed the dressing, applied skin prep to outer foot and wound cleanser to outer heel, opened up a Calcium Alginate dressing without washing hands or changing gloves, cut a piece of the dressing, handled the dressing with the same unclean gloves and applied it to the cover dressing, then applied Collagen powder to the heel wound and applied the dressing. On 02/10/20 at 9:40 AM, LPN #5 and LPN #4 were interviewed concerning not washing hands when discarding unclean gloves and applying new gloves, cleaning three buttocks wounds using the same gauze, using the same applicator to distribute treatment to the middle and inner buttock wounds, moving to Resident #112's left foot wound without washing hands or putting on clean gloves and handling Calcium Alginate dressing with unclean gloves and applying the dressing directly to the wound. LPN #4 and #5 stated understanding. The facility's policy titled Dressing Change (effective 11/30/14) documented, A clean dressing will [be] applied by a nurse to a wound as ordered to promote healing . This policy included in procedures for a dressing change, .Assemble equipment as needed for dressing change .Place supplies on prepped work surface .Perform hand hygiene .Apply gloves .Remove and dispose of soiled dressing .Remove gloves .Perform hand hygiene .Apply gloves .Cleanse wound as ordered .Remove gloves and perform hand hygiene .Apply treatment as order and clean dressing .Discard gloves and perform hand hygiene . (Sic) On 02/10/20 at 5:21 PM, the above finding was discussed with the the administrator and director of nursing (DON). On 02/11/20 at 9:04 AM, the DON was interviewed regarding the dressing change observation. The DON stated that it was wrong to perform a dressing change that way. No other information was provided prior to exit conference on 2/11/20. Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess and implement care for treatment of a blister for one of 34 residents (Resident #122) resulting in the development of an infected, necrotic pressure ulcer and failed to provide pressure ulcer dressing changes in a manner to prevent infection for two of 34 residents (Residents #122 and #112). The findings include: 1a) Resident #122 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Diagnoses for Resident #122 included end stage renal disease with hemodialysis, schizoaffective disorder, dementia, hypotension, dysphagia, anemia, neurocognitive disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #122 as cognitively intact, requiring the extensive assistance of two people for bed mobility and one person for dressing and daily hygiene. Resident #112's clinical record documented the resident was re-admitted to the facility on [DATE] following a hospitalization. The re-admission nursing assessment dated [DATE] documented, .Edema noted to LUE [left upper extremity]. Resident has ace wrap in place to LUE . This re-admission assessment documented the resident's only skin impairments were scabs on his right toes and bruises to the right hand. The re-admission physician orders dated 10/25/19 included no orders regarding the ACE wrap to the left arm. The clinical record documented a physician's order dated 10/28/19 for an occupational therapy (OT) consult to fit the resident for a left arm compression sleeve with instructions to, Apply ACE wrap uniformly to left forearm and elbow and upper arm until compression sleeve arrives. A nursing note and skin evaluation sheet dated 10/29/19 documented the resident was assessed with a blister on his left hand. The nursing note dated 10/29/19 at 5:24 p.m. documented, .Intact blister in, (Thenar webspace) on left hand. 0 [No] tx [treatment] @ this time is needed Once the blister opens tx will begin if needed . There was no notification to the physician and/or provider about the blister and no treatment ordered or implemented. An occupational therapy (OT) note dated 10/30/19 documented, MD [physician] orders for left arm compression sleeve. Facility had ACE bandage in place this date. The ACE bandage has rubbed areas of pressure in thumb web space and opposite side lateral of pinky finger. Thumb web space has large intact blister from pressure of ACE wrap. Also area of pressure from ACE wrap at lateral aspect of wrist crease. Nursing notified of areas of pressure. It is recommended by the CLT [certified lymphedema therapist] for nursing not to replace ACE bandage. Measurements taken for left arm compression sleeve .Communication with nursing regarding this therapist recommendation with ACE as the potential for further skin breakdown and blisters to open is great. Resident #122's nursing notes from 10/30/19 through 1/9/20 included no assessment or mention of the intact blister and rubbed areas on the left hand as reported by OT. The ACE remained in use for four days after the OT recommendation to discontinue the wrap due to pressure areas on the left hand. The record documented a physician's order dated 11/4/19 to discontinue the ACE wrap to the left forearm. A physician's order dated 11/22/19 documented, Compression arm sleeve and gauntlet (glove) to be donned [put on] after breakfast & doff [take off] after dinner for max 12 hrs [hours]/day with skin checks during & after wear Except on Tues/Thur/Sat - glove donned after dialysis + doff before 12 AM w/ [with] skin checks during and after wear. There were no skin assessments documented related to putting on and/or taking off the compression sleeve. Ten out of eighteen weekly skin audits for Resident #122 from 10/29/19 through 1/7/20 documented a skin impairment on the resident's left hand. The 10/29/19 skin check documented an intact blister on the left hand. The skin diagrams on assessments dated 11/8/19, 11/12/19, 11/29/19, 12/6/19, 12/10/19, 12/13/19, 12/20/19, 12/24/19, 1/3/20 and 1/7/20 marked a skin impairment on the resident's left hand but documented no description of the appearance, size, color or status of the impairment. These sheets listed the marked impairments as previously identified. The 11/12/19 assessment marked the resident with a scab on the left hand. The other weekly assessments (dated 11/1/19, 11/5/19, 11/15/19, 11/19/19, 11/26/19, 12/3/19 and 12/27/19) did not document a wound on the resident's left hand. The clinical record from 10/29/19 through 1/8/20 documented no notification to the physician regarding the left hand blister and pressure areas identified by OT. There were no physician's orders for treatment of the left hand blister when identified by nursing on 10/29/19 and assessed/reported by OT on 10/30/19. There were no documented assessments of the left hand blister after the OT note dated 10/30/19 other than scab on 11/12/19. A nursing note dated 1/9/20 documented the resident was sent to the emergency room (ER) from dialysis due to a change in condition. The resident was assessed at the emergency room with an infected, malodorous wound on the left hand. The emergency room record dated 1/9/20 documented the resident was received from dialysis after the resident became lethargic and had low blood pressure. The ER physician's examination dated 1/9/20 documented, .left hand between thumb and second index finger has open wound with purulent exudate malodorous . This ER physician's assessment documented, .with end-stage renal disease on hemodialysis, at baseline bedbound, debilitated presents with hypotension, lactic acidosis, hypoxia when he presented for dialysis today. A primary concern would be sepsis related to left hand wound that appears to be infected, versus complicated UTI [urinary tract infection] with chronic indwelling Foley catheter and history of complicated antibiotic resistant UTI in the past .Treat for sepsis with broad-spectrum antibiotics . The ER report listed, Infection of left hand .Patient with wound of left hand between first and second digit, purulent exudate .Broad-spectrum antibiotics with vancomycin and Zosyn IV [intravenous] . The resident was hospitalized for treatment of the infections and then re-admitted to the facility on [DATE]. readmission orders included daily dressing changes to the ulcer along with a topical debriding agent (Santyl). The physician's progress note dated 1/16/20 documented, .at dialysis was found to be hypotensive, encephalopathic, lethargic, and febrile and was admitted .He was found to have a left hand wound likely infected .Open wound of hand .this was felt to be infected status post 4 days of IV antibiotics now better . The resident was referred to a wound clinic for ongoing treatment of the left hand ulcer. The wound physician's progress notes dated 1/16/20 documented the wound measured 1.6 x 0.8 x 0.4 (length x width x depth in centimeters), with moderate serosanguineous exudate, 30% thick devitalized necrotic tissue, 30% slough, 30% granulation tissue. The physician performed surgical debridement of the devitalized necrotic tissue with removal of 0.5 cm depth of tissue. The wound clinic physician documented additional assessments as follows. 1/30/20 - measured 1.5 x 0.7 x 0.4 cm with moderate serosanguineous exudate, 20% necrotic tissue, 40% slough, 30% granulation, additional surgical debridement performed to remove necrotic tissue and slough 2/6/20 - measured 2.0 x 0.5 x 0.5 cm with moderate serous exudate with scab in place, treatment orders changed to collagen powder each day with daily dressing changes Resident #122's plan of care (initiated 8/5/19; revised 2/5/20) listed the resident had left arm edema, was totally dependent on staff for hygiene/dressing and was at risk of skin impairment. Interventions to prevent skin breakdown included, Observed for redness, open areas, scratches, cuts, bruises and report changes to the Nurse .Monitor/document/report PRN [as needed] any changes in skin status . There was no revision to the care plan about the left hand blister and/or scab until 1/17/20, after the resident's return from the hospital following IV antibiotic treatment for the infected ulcer and UTI. On 2/10/20 at 8:41 a.m., the licensed practical nurse (LPN #2) unit manager was interviewed about assessment and treatment for Resident #122's left hand pressure ulcer. LPN #2 stated the resident returned from the hospital in October 2019 with an ACE wrap on the left hand that was too tight. LPN #2 stated the blister at some point became a scab. LPN #2 stated the scab came off at dialysis (1/9/20) and there was a hole under it and dialysis sent him to the emergency room. LPN #2 stated the facility was not previously treating the scabbed area because it was not open. LPN #2 stated she was not sure when the scab started. On 2/10/20 at 9:00 a.m., LPN #1 that routinely cared for Resident #122 was interviewed about the left hand blister. LPN #1 stated the resident's left hand had a scab and when the scab came off there was a wound underneath. LPN #1 stated she was not sure what the scab was from or how the resident got the left hand ulcer. On 2/10/20 at 9:16 a.m., unit manager (LPN #2) stated she reviewed the clinical record and found a note on 10/29/19 indicating the wound started as a blister. LPN #2 stated she did not see any notification or treatment orders for the blister. On 2/10/20 at 10:00 a.m., LPN #2 stated she looked through all the notes again from 10/25/19 through 12/31/19. LPN #2 stated the only documentation about the blister was the 10/29/19 note listing an intact blister on the left hand. LPN #2 stated she found nothing about notification to the physician/provider of the left hand blister. LPN #2 stated again that the resident got the ulcer after his return from the hospital on [DATE] from an ACE wrap on the left hand that was too tight. On 2/10/20 at 11:00 a.m., the certified nurses' aide (CNA #2) that routinely cared for Resident #122 was interviewed. CNA #2 stated the resident had a scab on the left hand between his thumb and index finger. CNA #2 stated the resident had edema in the left arm and wore a compression sleeve/glove. CNA #2 stated the scab was on the left hand maybe a month before it came off and there was an open place under the scab. CNA #2 stated the scab was a little smaller than dime size and she reported it to the nurse but did not remember when she reported it. On 2/10/20 at 4:25 p.m., the physician's assistant (PA) that cared for Resident #122 was interviewed about the resident's left hand ulcer. The PA stated he was not aware of a wound on the resident's left hand until after he returned from the hospital on 1/13/20. On 2/11/20 at 9:40 a.m., accompanied by LPN #14, Resident #122's left hand ulcer was observed. The resident's pressure ulcer was in the space between the resident's left thumb and index finger. The ulcer was slightly smaller than the size of a quarter with irregular edges. There was black necrotic tissue along the wound edge near the thumb side with most of the remaining wound bed covered with light yellow colored slough. The visible wound bed was moist and beefy red in color. There was a small amount of reddish colored drainage on the removed dressing. On 2/11/20 at 8:40 a.m., the director of nursing (DON) was interviewed about any assessment and/or treatments for Resident #122's left hand ulcer. The DON stated the wound was identified by nursing as an intact blister on 12/29/19. The DON stated OT also assessed a large, intact pressure injury on 10/30/19 resulting from application of an ACE wrap. The DON stated she had no other documentation regarding the wound until it was identified at the emergency room on 1/9/20. The DON stated the intact blister should have been assessed as a stage 2 pressure injury. The DON stated the physician should have been notified and treatment initiated when found. The DON stated from talking with the floor nurses, the wound waxed and waned from a blister to a scab. The DON stated the resident had chronic swelling in the left arm and her review indicated this was a pressure injury resulting from the ACE wrap in place for edema. The DON stated some of the skin assessments marked an impairment on the left hand but documented no description and/or assessment of the wound. The facility's policy titled Performance Improvement Skin Meeting (effective 11/30/14) documented, .The Interdisciplinary team will review residents weekly with the following: Any resident with Pressure wounds .team will review each resident to ensure that interventions are established to improve the clinical condition and outcome of the resident, and review the clinical documentation for the resident to ensure that it is completed .team will review the progress of healing and develop any additional interventions as need [needed] to facilitate continue healing Current treatment effectiveness will be reviewed and revised as indicated. Review of the Pressure Ulcer/Non-Pressure Ulcer Record, the resident's care plan, nutritional status and progress notes . The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as, .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . The NPUAP defines a stage 2 pressure injury as, .Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . The NPUAP defines an unstageable pressure injury as, .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar [necrotic tissue]. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . NPUAP defines a medical device related pressure injury as, .injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system . (1) The NPUAP includes in best practices for the prevention of medical device-related pressure injuries (MDRPI), .Remove or move removable devices to assess skin at least daily .Educate staff on correct use of devices and prevention of skin breakdown .Be aware of edema under device(s) and potential for skin breakdown . (2) These findings were reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 2/10/20 at 5:00 p.m. and on 2/11/20 at 11:10 a.m. (1) NPUAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 2/12/20. www.npiap.com (2) Long-Term Care Prevention of MDRPIs. 2017. National Pressure Injury Advisory Panel. 2/12/20. www.npiap.com 1b) On 2/11/20 at 9:40 a.m., licensed practical nurse (LPN #14) was observed performing a dressing change to the pressure ulcer on Resident #122's left hand. LPN #14 placed a plastic bag with dressing supplies on Resident #122's bed covers. LPN #14 removed the supplies (gauze pads, bottle of Dakin's cleansing solution, scissors) from the bag and placed them directly onto the bedspread. LPN #14 washed her hands, put on gloves and removed the soiled dressing from the ulcer located between the resident's left thumb and index finger. LPN #14 changed gloves, applied Dakin's solution to a clean gauze pad and cleansed the wound. LPN #14 put on new gloves and cut the prescribed alginate dressing with scissors. LPN #14 changed gloves again and placed opened gauze packages on the bed covers, cut the border gauze in half and then applied collagen powder to the wound bed. LPN #14 made an additional cut of the alginate dressing with scissors that had been placed directly onto the resident's bedspread. LPN #14 put on new gloves, applied the alginate dressing to the wound and then the border gauze. LPN #14 then placed the bottle of Dakin's solution into the plastic storage bag, discarded supplies in the treatment room, placed the bag of supplies back into the treatment cart and washed her hands. The resident's pressure ulcer was in the space between the resident's left thumb and index finger. The ulcer was slightly smaller than the size of a quarter with irregular edges. There was black necrotic tissue along the wound edge near the thumb side with most of the remaining wound bed covered with light yellow colored slough. The visible wound bed was moist and beefy red in color. There was a small amount of reddish colored drainage on the removed dressing. LPN #14 prepared no clean space for the clean dressing change supplies as items, including scissors were placed directly on the resident's bedspread. LPN #14 performed no hand hygiene after removing the soiled dressing and prior to cleansing the wound. LPN #14 performed no hand hygiene after or between any of the glove changes during the dressing change observation. The scissors were not sanitized prior to cutting the dressing that was placed directly onto the wound and the scissors were placed on the resident's bed covers during the dressing change. On 2/11/20 at 9:50 a.m., LPN #14 was interviewed about lack of hand hygiene and placing supplies on the bedspread during the dressing change. LPN #14 stated she typically performed glove changes during dressing changes and did not think hand hygiene was required after removing gloves. LPN #14 stated she sanitized her scissors at times. Regarding placing clean supplies on the bedspread, LPN #14 stated the supplies were in a plastic bag and the opened gauze dressings were kept on the gauze papers. On 2/11/20 at 10:25 a.m., the director of nursing (DON) was interviewed about Resident #122's observed pressure ulcer dressing change. The DON stated hand hygiene was expected after removing soiled dressings, prior to cleaning the wound and before applying clean dressings. The DON stated hand hygiene was expected after glove changes and clean supplies were not supposed to be placed on the resident's bed. This finding was reviewed with the administrator and director of nursing during a meeting on 2/11/20 at 11:10 a.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide supervision to prevent accidents for one of 34 residents, Resident #51. Kitchen staff opened a locked door giving Resident #51 access to the outside. The door locked behind her and she was unable to reenter the building. Findings were: Resident #51 was admitted to the facility on [DATE] with the following diagnoses, including, but not limited to: Cellulitis, Lupus, Chronic pain syndrome, hepatitis C, emphysema, and lung cancer. The admission MDS (minimum data set) with an ARD (assessment reference date) of 12/09/2019, assessed Resident #51 as cognitively intact with a summary score of 15. The clinical record was reviewed on 02/09/2020. The following information was observed in the nurse's notes section: 11/28/2019 6 A [6:00 a.m.] Resident rested will in bed .s/p [status post] fall this shift Pt [patient] reports she used her tight hand to break her fall. No skin break. Pt wrapped her need [sic-knee] per her choice. 12/02/2019 IDT [interdisciplinary team] met to discuss resident fall with abrasion to knees. Resident went outside after being let out by staff and fell.reeducated staff to courtyard smoking area and educate staff to identify persons before letting them outside . 12/04/2019 IDT met to review residents recent fall with abrasions to knees. Resident was let outside by staff and resident fell outside. Interventions included neuros and reeducate resident to courtyard and educate staff to check with nurse before letting a resident outside . An SBAR (Situation/Background/Appearance/Review) form dated 11/27/2019 at 8:30 p.m. was observed in the clinical record and contained the following: Skin Evaluation: Skinned knee; Pain Evaluation: New pain, left knee-Intensity-8 Resident #51 was interviewed on 02/10/2020 at approximately 8:15 a.m. about her fall. She stated,Yea, that happened right after I got here. I got turned around, this place is a [NAME]. I thought I was going out to the courtyard to smoke. I went up the hall to the door there .that's the kitchen but I didn't know that. Somebody up there opened the door for me and I went outside. When I got out there I realized I wasn't in the courtyard. The door was locked behind me and I couldn't get back in. It was dark and I fell down. I hurt my wrist and tore my knee up. I walked around to the front of the building and came back inside. The unit manager, LPN (licensed practical nurse) #9 was interviewed on 02/10/2020 at approximately 8:30 a.m. She was asked about the door leading outside at the kitchen. She stated, It is locked, and it has a sensor on it if someone with a wander guard gets too close to it. She was asked if someone went out the door if it shut behind them and locked. She stated, Yes, it locks automatically when you shut it. A report of the incident was requested and received from the DON (director of nursing) on 02/11/2020. Per the investigation: Event date 11/27/2019 20:23 PM [8:23 p.m.] Per nursing staff, resident was let out the side door of 2NS by the kitchen staff who mistook her as a family member. Resident returned back inside and reported she fell. Skin tear to left knee Was the resident who fell attended by an employee: No; Location of event: Outside building on premises; Activity at time of event: Wandering aimlessly; Was the resident injured: Yes; What was the severity level of the injury? Minor injury . The above information was discussed during an end of the day meeting with the DON, the administrator, and corporate consultants on 02/10/2020. No further information was obtained prior to the exit conference on 02/11/2020.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility document review, the facility staff failed to prevent a significant medication error for one of 34 Residents. Resident #147 was given an extra dose of Methadone (classified as an opioid) which resulted in harm. The Findings Include: Resident #147 was admitted to the facility on [DATE] with a readmission of 2/7/20. Diagnoses for Resident #147 included; Osteoporosis, dementia, seizure disorder, and chronic pain. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/27/20. Resident #147 was assessed with a cognitive score of 7 indicating severe cognitive impairment. On 2/09/20 Resident #147's medical record was reviewed and evidenced a physician's progress note dated 1/20/20 that read [AGE] year old male who I am seeing today because of medication error. Patient was given double the dose of his methadone morning dose by mistake. This was quickly addressed and I was notified to monitor vitals. Patient had decreased respirations about 2 hours later, with a reported rate of 8 [per minute]. A stat order of 0.2 mg [milligrams] of naloxone [Narcan, opioid antagonist used for opioid overdoses] was given IM [intramuscularly], and this perked the patient immediately. He was back to his baseline the rest of the afternoon. His afternoon dose of methadone was skipped. He is now resting in his bed this evening. A physician's order for the time period of the incident indicated that Resident #147 was to receive Methadone 5 milligrams at 6:00 AM and at 5:00 PM for chronic pain syndrome. Resident #147's nursing notes or medication administration record (MAR) did not evidence any information regarding Resident #147's receiving an extra dose of Methadone. On 02/10/20 at 2:24 PM, unit manager (license practical nurse, LPN #4) was interviewed. LPN #4 said a nurse gave an extra dose of Methadone in error. When asked why the extra dose was given, LPN #4 said the night shift nurse gave the medication (Methadone) when it was scheduled then the day shift nurse gave another dose at around 9:30 AM. LPN #4 said that Resident #147 had already been declining and was lethargic prior to the extra medication dose, the physician was called did not come into assesses Resident #147 at that time but did order Narcan. LPN #4 was asked if an investigation was done. LPN #4 was not sure of an investigation but did say a medication error sheet was completed. On 02/10/20 at 4:12 PM the physician's assistant who wrote the physician's progress note (Other Staff, OS #2), was interviewed. OS #2 said, he was contacted via phone because an extra dose of Methadone had been given and Resident #147's respiratory rate was at 8 and Resident #147 was lethargic. OS #2 said because Resident #147's respiratory rate was not at baseline, he decided to give Narcan. OS #2 stated that Resident #147 responded quickly. OS #2 was asked if he knew how the medication was given in error. OS #2 took out his phone and read part of a text message indicating that a nurse had misread the MAR and gave the medication (Methadone) at 9:00 AM not realizing that a scheduled dose had been given prior. On 02/11/20 at 9:45 AM, staff provided a Medication Discrepancy Report that indicated Methadone was given at the wrong time. A narrative describing the incident read This nurse misread time beside of medication on MAR. Rsd [Resident] had scheduled dose Methadone 5 mg @ 6 AM, gave another dose @ 9:00 AM. Outcome to Resident, read in part [ .] Rsd assessed @ 2 pm and Resp [respiratory] decreased to 8 [breaths per minute] with periods of apnea [cessation of breathing]. Corrective action taken, read in part Naloxone [Narcan] gave STAT dose 0.5 ml [milliliter] IM, rsd [Resident] alert and verbal 1 min [minute] after administration. Measures taken to prevent reoccurrence, read Pay closer attention to MAR. A policy titled General Dose Preparation and Medication Administration was obtained and read in part 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, [ .] No other information was provided prior to exit conference on 2/11/20.