**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (R187) reviewed for accidents. R187 had an elopement from the hospital prior to admission and, following admission here, eloped from the building on 3 separate occasions. On the second elopement, R187 was missing for 2.5 hours, which required police and a K9 search to find R187. On the third elopement, R187 traveled 1.4 miles to a bridge, running through busy traffic, and attempted to jump off the bridge. Facility failure to provide adequate supervision created a finding of immediate jeopardy that began on 08/23/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/09/24 at 1:00 PM. The immediate jeopardy was removed on 08/26/24 and corrected on 08/27/24. This is being cited as past noncompliance. Findings: The facility policy titled Elopement dated June 2023, states, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. The facility policy titled Elopement Management dated June 2023, states, Each resident is assisted in attaining or maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate, and safety interventions to minimize elopement risk. Signaling devices may be used if able and determined to be an appropriate intervention. The goal of the elopement management system is to identify residents with potential exit seeking behavior to assure the care plan and [NAME] reflect effective and consistent interventions and safety measures and to assure staff are educated regarding the elopement management system and the resident's specific interventions. Practice guidelines: -Residents assessed on admission with the risk for elopement will have a. Interventions implemented to promote safety; and preventative measures implemented to mitigate elopement risk. R187 was admitted to the facility on [DATE] at 5:30 P.M. escorted by Adult Protective Service (APS), after being placed into Emergency Protective Placement on 08/21/24 at 3:57 PM while at the hospital. While waiting for treatment at the hospital, R187 had eloped. On 10/08/24 at 1:47 PM, Surveyor reviewed hospital emergency room documentation dated 08/21/24 which states in part, At 1453 the patient has eloped from the ER. Police called at 1554. Adult protective serves will be re-contacted. Per police report for hospital elopement, resident was located on [NAME] Street and complied with return to hospital. R187 had diagnoses of encephalopathy, unspecified amnesia, disorientation, acute abdomen, calculus of gallbladder without cholecystitis, alcohol use, unspecified in remission following elopement from hospital. Facility was unable to obtain a Brief Interview for Mental Status (BIMS) on admission as R187 refused to answer questions. Hospital records, dated 8/22/24, indicate the Montreal Cognitive Assessment (MoCA) (screening test for cognitive impairment) was given and R817 scored a 4. Less than 10: Indicates severe impairment. On 8/22/2024 at 11:40 PM, the facility documented a clinical admission note for R187 that states in part: -admission Details: Arrived by - Other: Protective Services -admission mode: walker. -Mental Status: Resident is experiencing signs of short-term memory loss. Oriented to person. Oriented to place. -Short-term memory loss: Unknown. -Level of cognitive impairment: Mild impairment (some confusion). Resident is coherent. Speech is clear. Language barrier: No. Resident makes self-understood. Resident understands others. -Mood and Behavior: Mood is pleasant, no unwanted behaviors witnessed. -Safety: Call light is within reach. -Physical restraints - none. -Able to move all extremities. Upper extremity ROM: No impairment. Lower extremity ROM: No impairment. -Gait is steady. -Balance is WNL (within normal limits). -Screening: Does the Resident currently or have a history of a substance use or been diagnosed with substance use disorder: No. -Education/Notification: Safety concerns - note: Elopement attempts while in hospital. On 8/22/2024 at 11:40 PM, the facility entered a nursing progress note that states in part: Screening: Resident has not faced a traumatic event or experience in the past. On 08/23/2024 at 12:04 AM, the facility completed an Elopement Evaluation, which showed a score of 5.0 (score above a 1 is at risk) based on answering Yes to the following questions: -Does the resident have a history of elopement or an attempted elopement while at home? -Does the resident have a history of elopement or attempted leaving the facility without informing staff? -Is the wandering behavior a pattern, goal directed i.e. specific designation in mind, going home, etc.? -Is the residence wandering behavior likely to affect the safety or well-being of self or other? -Has the resident been recently admitted or readmitted within the past 30 days and is not accepting the situation? Of note, the elopement assessment and wanderguard were not placed until over 6 hours after admission, putting R187 at risk of successful elopement during this time. Surveyor reviewed a nursing progress note from 8/23/2024 at 9:00 AM. Note Text: NEW admission: Res was awake all night. He couldn't rest early on the night shift and was coming to the window of the nurses station and asking questions with difficulty word finding, and word salad. One time wondered about sugar and diabetes. Another time said I am just going to my room, and I will die. Writer redirected res with conversation and a snack. Given a sandwich, and a soda and bag of chips. Res sat in lobby area, eating his snack. No further mention of death or dying. Res was concerned that he was not eating food away from staff or any others. Both staff left resident in lobby area eating, as he was content at approximately 0425. On 10/08/24 at 10:38 AM, Surveyor interviewed Dietary Manager (DM) F about R187's time at the facility and his elopements. DM F indicated on 08/23/24 at 4:30 AM, R187 was observed by DM F walking out the employee entrance which is off a hallway with administrative offices. Certified Nursing Assistant (CNA) N responded immediately and was able to convince R187 to return into facility and the incident was reported to NHA A at 4:43 a.m. On 10/08/24 at 1:47 PM, Surveyor requested from NHA A the facility's investigation for R187's elopements on 08/23/24. NHA A, provided a soft file investigation/conclusion summary dated 08/23/24 - 08/26/24 and signed by NHA A, regarding the second elopement, that states under the sections Conclusion/Root cause Summary: [R187] was admitted on [DATE] at approximately 4:30 PM. [R187] placed in room mid hallway from either exit door. On 08/23/24 at 4:30 AM, [R187] exited the employee door and an alarm sounded. [CNA N] responded and [CNA N] exited building with [R187]. [DM F] outside in parking lot when [R187] exited. [R187] aggressive and agitated. [CNA N] redirected and was able to escort [R187] into center after approximately 5 minutes. [R187] escorted to lobby for close supervision and wanderguard placed [CNA N] contacted [NHA A] via telephone. Television was on for [R187]. [R187] went to room stating was tired. [RN X] witnessed [R187] ambulating in hallway to room on hall 200. [R187] bypassed room and attempted to push open door at end of hall 200; however, it alarmed and [R187] closed door and retreated. [RN X] was in a resident's room and observed [R187] ambulating quickly toward hall 300. Hall 300 door sounded at approximately 5:30 AM. Staff responded to door. [CNA N] went out the door at end of hall 300 and began search for [R187]. [CNA N] on phone with [NHA A] during this time. Police contact immediately. [LPN K] updated resides local [DM F] took vehicle to begin neighborhood search for [R187]. Other managers contacted to come to center to assist. Police came to center within two minutes of calling. Police suspected [R187] was hiding in bushes as they responded within minutes. [R187] located two blocks from center near the church/courthouse. [R187] was sitting on the steps of the church police brought [R187] to the center. [R187] assessed by nurse. No injuries noted. [R187] taken to hospital by maintenance supervisor for further evaluation. [R187] returned to center approximately 1-1.5 hours later at approximately 10:30 AM. hospital emergency room for evaluation following elopement. Surveyor did not find any documentation in R187's medical record regarding the first and second elopements or evidence of increased supervision or additional interventions after the first and second elopement. Surveyor received and reviewed a written statement and signed event dated 8/23/24 by Registered Nurse (RN) X. RN X only worked this one shift for the facility. RN X's statement read: Approximately 4:30 AM, heard wanderguard alarm go off. [CNA N] and [RN X] both on Aspen wing ran to get alarm when [R187] exited the building and came back with [CNA N]. [RN X] was looking out windows and doors to see if [CNA N] needed help returning [R187] to facility. [RN X] was unable to see well, so opened emergency wing door at the end of Birch Hall. [CNA N] came to help [RN X] to shut off alarm as were looking for a key to silence the loud alarm. At opposite end of wing staff heard [R187] yelling out something about a fire but alarm was so loud not really able to hear [R187] who was walking very fast as [R187] went by the wing from [NAME] way toward lobby. Staff not sure when [R187] exited second time as the alarms were so loud and we were trying to silence them. We are also not sure what door [R187] exited. [CNA N] called NHA A at 4:43 AM to inform of inability to find resident [R187]. At this time [RN X], [CNA N] and [DM F] involved looking for resident soon another staff member [LPN K] came from other building to help look. [Assistant Director of Nursing (ADON) G] was phoned at 5:04 AM and asked for help. Maintenance man arrived and shut off alarm at 5:19 AM. Staff and police continually searching for [R187] outside of building as it was confirmed [R187] was not inside the building. At 7:10 AM by police staff noted when returned [R187] did not have the wanderguard on left wrist. [R187] did have wanderguard on left wrist when [R187] was eating sandwiches at 4:25 AM. Surveyor interviewed DM F regarding R187's second elopement. DM F indicated that at approximately 4:44 AM on 08/23/24, R187 attempted to elope out of 200-wing setting off emergency door alarm. R187 walked back toward nurses' station and DM F was asked by CNA N to assist RN X to shut off the 200-wing emergency door alarm as CNA N went to conduct morning cares on another resident. DM F returned to the nurses' station as was unable to assist shutting off 200 wing emergency alarm. RN X continued to attempt shutting off alarm. DM F then heard the 300-wing emergency door alarm activate and responded along with CNA N. Both quickly conducted a search inside the building and were unable to locate R187. Both DM F and CNA N notified RN X who called the police and then started looking outside and around the building to locate resident. CNA N contacted NHA A via telephone at 4:43 AM. Police were contacted at 4:49 AM by RN X. Maintenance was contacted and was able to shut off door emergency alarm at 5:19 AM. Of note, the nurse on duty was an agency nurse who was working her first shift and was not knowledgeable in how to operate the alarms. DM F indicated she got into car and drove around neighborhood on 08/23/24 from 4:45 AM to 7:18 AM but was unable to locate R187. On 08/23/24 at approximately 7:30 AM, police department brought R187 back to facility as R187 was found approximately 0.7 miles from facility sitting on church steps. R187 would need to cross several roads to get to the church. Weather was low of 63 degrees and R187 was dressed in hospital gown, underwear, and shoes. On 10/08/24 at 12:14 PM, Surveyor interviewed CNA O, who stated on 08/23/24 she came on shift at 6:00 AM. CNA O was told that a new admission came in on 08/22/24 and was missing for hours and around breakfast time police brought R187 back to facility. CNA O stated R187 did not have a wanderguard on nor was he on 15-minute checks. On 10/09/24 at 6:49 AM, Surveyor interviewed CNA N who indicated RN X was overwhelmed as it was the first time RN X has worked for facility. CNA N indicated R187 was a little restless during the shift and he heard the wanderguard alarm by employee entrance so CNA N went out and redirected R187 back into facility. CNA N indicated while that was happening RN X went down the 200 hall, as RN X thought R187 went out the emergency door which set off the emergency alarm. R187 became agitated and freaking out there was going to be a fire. We got R187 to remain calm. CNA N indicated he went to see if the emergency alarm would stop, but it needed a key. R187 then went out 300 hall door, setting off another emergency alarm which made the noise louder while CNA N was on the phone with NHA A and RN X was freaking out. The police arrived and searched for R187. CNA N indicated prior to R187 arriving to facility, staff were informed he was an elopement risk and stated there was definitely not enough staff, normally we have 2 CNAs. Surveyor received and reviewed a written statement and signed event dated 8/23/24 by CNA N, who wrote a statement of the two elopements on the morning of 8/23/24. Surveyor reviewed the facility soft file which included the written statement of CNA N which stated, statement taken via phone: 4:30 AM [CNA N] heard the wander alarm go off. [CNA N] went to check the front door and saw [R187] walking down the management hallway. [CNA N] turned to follow [R187] out the employee exit. [R187] was very upset agitated and almost combative. [CNA N] was able to deescalate [R187] into coming back to the facility. Upon entering the building [CNA N] asked [R187] to sit in the lobby in a recliner while [CNA N] silenced the wander alarm. [CNA N], then saw [R187] get up and walking go towards [R187's] room. At 5:30 AM [CNA N] heard the door emergency alarm go off on the 200 hall. [CNA N] went to look down that hall then heard the 300-door emergency alarm go off [CNA N] walked out those doors and did a search around the building . On 10/08/24 at 11:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K, regarding R187's 2nd elopement attempt. LPN K indicated they were called in by NHA A on 08/23/24 at approximately 5:00 AM, as a department head to come to facility to assist with a missing resident. LPN K indicated that during search for R187, LPN K ran into 2 deputies from the [NAME] County Police station who were also looking for resident and were able to locate R187 and brought R187 to facility. LPN K indicated hearing that R187 had another elopement episode but was not involved in that event. On 10/14/24 at 12:45 PM, Surveyor interviewed Police Officer Q, via telephone, who returned R187 through the front door of the nursing home after 2nd elopement from facility on 8/23/24. Surveyor asked if officer was aware of R187 wearing a wanderguard bracelet or if alarms sounded when going through the front. Police Officer Q stated there was no alarm sounding when they brought R187 back into the facility at 7:30 AM. R187 was missing from facility for 2.75 hours. Surveyor reviewed the police report for the second elopement that included in part: On Friday, August 23, 2024, Reported 4:49 AM. The notes were as follows: [R187], PATIENT ABSCONDED, LOOKING FOR ASSIST WITH LOCATING [R187]. UNKNOWN WHICH DOOR LEFT OUT OF FACILITY WEARING A PATIENT GOWN, 6'. [Deputy T] indicated the subject, [R187], had dementia, was possibly placed at the nursing home through social services and left agitated thinking the building was going to blow up. The information from August 21, 2024, indicated [R187] was supposed to be at the Black River Memorial Hospital under the care of Adult Protective Services. [Deputy U] Supplemental Report: K9 report: It should be noted that while enroute to the call, I came upon the missing person. This report is a summary of those events. Initial: On Friday, August 23, 2024, at approximately 6:43 AM, I, [Deputy V]. While enroute to the call, I noted a person matching [R187's] clothing description near the intersection of [NAME] Street and N 5th Street, in the City of Black River Falls, [NAME] County, Wisconsin. I notified dispatch and made contact with the party who verbally identified self as [R187]. [R187] began to repeatedly ask me about a wallet that was lost. [R187] initially appeared agitated, so I began to ask [R187] about the wallet to calm [R187] down. Eventually [R187] calmed down at sat by the curb. I explained to [R187] that we were looking for [R187] and asked [R187] if we could give [R187] a ride back to the nursing home. [R187] agreed to this. [R187] eventually was picked back up by [Officer L], which ended my contact. At this time R187 was taken to the emergency room for evaluation. Emergency notes states: -Discharge Disposition: Patient will return to Meadowbrook facility where has been placed under and adult protective hold by adult protective services for [NAME] County. Patient has been medically cleared to return to that facility. Electronically signed 08/23/24 at 9:08 AM. On 08/23/24 at 9:48 AM, the facility entered a nurse's note that states in part, Wanderguard applied to resident's right wrist after returning from ER for eval. On 08/23/24, (no time stamp), a care plan was initiated which states, Focus: The resident is an elopement risk/wanderer. Disoriented to place, has a history of attempts to leave facility unattended, and has impaired safety awareness. Resident is protectively placed through [NAME] County due to emergency incapacitation from hospital. Adult protective services involved. Goal: the resident will not leave facility unattended through the review date. On 08/23/24 at 3:00 PM, treatment order for monitoring wanderguard was placed into chart for monitoring every shift of placement. Intervention/Tasks: Wander Alert - Wanderguard. Wanderguard will be checked every shift per MAR/TAR. On 08/23/24, the facility initiated 15-minute checks on R187 signed and time stamped by facility staff from 10:30 AM to 6:45 PM. Of note, R187's second elopement took place within 9 minutes from returning to building after the first elopement. The 15-minute check intervention had already proven to be an ineffective intervention for increased supervision to prevent R187 from eloping. 3rd elopement: On 8/24/2024 at 1:50 AM, a nurse's note was entered stating, Approximately 7:00 PM, [R187] walked out of room door; turned right; and walked through the alarmed door at the end of the 200 wing. Staff [CNA N] ran out the door following [R187] down the street. Another staff [DM F] got in car and followed [R187]. [NHA A] was called, as well as law enforcement since [R187] was not willing to come back with staff. Law enforcement took to Hospital ER on a 72-hour hold. Protective Services was updated by law enforcement. Of note, ER states R187 presented to ER following event at 8:30 PM. On 10/08/24 at 12:14 PM, Surveyor interviewed CNA O regarding the third elopement. CNA O indicated later that evening on 8/23/24, she received a phone call at home from CNA P who was following R187 on foot. CNA P informed CNA O that R187 eloped and is really fast. CNA O got in car to assist in locating R187. CNA O stated R187 was observed weaving in and out of traffic on Main Street and was found at bottom of the Black River bridge. CNA O stated Civilian Z happened to be driving on the bridge and got out of car as well as CNA O. They approached R187 who was hanging onto bridge rails looking over into water and stated, If I jump here, I will survive, and making other comments about wanting to jump over bridge. Civilian Z scooped R187 up and moved R187 away from railing. Civilian Z and CNA O were able to calm R187 down and have him sit. Police arrived and took R187 to hospital. On 10/08/24 at 12:55 PM, Surveyor interviewed CNA P regarding the elopement event on the evening of 08/23/24. CNA P stated R187 was on 15-minute checks, not on 1:1 or line of sight that evening. CNA P stated she had clocked out of 12-hour shift (6:00 AM to 6:30 PM) but clocked back in because replacement CNA I, scheduled for 2:00 PM, had not yet shown up yet. When CNA I arrived at facility, CNA P saw R187 exit 200 wing emergency door and she followed R187 from the nursing home to the bridge on foot, while CNA I followed in car. R187 was running ahead of staff, dodging in front of cars, trying to get into parked cars, and walking down the middle of the road. On 10/15/24 at 1:54 PM, Surveyor interviewed CNA P via telephone regarding following R187 from facility to bridge. CNA P stated she was approximately a half block away from R187 and she was unable to prevent R187 from dodging between cars, attempting to get into cars or stop R187 from getting to the bridge. Police report for third elopement: On Friday, August 23, 2024, at approximately 7:08 PM, I, [Deputy V], was dispatched .for a report of a male party who had walked away from the nursing home. This male party was later identified as [R187]. It should be noted that I had previously dealt with [R187] earlier in the day when I was requested to come in and attempt a K9 track on [R187] as had left Meadowbrook Nursing Home but was later found. Dispatch advised Meadowbrook had called again stating had walked away from the building While enroute to the call, I heard [Trooper Y] advised was out with the [R187] near the intersection of Main Street and North Water where [R187] had attempted to jump off the bridge. Contact with [CNA O] and [CNA P]: Arrived at the above location and observed [R187] being held on to by [Trooper Y] and [Civilian Z]. During this time several unidentified individuals were on scene as well. I then asked to speak with [CNA P] who worked at the nursing home. [CNA P] explained to me that earlier in the day, [R187] had absconded from the nursing home which I was aware of. [CNA P] stated that evening, she went to go take care of another patient and saw [R187] just got up and took off. [CNA P] further stated that she then followed [R187] to where we currently were. I asked [CNA P] about [R187] jumping off the bridge to which she told me that [R187] kept saying that was going to do that and had attempted to do so. I asked [CNA O] if there were any locked doors or if [R187] could just walk out to which she told me [R187] could just walk out. I later learned [R187] had an alert bracelet that would alert staff if [R187] left the facility however, they would not physically stop a patient. [CNA O] stated that the facility did not have the manpower to deal with [R187] constantly running away. I asked [CNA O] where [R187] was before their facility to which she told me the hospital and [R187] had left there twice. Contact with [Civilian Z] I then spoke with retired officer [Civilian Z] who followed [R187] all the way from Falls Florists near South 7th Street and followed [R187]. [Civilian Z] stated as [R187] came near the intersection of Main and Water, [R187] then went into the oncoming lane and started making statements was going to jump off the bridge. [Civilian Z] stated since the nursing home staff was not close enough to stop [R187], [Civilian Z] intervened and stopped [R187] before [R187] made it over to the railing. [Civilian Z] stated once grabbed a hold of [R187] who stayed still. R187 was taken to the hospital at this time and did not return to the facility. On 10/09/24 at 6:43 AM, Surveyor toured the route as given per staff interviews and made these observations on what route R187 would have taken: R187 ran from the facility towards the bridge that overlooks the local river, approximately 1.4 miles from the facility. R187 would have been subject to traffic dangers as well, as this is a busy intersection with a three way stop and no stop-sign for vehicles leaving the downtown area. R187 made it to the bridge. The road is called I-94 alternative (intersection for state road 54 and 12 and is 40mph over the bridge and 25mph in the downtown area). The bridge overlooks the Black River and is over three stories high. The ground under the bridge is very rocky with a shallow river that comes from the Black River dam. The railing for the bridge is about 3' high and can easily be climbed over. There are no safety nets or high fences to prevent jumping. On 10/09/24 at 8:22 AM, Surveyor interviewed Chief Nursing Officer (CNO) M who first stated that facility was not aware that R187 eloped at the hospital prior to admission. At 9:10 AM, CNO M clarified the hospital referral paperwork indicated R187's elopement from the hospital. CNO M stated she had no idea why they accepted this resident. It was the job of DON AA to look at the acceptance paperwork, and DON AA left three days later; CNO M's assumption was that the acceptance paperwork was not looked at well. Surveyor asked CNO M if R187 had a wanderguard in place during the first and second elopements. CNO M stated that RN X referenced a wanderguard in written statement. Surveyor reviewed RN X's written statement. RN X's statement located in the facility soft file stated: Resident returned to facility at 7:10 AM, by police. Staff noted when returning to facility at 710 AM, by police, staff noted when returning he did not have the wanderguard on L wrist. [R187] did have wanderguard on L wrist when [R187] was eating sandwich at 4:25 AM. CNO M further indicated that RN X was new to the facility and when RN X heard the wanderguard, RN X was not aware where to look. CNO M indicated the facility should not have taken R187, as they did not have the staff to do 1:1 observations, which is why they did implement the 15-minute checks after the second elopement. On 10/16/24 at 2:44 PM, Surveyor interviewed Medical Director (MD) S, who has been the facility's medical director for the past 10 years. MD S stated has not been made aware of any resident elopements within the past few months. MD S stated would anticipate that the facility would work with the resident's primary physician to determine interventions in order to keep a resident safe. On 10/14/24 at 4:01 PM, Surveyor interviewed DON B regarding expectations of process to be completed upon becoming aware a resident is an elopement risk. DON B stated that when the facility is made aware of an elopement risk, especially when the Director of Nursing at the time was aware of R187's elopement attempts prior to admission, would expect an assessment would immediately be completed, a wanderguard placed on resident, documented in resident's chart, treatment record updated for every shift monitoring, physician made aware along with resident and/or representative, and would expect a baseline care plan developed that includes triggers and interventions. The facility's failure to ensure a resident with a known history of elopements had the supervision to prevent accidents created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 08/23/24. On 08/26/24, the facility identified the deficient practice that occurred when the facility staff did not provide increased supervision after a resident eloped from the building. The facility took steps to correct the deficient practice and ensure compliance starting on 08/26/24. The immediate jeopardy was removed on 08/26/24 and corrected on 08/27/24 when the facility completed the following: The immediacy was removed on 8/26/24 when all staff education was provided that included the following: When a resident displays exit seeking behavior, supervision should be provided. Supervision includes: -resident being assisted to a common area. -resident engaged in activities of interest. -resident provided psychosocial support. -resident family contacted and included if able. -increased visits from facility managers. -staff coordination on who will be providing the increased supervision and for how long and when to provide relief. -if resident behaviors continue increased 1:1 support may be needed per staff discussion which includes DON/NHA/designee. Wanderguard does not replace supervision. Staff should be proactive and increase supervision as needed when resident displays exit seeking behavior. Staff should contact DON/NHA/designee for additional support and guidance. All elopement risk assessments were updated. All elopement residents' care plans were updated. Based on this determination, the citation is being issued as past non-compliance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R6) at high risk for pressure ulcer development, received the necessary treatment and services needed to prevent the development of a pressure injury. R1 was admitted to the facility with a brace and ace bandage on her leg. R1 was identified as being at risk for pressure injuries and a care plan was not developed. The facility did not assess the skin under the brace/ace bandage routinely, which lead to multiple pressure injuries. The pressure injuries became infected, which required R1 to be hospitalized and have a surgical procedure and antibiotics. Facility failure to assess R1's skin under her brace/ace bandage routinely led to the development of multiple pressure injuries which created a finding of immediate jeopardy that began on 05/15/24. Surveyor notified Nursing Home Administrator of the immediate jeopardy on 07/03/24 at 1:20 p.m. The immediate jeopardy was removed on 07/05/24. However, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by: The facility did not follow R6's plan of care of placement of a right heel cup to prevent the redevelopment of a pressure injury. This is evidenced by: Example 1: The facility policy entitled, Pressure injury Prevention Guidelines, dated 2022, states in part: Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust the device as needed for proper fit. The National Pressure Injury Advisory Panel prevention and treatment of pressure ulcers/injuries quick reference guide 2019 recommendations for device related pressure injuries: Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. Reduce and/or redistribute pressure at the skin-device interface by regularly rotating or repositioning the medical device and/or the individual. Providing physical support for medical devices in order to minimize pressure and shear. Removing medical devices as soon as medically feasible. Provide high-calorie, high-protein, arginine, zinc and antioxidant oral nutritional supplements or enteral formula for adults with a category/Stage II or greater pressure injury who are malnourished or at risk of malnutrition. R1 was admitted to the facility on [DATE] and has diagnoses that include displaced fracture of the right ulna, fracture right tibia, right tibial plateau fracture repair, falls, subdural hematoma, weakness, atrial fibrillation, and lymphedema. Hospital discharge instructions included tibial plateau fracture repair. Keep cast/splint clean and dry. Weight bearing instructions right lower extremity: toe touch weight bearing. Follow up in 2 weeks for wound check, staple removal. The facility did not clarify discharge instructions for removal of leg brace. 04/18/24 Braden states - bedfast resident is completely immobile does not make even slight changes in body or extremity position without assistance .Braden score 12 High Risk. Additional clinical suggestions: is left blank. Minimum Data Set (MDS) 5 day admission assessment, dated 04/24/24, documented a brief interview of mental status score of 13, cognitively intact. The MDS documents R1 as being dependent on staff for bed mobility and transfers, at risk for pressure injuries and no current pressure injuries. The MDS did not document pressure reducing devices, no turning repositioning program, and no nutritional or hydration interventions were utilized. R1's care plan on admission does not mention skin. No interventions are listed or put into place on the plan of care in relation to skin or prevention of pressure injuries throughout the resident's stay. The initial and final care plans for R1 read the same. Resident has limited physical mobility. Goal: Resident will increase level of mobility through next review, approaches approach resident offer assistance to the bathroom every 2-3 hours around the clock. Per resident please wake up every 2-3 hours to offer bathroom assistance - 2 assist with full body lift. Resident experiences isolation due to being non weight bearing and fear of the hoyer resident will express feelings of around loneliness and isolation when she feels them. Encourage resident to express feelings. R1's treatment administration record (TAR) for April states, Keep cast/splint dry three times a day - this is initialed three times daily, beginning on April 19. Weight bearing instructions: RLE [Right lower extremity], to [should be toe] touch weight bearing, every shift - this is initialed three times a day beginning on April 18. R1's progress notes state in part: 04/18/24 - pain lower Right lower leg: 1 aching, daily Clinical admission details: dated 04/18/24 - right lower leg skin issue: Brace in place . (Surveyor was unable to locate admission skin assessment of the right lower leg.) 04/19/24 - pain in lower legs 7/10 and received scheduled Tylenol - effective 04/21/24 Resident remained in bed all shift complaint of lower legs hurting her a little bit per her usual PM complaint. Pain Continues Low level relieved by Tylenol. 04/21/24 Skin only evaluation -external device removable - yes- External device removed and skin inspected - no. 04/25/24 Progress notes, Resident is bed fast all or most of the time, pain in right lower leg, resident position changed. Non medication interventions provided relief. 04/30/24 Progress notes, Right lower leg brace in place. 05/01/24 Resident seen at [clinic name] Ortho advance to toe touch weight bearing. (This was actually in place on initial admission information.) Nursing progress notes state 05/03/24, Call to Ortho for clarifications for removal of brace. Per Ortho MD brace can be removed while in bed. Brace must be on for all transfers in the unlocked position. 05/10/24 Right lower leg: Brace in place. 05/12/24 Right lower leg: Brace in place. 5/12/24 Resident stayed in bed. Resident refused to have brace removed from right lower extremity. The facility did not document skin assessments for under the right leg brace between 05/03/24 when confirmation to be able to remove brace and 05/14/24. Pressure Injury Tools, dated 05/15/24, read in part: Right inner thigh, 3 areas, this is most superior. Pressure injury 1, length 11.3 cm by width 1.4 cm depth 0 - Deep tissue Pressure injury - skin closed deep purple, almost black necrotic area - plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Pressure injury 2, Right inner thigh, middle area, length 6.5 cm by width 7.8 cm depth 0 - deep tissue Pressure injury - skin closed, necrotic tissue present 100% deep purple, almost black necrotic tissue noted, almost like blood blister, no open areas. plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Pressure injury 3, Right inner thigh, most inferior of three areas, length 1.5 cm by width 9 cm depth 0 Deep Tissue Pressure Injury- skin closed necrotic tissue present - dark purple, almost black, appears to be blood blister or necrotic area from improperly applied ace bandage no open areas. plan/treatment - monitor on TAR until healed. Assess for signs and symptoms of infection. Interventions - nutrition or hydration intervention to manage skin problems. Physician notification form dated 05/15/24 notes 3 areas of concern on her inner right thigh. 1. Measures 11.3 cm x 1.4 cm 2. Measures 6.5 cm x 7.8 cm 3. Measures 9 cm x 1.5 cm All areas are dark purple/black, appear to be necrotic areas from ace bandage. Peri-wound area is red, but blanchable. Resident reports burning and pain when touching area. Lotion was applied and ace wrap re-wrapped. MD responded to notification on 05/30/24: Evaluated today will likely need debridement but recommend eval and treat by wound care center and nursing. Keep ace wrap/tubi grips off wound area, Finish ABX last day today. (This antibiotic began on 05/24/24) Continue Tylenol prn for pain. Clinic note, dated 05/16/24, a fax message from the facility to clinic: 3 areas of concern on her inner thigh measuring 11.3 x 1.4 cm, 6.5 cm x 7.8 cm, 9 cm x 1.5 cm. All areas are dark purple/black appear to be necrotic areas from Ace bandage. Physician Assistant (PA) I requested more information about the areas from the facility. 05/16/24 Progress Notes - Right lower leg: Brace in place Clinic note, dated 05/17/24, telephone message from License Practical Nurse (LPN) D to the clinic. Discolored spot update. Right leg looks more like a bruise behind right knee. Area is not open, just bruised, no blisters, not necrotic. Painful to touch .looks like the brace was rubbing causing pressure in this area. Patient wanting to stay in bed due to the hoyer lift straps rub/sit on the sore, bruised area. PA I responded to continue with efforts to offload pressure at the site. Clinic note, dated 05/23/24, message from Medical Doctor (MD) J to facility: Possible cellulitis. She had an abrasion to her right upper leg and developed some surrounding redness, tenderness, induration. Appears to be a cellulitis. Empiric antibiotic recommended. Escalate therapy to clinic or emergency department visit if worsening. MD J ordered to start Cephalexin Capsule 500 mg every 6 hours for 7 days. Physician notification form dated 05/29/24 had no information from the facility only had a physician's response. The response documented to consult wound clinic for medial knee wound and wound care to medial knee with ABD, gauze and bacitracin as needed. Pressure injury tools dated 05/30/24 read in part: Pressure injury 1, Right medial anterior thigh, length 3.5 cm width 8 cm depth .1 cm unstageable pressure injury - necrotic tissue present - 100% black Eschar, summary of findings - worsening - md notified, plan/treatment monitor in TAR until healed, assess for signs and symptoms of infection, heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed, pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems. Pressure injury 2, Right medial posterior thigh, length 1.5 cm width 2 cm depth 0 cm - unstageable - necrotic tissue present 100% eschar /black initial documentation was entered as a DTI but is not due to thick layer of eschar with charcoal appearance of skin. Infection suspected, yes, remains on antibiotic for cellulitis unchanged plan/treatment monitor in TAR until healed assess for signs and symptoms of infection, heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed, pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems. Pressure injury 3, Right posterior thigh fold, length .7cm width .4 cm depth .1 cm stage 3 pressure injury granulation tissue present slough tissue present 20% slough 80% granulation. Pressure injury 4, Right calf, length .2 cm width 2.5 cm depth 0 Deep tissue pressure injury closed 100% dark purple maroon discoloration non blanchable skin- unchanged - plan/treatment monitor in tar until healed assess for signs and symptoms of infection , heel protectors, float heels off bed, specialty mattress, roho cushion, leg protector, pressure reduction device for chair, pressure reduction device for bed , pad equipment, lie down after meals, maintain wheelchair position, nutrition hydration intervention to manage skin problems (none of these listed interventions were added to the plan of care). Doctor notified. A fax from MD F on 05/31/24 with orders to coordinate surgical consult for right upper leg wound needing a surgical debridement. Physician notification form sent to doctor on 05/31/24, medical device related pressure injuries. 1. Right thigh x 2 - unstageable 1. Medial anterior: 3.5 x 8 cm total area of 100% eschar. Small area where eschar is peeling back had depth of 0.1 cm 2. Medial posterior: 1.5 cm x 2 cm total area black 100% eschar. 2. Right posterior thigh fold - Stage 3 Area measures 0.7 cm x 0.4 cm x 0.1 cm, wound bed 80% granulation / 20% slough. Light serosanguineous drainage noted. 3. Right lower calf - DTI (Deep tissue injury), Area measures 0.2 cm x 2.5 cm. No drainage dark purple/maroon no blanchable. Requested: Can we start Juven oral packet 1 packet po BID (two times a day) for wound healing. Can we get orders for right calf DTI to apply skin prep and cover with bordered foam every Monday/ Wednesday/ Friday. Right thigh unstageable Pressure Injury x 2 cleanse with normal saline pat dry apply bacitracin to any open areas cover with ABD pad and secure with tape BID and PRN until wound clinic appointment? Right posterior thigh fold - cleanse with normal saline, pat dry, calcium alginate ag to wound bed, zinc to surrounding tissue and cover with ABD pad daily and prn. MD F gave orders for referral to general surgery. Agreed with wound care nurse recommendations. The facility's physician notification form, dated 06/03/24, documented PA I gave new order for right lower extremity to cleanse and cover with nonadherent pad daily prn with gauze and bacitracin until seen at wound clinic. Initial wound care consult dated 06/04/24: Right anterior lateral shin: Patient noted to have approximate 3+ lymphedema without active lymphorrhea. Unstable eschar, this was removed revealing an ulceration that is full thickness. No evidence of clinical infection at this time. Wound: Right anterior lateral shin 1.2 cm x 0.5 cm x 0.1 cm - debridement, wound culture obtained. Medial posterior right proximal calf: Full thickness ulceration covered with approximate 40% non-adherent and non-stable eschar with surrounding slough and bioburden. Removed eschar, bioburden and slough exposure of subcutaneous fat, no evidence of muscle, tendon, nor bone exposure. Mild odor. Wound: 7.4 cm x 9.2 cm x 1.2 max depth - varying. Wound culture obtained. The furthest posterior extent there is a satellite ulcer that is separated by a small skin island between the primary ulcer and this satellite ulceration. Covered in 100% eschar. Removed eschar, no evidence of muscle, tendon, nor bone exposure. No evidence of granulation tissue, but the base appears viable. Right proximal medial calf - posterior satellite ulcer wound: 2.5 cm x 3.5 cm x 1.0 cm Mild odor. Visit diagnoses: Primary: Pressure injury of right posterior calf, stage 3. 06/04/24 Juven nutritional supplement was ordered and began 20 days after the pressure injury was first noted. Pressure Injury Tools dated 06/06/24 read in part: Pressure injury 2, Right Medial posterior thigh push tool merged into right medial anterior thigh after debridement at wound care clinic. Both wounds now charted on PUSH tool 1. Length 0 width 0 and depth 0 unstageable pressure injury, obscured full thickness skin and tissue loss, The facility was unable to locate or provide Surveyor with a push tool for pressure injury #1 on this date. Pressure injury 3, Right posterior thigh fold, length .3 width 2 cm depth .1 cm stage 3 pressure injury: Full thickness skin loss. Granulation tissue present, slough tissue present, 10% slough 90 % granulation, moderate, serosanguineous drainage - worsening - antibiotic started- new wound care orders obtained. Peri wound tissue improved but total size larger than last week. Pressure injury 4, Right calf, length .2 width 1.5 depth 0 Deep tissue injury: persistent non-blanchable deep red, maroon or purple discoloration, closed 100% dark purple/maroon. Non blanchable. Improving. Improvement noted with current treatment orders. Will continue to monitor. Physician notification form, dated 06/10/24, MD F responded with a referral made to [Name] wound center follow-up there within the next week. Clinic note, dated 06/11/24, telephone message from facility staff LPN L to the clinic requesting more pain medication. MD F provided orders for tramadol 50 mg every 8 hours prn, 1000 mg Tylenol every 6 hours scheduled. Clinic note, dated 06/12/24, telephone message from facility staff to the clinic requesting pain medication for wound care and scraping. MD K provided orders of Hydrocodone-Acetaminophen 5-325 mg every 6 hours for 5 days. Pressure Injury Tools dated 06/13/24 states in part: Pressure injury number 1, Right medial thigh, length 7.4 cm width 13 cm depth 1 cm - unstageable pressure injury: obscured full thickness skin and tissue loss. Adipose tissue, granulation tissue present, slough tissue present. 10% gran, 90% slough/adipose tissue/eschar. Purulent heavy drainage, odor present- new onset of erythema, induration, warm to touch increased tenderness and odor with purulent drainage. Resident sent out to Hospital due to acute wound decline. MD updated and aware and gave orders to send out. Pressure injury number 3, Right posterior thigh fold, length .3 cm width 1.5 cm depth .1 cm - Stage 3 pressure injury: Full thickness skin loss, granulation slough tissue present. 10% slough, 90% granulation, moderate serosanguinous drainage present, improving. Sent out to hospital d/t acute change in wound with decline. Pressure injury number 4, Right calf, length .2 cm width 1 cm depth 0 cm. Deep tissue injury, closed, faded discoloration noted with improvement. Sent out to hospital d/t acute change in wound with decline. Pressure injury number 5, date acquired 06/13/24 Left medial thigh length 1 cm, width 2 cm, depth 0, unstageable pressure injury: obstructed full thickness skin and tissue loss. Necrotic tissue present 100% obscured due to eschar. First observation, sent out to hospital d/t acute change in wound with decline. 06/13/24 progress note: discharged - to hospital, doctor aware due to wound decline. Right medial thigh wound larger, strong foul odor, increased pain tenderness, increased drainage. Chills and sweating. 06/14/24 clinic communication - Resident admitted to hospital for wound that is not healing. Hospital documentation: 06/13/24 Hospital diagnosis: Infected wound right thigh .right thigh wound culture growing E.coli and Pseudomonas. Patient taken to the Operating Room (OR) on 06/14/24 for wound debridement. History of present illness: .Her wound originated apparently secondary to bracing after treatment to surgically repair a tibial plateau fracture after a fall . Physical exam: There is a large lesion on the right medial thigh approximately 10 x 18 cm, deep down to the subcutaneous fat and some areas in through the subcutaneous fat near the layer of the muscle and other areas. There is eschar present inferiorly and there is odor present. There is a second lesion in the left medial thigh a 1.5 cm diameter eschar with a little surrounding erythema . Medical decision making: The wound appears significantly deeper than was 3 days ago .A culture from 3 days ago revealed that the wound grew polymicrobial flora .a repeat culture was ordered . Assessment/Plan: Patient started on cefepime and vancomycin. 06/14/24 Surgical progress note in part: Resident has a large necrotic wound of the right thigh .the wound was several centimeters deep . I then used a 15 blade to debride black eschar .There was necrosis of the subcutaneous fat which was debrided out with a 15 blade . On 07/02/24 at 4:15 PM, Surveyor interviewed LPN D and Registered Nurse (RN) E. LPN D stated that staff was not looking at skin underneath the brace/ace bandage and did not remove the brace or ace bandage until after receiving an order that the brace could be removed on 05/03/24. LPN D stated that she was not shown or taught how to remove the immobilizer brace. RN E stated that the last two weeks of May the brace was off. LPN D stated the resident would refuse to have the brace removed. Surveyor's review of documentation revealed this was rarely documented. Surveyor asked what interventions were put into place to prevent R1's pressure injuries. RN E indicated R1 had a full pressure reduction bariatric air mattress in place and used pillows for repositioning. LPN D stated at times she used a rolled-up towel between R1's legs. They indicated R1 had a Roho cushion in her wheelchair, but she rarely got out of bed. RN E stated they started the Juven supplement (a nutritional supplement used to aid in healing) on 06/04/24. On 07/02/24 at 6:50 PM, Surveyor interviewed Nursing Home Administrator (NHA) B who stated a skin assessment should have been done on admission, including looking at the skin underneath the brace and ace bandage. When asked if skin under braces and ace bandages should be inspected routinely, NHA B stated, Yes. On 07/03/24 at 12:55 PM, Surveyor interviewed MD F who stated she first saw R1's wounds on 05/30/24, to the best of her recollection. Surveyor asked if she was aware the facility had not been inspecting R1's skin under the brace and ace bandage. MD F stated she was not aware one way or the other. Surveyor asked if R1's wounds would have been preventable if facility staff were removing the ace bandage and brace and assessing R1's skin. MD F stated probably. The failure to put measures in place to prevent the development of a pressure injury and to promote the healing of pressure injuries created a reasonable likelihood of serious harm which led to a finding of immediate jeopardy that began on 05/15/24. The facility removed the immediate jeopardy on 07/05/24 when it had completed the following: 1. Provide education to all nursing staff on skin policies and procedures, including admission [NAME] assessments, and implementing orders to check skin under medical devices daily for signs of pressure related injuries, and timely updates with new skin issues/breakdown with orders obtained and care plans updated. 2. Provide education to the Interdisciplinary Team (IDT) on new admission review to ensure skin assessments are completed and schedule is in place in the treatment administration record (TAR) to check under any medical device daily for signs of pressure related injuries. 3. Provide education to all nursing staff, minimum data set (MDS) coordinator, and IDT on ensuring care plans with specific interventions are implemented for all residents at risk of developing pressure injuries. Education including review of care plans, evaluations of effectiveness of interventions, and addition of new interventions if needed. 4. Perform a facility-wide skin sweep by 07/05/24 to ensure all residents at risk for pressure injuries have care planned interventions, all current skin conditions are documented and on the weekly wound tracking document, and any new skin concerns are identified, and the physician and resident's power of attorney (POA) if applicable are updated with orders obtained and care plan updates are made. 5. Director of Nursing (DON)/designee will conduct new admission audits daily to ensure orders are in place to check under medical devices for those utilizing x 4 weeks, then weekly x 4 weeks. 6. DON designee will conduct weekly audits x 4 weeks, then bi-weekly x 4 weeks, of resident care plans to endure interventions are in place and effective for those at risk for pressure injuries. 7. Medical devices added to IDT daily clinical board to ensure orders in place for skin monitoring. 8. The results of all audits will be brought to monthly quality assurance performance improvement (QAPI) meeting to determine effectiveness and if additional audits or education are needed. Example 2: R6 was admitted to the facility on [DATE] with unspecified dementia, type 2 diabetes, and failure to thrive. R6's care plan dated 01/12/24 states, The resident is at risk for pressure injury r/t (related to) decreased mobility, muscle weakness, and presents of pressure ulcer. On 04/05/24, R6 received an order for R (right) Heel cup to right heel at all times for pressure relief. Check for placement each shift. On 07/05/24, facility updated order to continue R heel cup to right heel at all times for pressure relief. Check placement each shift. On 07/10/24, Surveyor reviewed Treatment Administration Record (TAR) which was signed off each shift during the month of July 2024 of having R heel cup in place. On 07/10/24 at 1:15 PM, Surveyor was unable to visualize R heel cup as resident was wearing shoes. On 07/10/24 at 1:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding the R heel cup for R6. CNA G stated not recalling the last time she had seen the heel cup as the area is healed. On 07/10/24 at 1:45 PM, Surveyor interviewed LPN D regarding the R heel cup. LPN D stated R6 has been getting out of bed more lately and has not been wearing the heel cup as he is wearing shoes. LPN D stated would contact hospice to have discontinued. On 07/10/24 at 1:50 PM, Surveyor interviewed RN H, who indicated the order for heel cup has been discontinued. On 07/11/24 at 5:56 AM, Surveyor received further information from RN H, indicating R heel wasn't a true DTI, but a discolored area. The order for the heel cup was put in place, and then three weeks ago R6 started getting up more, going outside more and wearing shoes. The heel cup needed to be taken off when wearing shoes. The facility failed to adjust the order to read wear the heel cup when in bed with his heel boots.